72: Detecting, Assessing, & Responding to Elder Mistreatment

Elder mistreatment is a common yet underappreciated health issue affecting an increasing number of older adults each year.

Elder mistreatment can have a detrimental impact on victims’ health and well-being and add significant costs to the health care system. Yet barriers to reporting incidences of elder mistreatment are significant. Patients may be unable to report because of cognitive impairment or social isolation. They may feel afraid, embarrassed, or ashamed, and perhaps worry about the repercussions of reporting (ie, retribution from those who are mistreating them, including caregivers or nursing home staff). Health care providers may have concerns about making the situation worse with reporting or intervention, may lack training in recognizing mistreatment, may be uncomfortable confronting the possible abuser, may be afraid of retaliation against the victim, or may not want to be involved in the legal system. That caregivers and family members are themselves most likely to be responsible for mistreatment in the community is a further challenge. As a result, it is estimated that as many as 4 of 5 cases of elder mistreatment remain unreported. By identifying instances of potential elder mistreatment, health care professionals play an important role for victims whose physical and mental health is at risk. The importance of this role is underscored by studies showing that elder mistreatment victims experience a significant increase in mortality. One large longitudinal study found that 9% of victims of elder mistreatment were alive after 13-year follow-up compared to 41% who had not experienced abuse and that victims of elder mistreatment were 3 times more likely to die during one 3-year period. Elder mistreatment victims are also at higher risk for other adverse outcomes including nursing home placement and depression.

According to the National Elder Abuse Incidence Study, 510,000 adults age 60 years and older experience some form of mistreatment each year. Only 21% of cases were reported to and verified by adult protective services (APS) agencies. A growing number of cases are occurring in nursing homes and other long-term care facilities, where some form of abuse is one of the most common complaints among residents. Abuse commonly reported in nursing homes includes physical abuse, neglect, sexual abuse, and financial abuse or misappropriation of property. State long-term care ombudsman programs are now federally mandated to report events of elder mistreatment that occur in institutions, though the majority of complaints to the state programs are filed by residents, family, and others. There were approximately 269,000 complaints of elder mistreatment in long-term care facilities reported to the National Ombudsman Reporting System in 2008, a number that is likely to grow as the population in nursing homes expands to meet the needs of our aging society.

Signs & Symptoms

There are various definitions of elder mistreatment. The American Medical Association describes elder mistreatment as an act of omission or commission that results in harm or threatened harm to the health or welfare of an older adult. As defined by the National Center for Elder Abuse, elder abuse is a term referring to any knowing, intentional, or negligent act by a caregiver or any other person that causes harm, or serious risk of harm, to a vulnerable adult. Elder mistreatment appears in several forms of abuse (Table 72–1): physical, sexual, psychological or emotional, financial, and neglect or self-neglect. The following terms were derived by the NCEA definitions:

Physical—

Physical abuse is defined as physical contact that may result in any type of pain or injury. Physical abuse also may include unwarranted administration of drugs, physical restraints, force-feeding, or physical punishment. Physical findings potentially associated with physical abuse include a pattern of bruising or burns, including burns in the shape of an object or bruises that encircle an elder person’s arms, legs, or torso, broken bones, sprains, dislocations, internal injuries, open wounds, cuts, and untreated injuries. A patient’s report is typically essential in identifying instances of physical abuse.

Sexual—

Sexual abuse is sexual contact or behavior of any kind with an older adult that is either against their will or with an older adult who lacks capacity to give consent. Physical findings associated with sexual abuse may include bruises or bleeding around the genitals or chest, unexplained sexually transmitted diseases or genital infections, unexplained genital bruising or bleeding, torn, stained, or bloody clothing especially underwear, and new injuries. In addition to the patient’s report of sexual abuse, potential signs of sexual abuse include an unusual or inappropriate relationship between the patient and potential abuser.

Psychological or emotional—

Psychological or emotional abuse is defined as words or actions that spur emotional stress. Physical signs may include functional decline, behavior changes in the patient, significant weight loss or gain, and worsening of medical conditions or new onset medical conditions. Other signs of possible psychological abuse include a passive or evasive affect, fear (possibly in the presence of an abuser), or increased confusion or agitation. Differential diagnosis for depression, cognitive impairment, or worsening dementia is important when evaluating for psychological abuse and is discussed further below. Reporting of psychological abuse is not required in all states (eg, California) and health professionals may wish to seek the outside consultation of a mental health or social worker where psychological abuse is suspected.

Financial—

Financial abuse the misuse of finances or possessions of an older adult for another’s gain. Financial abuse is one of the most common forms and may occur in any context, including among family caregivers, friends, and in nursing homes or long-term care facilities. Financial abuse is often accompanied by social isolation or loneliness when an older adult either agrees to enter into an arrangement where friendship is traded for money or other gain or when the perpetrator isolates older adults to exert undue influence over their finances. Forcing an older adult to the automated teller machine or a check-cashing business to withdraw cash is also common and may be considered both financial abuse and abduction. Older adults who are victims of financial exploitation may have diminished mental capacity to understand their decisions. Potential signs of financial abuse include a findings of a patient living well below the patient’s means. Discomfort/evasiveness when discussing finances, ambiguity of the patient’s finances, a patient’s unexplained inability to pay bills, inability to buy food or medications, unexplained sudden changes to legal documents, and over-eagerness by another in the older patient’s assets.

Neglect—

Neglect is the failure to provide any care or responsibilities that they must provide for the patient. Neglect can be active or passive and can be either intentional or unintentional. Common physical signs of neglect include malnutrition, dehydration, poor hygiene, inadequate or inappropriate clothing, and decubitus ulcers or bedsores. Other signs to look for are sudden or questionable deteriorations of health or the absence of needed assistive devices including assisted hearing devices, eyeglasses, dentures, and walking devices/wheelchairs. Self-neglect occurs when an older adult with cognitive or functional impairment cannot care for themselves nor attain help to get the care needed. Self-neglect may coincide with neglect of family or other caregivers or may occur when an older adult refuses help and/or takes efforts to conceal their inability to meet basic needs.

A number of chronic illnesses and injuries sustained by older adults may mimic mistreatment. Consequently, it can be challenging for clinicians to make the definitive diagnosis of elder mistreatment or self-neglect. Dramatic injuries such as fractures, burns, contusions and lacerations that are accompanied by a credible patient history pose no diagnostic quandary; however, subtle presentations of medical problems over long periods of time can be difficult to distinguish from elder mistreatment. Therefore, self-neglect or elder mistreatment should be included in differential diagnosis when evaluating older adults. Table 72–1 lists some examples of underlying medical problems that could mimic elder mistreatment.

Elder abuse affects people of all ethnic backgrounds and social status. It affects both men and women. Similarly, those who commit elder abuse come from all backgrounds and can have close or distant connections to the victim. Table 72–2 lists common risk factors for suffering from and committing elder abuse.

There are multiple screening and assessment tools for elder mistreatment, but health care professionals may neither have access to them nor have been trained to administer them. To date, there is no widely accepted single screening tool or method of assessment for elder mistreatment. Some tools may be useful to identify those at risk for abuse while others are useful to identify ongoing abuse. Cohen et al have categorized different instruments into 3 categories:

• Direct questioning of the suspected abuse or self-reporting of abuse (eg, Hwalek-Sengstock Elder Abuse Screening Test [H-S/EAST], Vulnerability to Abuse Screening Scale [VASS])

• Tools that look for signs of abuse (eg, Elder Assessment Instruments [EAI] by Fulmer and Wetle)

• Tools that evaluate the risk of abuse (eg, Indicators of Abuse Screen [IOA] by Reis and Namiash)

The American Medical Association recommends that all physicians routinely inquire about the physical, sexual, and psychological abuse of an older patient as part of the medical history. Physicians should also consider abuse as a factor in the presentation of medical complaints as abuse may adversely affect patients’ health status or ability to adhere to medical recommendations.

A direct approach to a patient who is a possible victim of elder mistreatment is advised. Health care professionals should question the patient and caregiver separately and identify potential red flags. Many health care interactions, such as those that take place in an emergency room, may not allow for a comprehensive elder mistreatment screen. In these cases a single-question or 3-question screen can be used.

• Single question screen: Are you being abused or neglected?

• Three-question screen: Do you feel safe where you live? Who prepares your meals? Who takes care of your checkbook?

Table 72–3 includes additional suggested questions that are commonly used in screening for elder abuse.

Suspected elder mistreatment victims should undergo comprehensive geriatric assessment in addition to the traditional history and physical exam. This should include an assessment of their psychosocial and functional capabilities or limitations (see Chapter 2, “Consideration of Function & Functional Decline,” Chapter 4, “The Social Context of Older Adults,” and Chapter 6, “Geriatric Assessment”). An interdisciplinary approach to the assessment and plan is highly desirable. The following was adapted from Breckman and Adelman:

History Taking

When taking a medical history from an older adult, conduct interviews in a private space and with the patient alone. The patient and examiner should be at eye level, and any assistive devices needed for communication should be provided (ie, hearing devices, amplifiers, glasses, dentures). The health care professional should be cognizant of cultural sensitivity during the history and examination, as cultural differences may contribute to varying perceptions of what constitutes elder mistreatment.

Clinicians must determine the patient’s cognitive status (see Chapter 22, “Cognitive Impairment & Dementia”). Assessing the patient’s level of cognitive functioning may require further evaluation.

Health care professionals need to differentiate possible signs and symptoms of abuse from medical conditions. It is important to determine the patient’s functional status and ability to perform activities of daily living. If the patient needs assistance, then it is essential to find out if the patient has access to help as well as the knowledge of who is to provide assistance.

It is important to explore the patient’s living arrangement, as patients and potential abusers may live in the same household. Determining how long the patient has been living with that person(s), as well as who pays the bills and who owns or rents where the patient lives, can provide critical information regarding the potential for mistreatment. Questions about the financial status of the patient can help in assessing potential financial abuse. Identify the person who manages a patient’s finances and whether the patient is dependent on others for living and personal expenses. Social support should be determined as victims of elder mistreatment are often socially isolated. Table 72–4 summarizes the symptoms of elder mistreatment to look for in the medical history.

Physical Exam

The physical exam should include full examination of the patient, from head to toe. It should begin with general observation, including appearance, signs of dehydration, weight loss, and hygiene. A complete exam should include visual examination of a patient’s body and skin for any evidence of physical abuse, poor hygiene, skin breakdown; a musculoskeletal examination for signs of fractures or previous fractures; a complete neurologic examination to search for possible signs of delirium, cognitive impairment or dementia; and a genitourinary and rectal examination for signs of sexual abuse. If there are any signs of mistreatment, then further laboratory tests and radiologic examinations should be done depending on the findings. Some examples of suggested further testing include diagnostic imaging for fractures, checking electrolytes for dehydration, liver function tests for malnutrition, and/or checking hemoglobin and hematocrit for anemia.

Elder mistreatment is a complex medical problem that requires a multidisciplinary treatment approach. Each case of elder abuse or neglect necessitates individualized assessment and treatment planning.

Medical Intervention

Documentation—

Documentation of the abuse or neglect should be completed regardless of the health care setting. The provider should record the chief complaint in the patient’s own words if possible. Proper documentation should include a complete medical and social history. If appointments are repeatedly canceled, the name of the caller should be noted. If injuries are present, the type, number, size, location, and color, as well as the patient’s overall state of health, the resolution of the problems, and possible causes should be included. The provider should render an opinion on whether injuries were adequately explained by the history. All laboratory or radiologic and imaging studies should be recorded. If it is possible, obtain color photographs. If the police are called, the name of the officer, actions taken, and police incident number should be documented as well as the date and time the report was made to APS and the name of the person taking the report. The diagnosis of elder mistreatment should be included in the medical problem list.

Reporting—

Health care professionals make up the greatest reporting source of potential elder mistreatment to APS agencies. Legal requirements differ from state to state. Knowing your state’s reporting system is crucial. Nearly all states mandate health care providers to report cases of elder abuse. (Colorado, New York, North Dakota, and South Dakota do not currently mandate health care providers to report suspected or identified cases of elder abuse, but have voluntary reporting systems.) In some states, health care providers can be found negligent if they do not report suspected mistreatment. The website for National Center on Elder Abuse, which is part of the Administration on Aging, lists state directory of help lines, hotlines and elder abuse prevention resources (http://www.ncea.aoa.gov).

Discharge or ongoing care planning—

The provider must ensure that the older adult’s medical and safety needs have been met. If the patient does not meet the criteria for admission to the hospital after the provider has documented the findings and filed a report, the provider must be sure that the home environment is safe and that there is assistance at home for functionally and/or cognitively impaired patients. A social work consultation or consultation with an APS specialist may be necessary before discharge in order to develop a safety plan.

Elder mistreatment is often a chronic problem and patient’s with history of elder mistreatment should be referred to a physician or medical team with whom the elder can have an ongoing relationship. Elder mistreatment presents special difficulties for the patient in terms of function, decision-making capacity, and health and social support. These interrelated problems are best handled by a team of professionals from medicine, law, and social services. Clinicians should be skilled in the recognition of geriatric syndromes and familiar with local agencies that provide services to a mistreated older patient. Comprehensive geriatric assessment and intervention may be needed for vulnerable abused or neglected elders (see Chapter 6, “Geriatric Assessment”). It is often helpful to discharge the patient to their home with as many appropriate services as possible. Home health agencies can provide in-home assessments by social workers or nurses. Other referral sources include drug and alcohol rehabilitation services, and legal assistance or advocacy groups.

Assessment of decision-making capacity—

In many instances, the mistreated elder is vulnerable because the elder lacks the capacity to participate fully in decision making. Additionally, acute illness can reduce an older person’s ability to make rational and informed decisions. A competent individual has the right to be a fully informed participant in all aspects of decision making and has the right to refuse care. However, patients who lack decision-making capacity and whose expressed choices may lead to harm or even death need protection and assistance. The determination of neglect versus informed personal choices will hinge on an older adult’s capacity to participate in the elder’s own care. Therefore, it is essential to determine each patient’s decision-making capacity whenever assessment for elder abuse or self-neglect is in question (for more on informed decision making, see Chapter 12, “Ethics & Informed Decision Making”).

Social Services Intervention

APS or similar entities can provide social interventions in almost every jurisdiction in the United States. APS specialists usually receive reports, conduct investigations, and coordinate social interventions. They elicit input from collateral sources such as friends and family members of the patient and consult with other social workers, physicians, and nurses. After the APS specialists complete the investigation and comprehensive in-home assessment of the patient’s situation, they develop plans to address mistreatment issues and other problems they have identified. APS works closely with victims, families, and other involved parties. APS’s goal is to ensure that the service provided is the least-restrictive alternative, reflects the patient’s preferences, and maximizes the older adult’s independence. When a patient has the capacity to make informed decisions, the APS specialists advocate for the right to refuse services if the individual does not want intervention. As advocates of a legal jurisdiction, APS specialists are bound by statutory limitation and may not impose services such as medical care if the patient is capable of making decisions.

Legal Interventions

Although laws differ from state to state, law enforcement is generally involved in cases in which crimes are committed against older adults, including physical abuse, neglect with malicious intent, financial exploitation and other forms of elder mistreatment. Police officers investigate cases for evidence to help prosecutors pursue perpetrators. Officers of the court and judges participate in guardianship hearings when appropriate. Members of law enforcement and the legal profession help link older persons with agencies and other resources available to victims of crime. Forensic pathologists work closely with law enforcement officers to determine the cause of death in cases of suspected homicide resulting from abuse or neglect.

Elder mistreatment, particularly abuse, neglect and financial exploitation, can be a common occurrence. Health care providers should screen and assess for potential abuse. Making a diagnosis of elder mistreatment can often be difficult but knowing the signs and symptoms and maintaining a high index of suspicion can help identify potential victims and abusers. Knowledge of your state’s reporting system and laws is essential. The goal of treatment for patients who are victims of elder mistreatment is to improve their safety, health, and well-being.

Administration on Aging. www.aoa.gov

Agency for Healthcare Research and Quality. www.ahrq.gov/

Long-Term Care Ombudsman Resource Center. www.ltcombudsman.org

National Center on Elder Abuse. www.ncea.aoa.gov

National Committee for the Prevention of Elder Abuse. www.preventelderabuse.org

National Council on Child Abuse and Family Violence. www.nccafv.org/elder.htm

WHO: Elder abuse. www.who.int/ageing/projects/elder_abuse/en/