Elder Abuse: “It Shouldn’t Hurt To Be Old”*
Patricia A. Bomba
CLINICAL PEARLS
Elder abuse is a hidden public health issue.
Elder abuse results in increased mortality rates and unnecessary suffering, injury pain, decreased quality of life, and loss or violation of human rights.
Elder abuse is under-recognized, underreported, and underprosecuted.
Financial exploitation is common and often associated with other types of abuse.
Neglect is the most prevalent form of elder abuse.
Any vulnerable older adult is at risk of mistreatment.
Perpetrators are family members in most cases.
Self-report cannot be relied upon to identify cases.
Self-report may be compromised by cognitive impairment, fear, family situations, caregiver, and cultural issues.
Elder abuse may be missed by failure to consider the diagnosis.
The ethical challenge is to balance our professional duty to protect the safety of the vulnerable elder with the elder’s right to self-determination.
Reporting elder abuse to protective services is mandatory in most but not all states.
Elder abuse (also known as elder mistreatment) refers to intentional actions by a caregiver or other person who stands in a trusting relationship to the elder, which cause harm (whether or not harm was intended) or create a serious risk of harm to a vulnerable elder. The concept also includes failure by a caregiver to satisfy the elder’s basic needs or protect the elder from harm. Elder abuse is a growing problem in every community and among all social strata and is under-recognized, underreported, and underprosecuted. It is an independent risk factor of increased mortality rates in older adults.1 Elder abuse includes acts of commission and omission and involves medical, psychological, social, legal, ethical, financial, and environmental concerns.
Health care professionals are in a pivotal position to identify and intervene on behalf of their victimized patients. To do so, all health care professionals must maintain a high index of suspicion for elder abuse, neglect, and financial exploitation in all health care settings. This implies a commitment to screenings of all elders and an understanding of how to perform more detailed diagnostic assessments when needed. All members of the health care team, especially physicians, nurses, and social workers, must know when to refer patients for additional assessment and when and how to use community resources effectively. The ethical challenge for the physicians is to balance their professional duty to protect the safety of vulnerable elders with the elder’s right to self-determination.
DEFINITIONS
Elder abuse is an all-inclusive term representing all types of mistreatment or abusive behavior toward older adults. These may be acts of commission or omission, or neglect. They may be intentional or unintentional. Whether a behavior can be labeled as abusive, neglectful, or exploitive depends on its frequency, duration, intensity, severity, consequences, and cultural context. In discussions with older adults, the term elder mistreatment may be preferred. It is also recognized that victims of domestic violence grow old.
Definitions and legal terminology vary from state to state. Experts recognize elder abuse as the willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical harm, anguish, or mental illness. As defined by the National Center on Elder Abuse,2 physical abuse is the use of physical force that results in injury, physical pain, or impairment. Sexual abuse is defined as nonconsensual sexual contact of any kind with an elderly person. Psychological abuse is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts. Neglect, the most prevalent form of elder abuse, is defined as the refusal or failure to fulfill any part of a person’s obligations or duties to an elder, including the provision of goods or services, which are necessary to avoid physical harm, mental anguish, or mental illness. Abandonment is defined as the desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder or by a person who has physical custody of an elder. Financial exploitation is the illegal or improper use of an elder’s funds, properties, or assets. It is the fastest growing form and is frequently linked with other types of abuse.
PUBLIC HEALTH ISSUES
Incidence and Prevalence
In the preceding decade, five community surveys showed that 5% of older adults report experiencing instances of domestic elder abuse, neglect, and financial exploitation. The lack of consistency in terminology used among the 50 states and variation in reporting standards contribute to inadequate incidence and prevalence data. To obtain more valid incidence data, the Congress mandated a national study in 1996. A “sentinel” approach was employed, similar to previous federally sponsored child abuse surveys. This methodology assumes that reported cases present only the proverbial “tip of the iceberg” and that many more cases in the community are never reported. Through a random sampling process, 20 counties were selected to serve as the sample sites. In each county, information on the cases was obtained from the local Adult Protective Services agency and a specifically trained group of individuals, or the sentinels, who were drawn from agencies that normally serve older people, such as hospitals, clinics, law enforcement agencies, senior citizens programs, and banking institutions. The results of the National Elder Abuse Incidence Study3 estimated that nearly a half a million persons aged
60 and older living in domestic settings were abused, neglected, or exploited in the United States in 1996. Of this total, only 70,942 cases were reported and substantiated by Adult Protective Services. The remainder were not reported but were identified by the “sentinels.” In other words, for every case reported to the Adult Protective Services, it is assumed that there were five cases that were not reported. Further projecting the estimates—recognizing those that were never reported nor recognized—it was estimated that there were between 820,000 and 1.86 million abused older people in the country.
60 and older living in domestic settings were abused, neglected, or exploited in the United States in 1996. Of this total, only 70,942 cases were reported and substantiated by Adult Protective Services. The remainder were not reported but were identified by the “sentinels.” In other words, for every case reported to the Adult Protective Services, it is assumed that there were five cases that were not reported. Further projecting the estimates—recognizing those that were never reported nor recognized—it was estimated that there were between 820,000 and 1.86 million abused older people in the country.
As a point of comparison, the 1996 US Cancer Statistics for older adults reveals 133,000 cases of colon cancer per year, 66,000 cases of cervical cancer per year, and 185,000 cases of breast cancer per year. The incidence of elder abuse and neglect cases increased by 128% between 1986 and 1996. The National Center for the Prevention of Elder Abuse estimates a 60% increase since 1996.4 The most frequently cited prevalence figure is 32 seniors per 1,000.
Mortality Rates
Elder abuse results in increased mortality rates.1 Dr. Mark Lachs evaluated data from the New England Established Population for Epidemiological Studies of the Elderly, which followed an annual health survey of 2,812 community-dwelling adults aged 65 or older. He compared these data against reports of elder abuse and neglect made to the local Adult Protective Service over a 9-year period. The survival rates of the nonabused and abused were tracked. By the 13th year following the initiation of the study, 40% of the nonabused group was still alive, compared to 17% of those seen for self-neglect. Only 9% of those seen for elder mistreatment were still living. No other significant factors predictive of mortality were found, including age, gender, income, functional status, cognitive status, diagnosis, and social support.
Elder Abuse as a Geriatric Syndrome
Over the last two decades, studies have documented physicians’ failure to diagnose a variety of common conditions in elderly people in the course of “usual and customary care.” Examples include dementia, depression, and general functional decline. Geriatricians have conceptualized these entities as “geriatric syndromes,” or common clinical problems that rarely have a single, underlying, pathophysiologic process, which is typically sought in the pure medical model. More often, there are several contributing factors that shape the clinical presentation. Typically, environmental factors play a prominent role. Interventions are multiple and directed at specific pathology, as well as contributing environmental factors. Elder abuse has many of the characteristics of a geriatric syndrome.
Framing elder abuse as a geriatric syndrome provides a conceptual starting point from which the physician and health care professional can begin to address mistreatment, from screening to management. Definitive diagnosis and management requires a comprehensive evaluation of all potentially contributing factors. The relative contribution of comorbid medical conditions, environmental factors, and social influences must be determined before rational interventions are developed.
From the perspective of physicians, Dr. Mark Lachs identified three major causes generic to the problem of family violence: Clinical and academic discomfort, time and reimbursement constraints, and perceived impotence.5 Many physicians feel uncomfortable inquiring about domestic violence and may feel clinically incompetent because they lack formal training. Family violence does not fit neatly within the traditional medical paradigm of symptoms, diagnosis, and treatment. Personal identification with patients may preclude the proper evaluation of family violence.
From an academic perspective, additional research focused on elder abuse and neglect is urgently needed. Time and reimbursement constraints hinder evaluation of elder abuse, which is a time-consuming process. A complete assessment may not be practical, particularly if discovery occurs in the midst of a routine evaluation. Scheduling a longer follow-up visit or referral is essential. Awareness of available community resources provides professionals with an important timesaving advantage.
Unfortunately, many physicians perceive that they are unable to make a difference. Some express the belief that it was the duty of the victims to separate from an abusive environment and that they doubted that counseling would achieve a positive outcome. Some physicians express unsatisfactory outcomes with previous patients, which created skepticism that they could serve any useful role. This attitude views the problem as a social issue and, therefore, places it outside their professional boundaries. Signs and symptoms of elder abuse may be dismissed as inevitable aspects of aging or ascribed to comorbid diseases (see Table 9.1).
Fractures can be attributed to osteoporosis. Direct reports of abuse may be dismissed as manifestations of dementia, delirium, delusion, or confusion, or even side
effects of polypharmacy. Depression and pain may be underreported by the patient and therefore unrecognized and untreated by the physician. Because chronic pain can lead to depression, social isolation, and neglect, early identification is critical.
effects of polypharmacy. Depression and pain may be underreported by the patient and therefore unrecognized and untreated by the physician. Because chronic pain can lead to depression, social isolation, and neglect, early identification is critical.
TABLE 9.1 SIGNS AND SYMPTOMS OF ELDER ABUSE VERSUS ASPECTS OF AGING OR COMORBID DISEASE | ||||||||||||||
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Failure to thrive is often blamed on general frailty, when in fact it can be the result of the deliberate withholding of food or medicines by a care provider. Unless clinicians consider elder abuse in the differential diagnosis of these presentations, these “false-negatives” will continue.
WHEN TO SUSPECT ELDER ABUSE AND NEGLECT
CASE ONE
Mrs. S., who is 75 years old and suffers from moderate dementia, is accompanied to her doctor’s visit by her husband of 50 years. Mrs. S. has been a patient for only about 1 year, and the reason for the change of physicians is never broached. Mr. S. explains that her dementia causes her to give inaccurate answers to most health questions. Often during the examination, when he speaks for Mrs. S., she gets “weepy” and this causes him to tell her to stop crying and answer the questions asked of her.
Although the doctor has suggested assistance at home, Mr. S. “forgets” to follow up or refuses nursing visits at home when a nurse arrives. Mr. S. feels he can take care of his wife alone and that she is “fooling” the doctor about her memory loss.
Relevant issues:
Why did they leave their previous doctor?
Have they had multiple doctors over the last few years (i.e., “doctor hopping”)?
Do the medical professionals allow Mr. S. to speak for his wife? Do they believe that because she is demented, nothing she says is accurate? Why is she never alone?
Why does she get “weepy” when her husband intervenes? Is there a pattern?
Are Mr. S.’s opinion about his wife’s dementia and his resistance to outside services “red flags” for possible abuse or neglect?
Vulnerability
Although there is no single explanation for elder abuse and neglect, one central element is vulnerability—any condition that allows another person to take advantage of the victim. It is not the same as being cognitively impaired, although cognitive impairment can certainly lead to vulnerability. There are multiple ways in which a person can be vulnerable, including being seriously medically ill, physically or emotionally dependent, lonely, depressed, or grieving. Fear, early life experiences, substance use, and personality traits also contribute to vulnerability.
Risk Factors
The National Elder Abuse Incidence Study3 published in 1998 found that the median age of the victims was 76.5 years and that elders aged 80 years and older were abused two to three times more often than younger people. Half of the abused individuals were physically dependent on others. Women were abused more often than men, even after accounting for their proportion in the aging population. The perpetrators were family members (often with a history of substance abuse) in 90% of the cases. The remaining 10% were caregivers, companions, “scam artists,” and others. The study found that the most frequent reporters of elder abuse to Adult Protective Services were family members; hospitals were responsible for 17.3% of such reports, whereas physicians, nurses, and clinics in the community reported only approximately 8% to 10% of cases. Individuals having more contact with “social systems,” such as Medicaid clients, were more frequently reported as victims (see Table 9.2A, B).
High-risk factors for abuse include poor health, cognitive and functional impairment in the elder, substance abuse or mental illness on the part of the elder or abuser, dependence of the abuser on the victim, shared living arrangements, social isolation, external factors causing stress, and a history of domestic violence. A number of recent studies have demonstrated that medical disease plays a greater role in abuse than previously recognized.6 Independent risk factors for elder mistreatment include dementia, depression, and malnutrition. Other common associated clinical diagnoses include alcohol abuse, psychosis, and executive dysfunction. A recent study examined the prevalence and 3-year incidence of abuse among postmenopausal women and found that they were exposed to abuse at similar rates
to younger women. The study concluded that abuse poses a serious threat to their health (see Table 9.3).7
to younger women. The study concluded that abuse poses a serious threat to their health (see Table 9.3).7
TABLE 9.2 RISK FACTORS FOR VICTIMS AND PERPETRATORS | |||||||||||||||||
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TABLE 9.3 MOST COMMON DIAGNOSES ASSOCIATED WITH ELDER ABUSE | ||||||||
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“Red Flags”
Elder mistreatment must be considered whenever:
there are unreasonable delays in seeking medical attention between the injury or illness and the clinical assessment;
the history from the victim and the perpetrator significantly differs or when explanations are implausible or vague;
lab test or x-ray results are suggestive of abuse or inconsistent with the history and physical examination;
there are frequent emergency room visits for exacerbation of chronic disease despite a comprehensive plan for medical care and adequate resources, particularly if different facilities are used;
patients practice “doctor hopping” (frequent changes in clinicians); orRelated posts:
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