Mistreatment and neglect

Abuse and neglect of older adults is a common yet underreported problem that will be growing in scope. Although the number of older adults is increasing, the number of available trained caregivers is decreasing. This demographic trend of more vulnerable adults and fewer people to care for them combined with a national trend of decreasing social services is a harbinger of a new epidemic.

CASE 1 Doris Johnson (Part 1)

Doris Johnson is an 86-year-old woman who comes to your office for a routine visit. She has been living in her own home by herself since her husband died 12 years ago. Although she has Parkinson’s disease, diabetes, and hypertension, she has remained independent. Over the past year, she has had some decline in her function and requires meals-on-wheels and other services to remain at home. Her daughter Betsy recently moved from another state to live with Ms. Johnson and provide assistance.

The physical examination reveals a pleasant woman who has a moderate amount of tremor at rest and who ambulates slowly with the aid of a walker. You notice that Ms. Johnson seems withdrawn during this visit, and she tells you that it has been difficult to adjust to having a new person in the house even though she knows she needs help to stay there. Ms. Johnson’s next visit is an urgent appointment because she fell and has multiple large bruises on her upper arms and forehead. Betsy brings her to see you and reports, “I just found Mom on the floor this morning.” Ms. Johnson nods in agreement but says little else. No medical treatment is needed and she goes home. Three weeks later another urgent appointment is made: Ms. Johnson has a dislocated shoulder and bruises on her upper chest wall. Again, her daughter reports that Ms. Johnson fell. In spite of Betsy’s protests, you ask her to leave the exam room so that you may speak privately with Ms. Johnson. When you ask Ms. Johnson what happened, she breaks down in tears and reports that her daughter has been taking her money for years. You discover that Betsy moved in because she had no other place to live but promised that she would care for her mother in exchange for room and board. Once she was living there, Betsy asked her mother to sign over bank accounts. Initially, Betsy “just yelled at me and threatened to put me in a nursing home. But over the past month, Betsy became more aggressive and pushed me down several times. Last night she grabbed me and punched me because I would not sign the house over to her. I’m so ashamed … I never thought my own daughter would do this to me.”

1. Did you notice anything at the first visit that may have led you to worry about the possibility of abuse?

2. Do you think Ms. Johnson would have told you what happened if Betsy had been in the room?

Translating the definition of abuse (Box 33-1) to a diagnosis of abuse is not easy nor is it straightforward: It is often difficult to distinguish between injuries that occur through innocent mechanisms (e.g., tripping and falling) and those that occur as a result of abuse (e.g., being punched). Although some acts of commission or omission are blatantly abusive, there is no simple method to tell when some acts, such as poor care, cross the line to become abuse. However, this does not excuse the need to make a diagnosis at the earliest possible time. Primary care providers are in a unique position to prevent, recognize, and respond to mistreatment. They are often the first to identify both victim and perpetrator and, therefore, must be mindful of the possibility of abuse as well as be able to respond to its occurrence. Physicians are among the least likely to report suspicion of abuse to Adult Protective Services (APS).²

BOX 33-1

ELDER MISTREATMENT: DEFINITION

• Intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder.

• Failure by a caregiver to satisfy the elder’s basic needs to protect the elder from harm.

From Bonnie R, Wallace R. Elder mistreatment: Abuse, neglect and exploitation in an aging America. Washington, DC: National Academy Press; 2003.

Clinicians in primary care are in a unique position to prevent, recognize, and respond to abuse. However, health care professionals, particularly physicians, are among the least likely to report suspected abuse to Adult Protective Services.

Incidence and impact

Best estimates suggest that between 1 and 2 million Americans age 65 and older have been the victim of elder mistreatment or neglect by a caregiver.¹ Only 1 in 24 cases is reported to local authorities for intervention.³ Several studies have evaluated the prevalence of specific forms of elder mistreatment in community-dwelling older adults. The National Elder Mistreatment Study published in 2010 projected the prevalence of emotional mistreatment at 4.6%, physical mistreatment at 1.6%, sexual mistreatment at 0.6%, and financial abuse at 5.2% per year.⁴ Prevalence of verbal mistreatment has been found to be as high as 9%.⁵ Contrary to popularly held perceptions, family members, particularly adult children and spouses, are the most common perpetrators of abusive acts (Figure 33-1).² Unfortunately, victims of abuse face increased mortality rates as compared to unabused patients.⁶ When all other risk factors are taken into account, elder abuse by itself imposes a threefold increase in the risk of death of community-dwelling older adults.⁷ These patients have more psychiatric and physical disorders manifested by increased numbers of hospitalizations and emergency department visits. With increased life expectancy, it is projected that the older adult population will almost double in size to 20% of the U.S. population by 2030.⁸ The pool of potential victims is growing at a rapid rate.

Figure 33-1 Breakdown of suspected perpetrators of elder abuse. Note: Only 16% of perpetrators are nonfamily members. (Adapted from National Center on Elder Abuse. National Elder Abuse Incidence Study: Final report. Washington, DC: Department of Health and Human Services Administration for Children and Families and Administration on Aging; September 1998.)

CASE 1 Discussion

As primary care provider for Ms. Johnson, you correctly evaluated her. You were observant, noting that the patient was withdrawn and that the bruises were in unusual locations for a fall; you had the daughter leave the room so that Ms. Johnson could tell her story; you were reassuring but direct in asking Ms. Johnson what happened. This case illustrates the common finding that victims of abuse are often subjected to multiple types of mistreatment over a prolonged period of time. As is quite common in elder mistreatment, Ms. Johnson experienced financial, psychological, and physical abuse for many years.

The primary care clinician is in an excellent position to prevent abuse if warning signs are recognized. Although caregiver stress may trigger abuse, it is not an excuse for abuse.

Risk factors and pathophysiology

Risk factor assessment is important to identify potential elder mistreatment victims and initiate treatment. Risk factors are found in the victim, perpetrator, and sociocultural environment in which they are embedded (Box 33-2). Dementia is a known risk factor for mistreatment. In a study published in 2010, 47% of patients with dementia were found to be mistreated by their caregiver. Associated factors thought to increase the risk of abuse in people with dementia include caregiver depression, anxiety, and perceived burden of care; and care recipients with physically aggressive behaviors. This study found that when asked, caregivers of patients with dementia will acknowledge abuse.⁹ Alcohol and/or drug abuse among perpetrators of elder mistreatment is also common.¹⁰

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