Elder Abuse

Physical or psychologic mistreatment, neglect, or financial exploitation of the elderly.

Several types of abuse are common--physical abuse, psychologic abuse, neglect, and financial abuse. Each type may be intentional or unintentional. The perpetrators are usually spouses or adult children but may be other family members or paid or informal caregivers.

Physical abuse is the use of force that results in physical or psychologic injury. It includes striking, shoving, shaking, beating, restraining, and improper feeding. It may include sexual assault (any form of sexual intimacy without consent or by force or threat of force).

Psychologic abuse is the use of words, acts, or other means that cause emotional stress or anguish. It includes issuing threats (eg, of institutionalization), insults, and harsh commands; remaining silent; and ignoring the person. It also includes infantilization (a patronizing form of ageism in which the abuser treats the victim as a child), encouraging the victim to become dependent on the abuser.

Neglect is failing to provide food, medicine, personal care, or other necessities.

Financial abuse is the exploitation of or inattention to a person's possessions or funds. It includes swindling, pressuring a person to distribute assets, and managing a person's money irresponsibly.

Epidemiology and Risk Factors

Although the true incidence is unclear, elder abuse appears to be a growing public health problem in the USA. In a large U.S. urban study of persons >= 65 years, 3.2% were victims of physical abuse, psychologic abuse, or neglect. Because certain forms of abuse (eg, financial exploitation) were not included, the actual incidence of mistreatment was probably higher. In more recent studies conducted in Canada and western Europe, the incidence of abuse was comparable to that in the USA.

For the victim, risk factors for abuse include impairment (chronic diseases, functional impairment, cognitive impairment) and social isolation. For the abuser, risk factors include substance abuse, psychiatric disorder, history of violence, stress, and dependence on the victim (including shared living arrangements--see Table 15-1).

Diagnosis

Abuse is difficult to detect because many of the signs are subtle and the victim is often unwilling or unable to discuss the abuse. Victims may hide abuse because of shame, fear of retaliation, or a desire to protect the abuser. Sometimes, when abuse victims seek help, they encounter ageist responses from health care practitioners, who may, for example, dismiss complaints of abuse as confusion, paranoia, or dementia.

Social isolation of the elderly victim often makes detection difficult. Abuse tends to increase the isolation, because the abuser often limits the victim's access to the outside world (eg, denies visitors, refuses telephone calls).

Symptoms and signs of abuse may erroneously be attributed to chronic disease (eg, a hip fracture attributed to osteoporosis). However, certain clinical situations are particularly suggestive of abuse (see Table 15-2).

History: If abuse is suspected, the patient should be interviewed alone, at least for part of the time. Other involved persons may also be interviewed separately. The patient interview may start with general questions about feelings of safety but should also include direct questions about possible mistreatment (eg, physical violence, restraints, neglect). If abuse is confirmed, the nature, frequency, and severity of events should be elicited. Abuse usually becomes more frequent and severe over time. The circumstances precipitating the abuse should also be sought (eg, alcohol intoxication).

Social and financial resources of the patient should be assessed because they affect management decisions, eg, living arrangements or the hiring of a professional caregiver. The examiner should inquire whether the patient has family members or friends able and willing to nurture, listen, and assist. If financial resources are adequate but basic needs are not being met, the examiner should determine why. Assessing these resources can also help identify risk factors for abuse (eg, financial stress, financial exploitation of the patient).

The interview with the family member should avoid confrontation. The interviewer should explore whether caregiving responsibilities are burdensome for the family member and acknowledge the caregiver's difficult role, if appropriate. Inquiries are made about recent stressful events (eg, bereavement, financial stresses), the patient's illness (eg, care needs, prognosis), and the reported cause of any recent injuries.

Physical examination: Signs that aid in the diagnosis of abuse are listed in Table 15-3. The patient should be thoroughly examined, preferably at the first visit. The physician may need to seek help from a trusted family member or friend of the patient, state adult protective services, or, occasionally, law enforcement agencies to persuade the caregiver or patient to permit the evaluation. A referral to adult protective services is mandatory in most states.

Cognitive status should be assessed, eg, using the Mini-Mental State Examination. Cognitive impairment is a risk factor for elder abuse and may affect the reliability of the history and the patient's ability to make management decisions.

Mood and emotional status should be assessed. If the patient feels depressed, ashamed, guilty, anxious, fearful, or angry, then the beliefs underlying the emotion should be explored. If the patient minimizes or rationalizes family tension or conflict, or is reluctant to discuss abuse, the examiner should determine whether these attitudes are interfering with recognition or admission of abuse.

Functional status, including the ability to perform activities of daily living (ADLs), should be assessed and any physical limitations that impair self-protection noted. If help with ADLs is needed, the examiner should determine whether the current helper has sufficient emotional, financial, and intellectual ability for the task. Otherwise, a new helper needs to be identified.

Coexisting disorders that are being caused or exacerbated by the abuse should be looked for.

Laboratory tests: Imaging studies and other laboratory tests (eg, electrolytes to determine hydration, albumin to determine nutritional status, drug levels to document compliance with prescribed regimens) are performed as necessary, both for diagnosis and for documentation of the abuse.

Documentation: The medical record should contain a complete report of the actual or suspected abuse, preferably in the patient's own words. A detailed description of any injuries should be included, supported by photographs, drawings, x-rays, and other objective documentation (eg, laboratory test results indicating drug or electrolyte levels) where possible. Specific examples of how needs are not being met, despite an agreed-on care plan and adequate resources, should be documented.

Prevention and Prognosis

A physician or other health care practitioner may be the only person an abuse victim has contact with other than the abuser and should therefore be vigilant for risk factors and signs of abuse. Recognizing high-risk situations can prevent elder abuse (eg, when a frail or cognitively impaired elderly person is being cared for by someone with a history of substance abuse, violence, psychiatric disorder, or caregiver burden [the degree of stress caused by caregiving]). Physicians should pay particular attention to those situations in which a frail elderly person (eg, a person with a recent history of stroke or a newly diagnosed condition) is discharged into a precarious home environment. Physicians should also keep in mind that abusers and victims may not fit stereotypes.

Elderly persons often agree to share their homes with family members who have drug or alcohol problems or serious psychiatric disorders. A family member may have been discharged from a mental or other institution to an elderly person's home without having been screened for a risk of causing abuse. Physicians should therefore counsel elderly patients considering such living arrangements, especially if the relationships were fraught with tension in the past.

Abused elderly persons are at high risk of death. In a large 13-year longitudinal study, the survival rate was 9% for abuse victims compared with 40% for nonabused controls. Multivariate analysis to determine the independent effect of abuse revealed a threefold higher mortality for abused patients over a 3-year period after the abuse than for controls over a similar period.

Treatment

An interdisciplinary team approach (involving physicians, nurses, social workers, lawyers, law enforcement officials, psychiatrists, and other practitioners) is essential. Any previous intervention (eg, court orders of protection) and the reason for its failure should be investigated to avoid repeating any mistakes.

Intervention: If the patient is in immediate danger, the physician, in consultation with the patient, should consider hospital admission, law enforcement intervention, or relocation to a safe home. The patient should be informed of the risks and consequences of each option. If the patient is not in immediate danger, steps to reduce risk should still be taken but are less urgent. The choice of intervention depends on the abuser's intent to harm. For example, if a family member administers too much of a drug because the physician's directions are misunderstood, the only intervention needed may be to give clearer instructions. However, a deliberate overdose requires more intensive intervention.

In general, interventions need to be tailored to each situation. Interventions may include medical assistance; education (eg, teaching victims about abuse and available options, helping them devise safety plans); psychologic support (eg, psychotherapy, support groups); law enforcement and legal intervention (eg, arrest of the abuser, orders of protection, legal advocacy [including protecting assets]); and alternative housing (eg, sheltered senior housing, nursing home placement). Counseling the victim usually requires many sessions, and progress may be slow.

If the victim has decision-making capacity, he should help determine his own intervention. If the victim does not have decision-making capacity, the interdisciplinary team, ideally with a guardian or objective conservator, should make most decisions. Decisions are based on the severity of the violence, the lifestyle choices previously made by the patient, and the legal ramifications. Often, there is no single correct decision, and each case must be carefully followed up.

Nursing and social work issues: As members of the interdisciplinary team, nurses and social workers can play an important role in preventing elder abuse. A nurse and/or a social worker can be appointed as coordinator to ensure that pertinent data are properly recorded, that relevant parties are contacted and kept informed, and that necessary care is available 24 hours/day. In-service education on elder abuse should be offered to all nurses and social workers annually. In some states (eg, New York), education on child abuse (but not yet on elder abuse) is mandatory for physician, nursing, and social work licensure.

Reporting: The reporting of suspected or confirmed abuse is mandatory in all states if the abuse occurs in an institution, and in most states if it occurs in a home. Indeed, all U.S. states have laws protecting and providing services for vulnerable, incapacitated, or disabled adults. In more than three quarters of U.S. states, the agency designated to receive abuse reports is the state social service department (adult protective services). In the remaining states, the designated agency is the state unit on aging. For abuse within an institution, the local long-term care ombudsman office should be contacted. Telephone numbers for these agencies and offices in any part of the USA can be found by calling the Eldercare Locator (800-677-1116) or the National Center on Elder Abuse (202-682-2470) and giving the patient's county and city of residence or zip code. Health care practitioners should know reporting laws and procedures for their own states.

Caregiver issues: Caregivers for elderly persons who have chronic medical and functional problems may not realize that their behaviors sometimes border on being abusive. These caregivers may be so immersed in their caregiving roles that they become socially isolated and lack an objective frame of reference for what constitutes normal caregiving. The deleterious effects of caregiver burden, including depression, an increase in stress-related medical conditions, and a shrinking social network, are well documented. Physicians need to point out these effects to caregivers. Services to help caregivers include adult day care, respite programs, and home health care.