Elder Abuse and Neglect
Perspective
Currently, 13% of the population in the United States is estimated to be 65 years of age or older.1 The elderly segment of the population is expected to increase to 16% of the population by 2020 and 20% of the population by 2050.2 Furthermore, the “oldest” old (85 years and older) will make up an increasing proportion of the population. At this time, older patients make about 15% of emergency department visits. This number is expected to increase to 25% by the year 2030, with 5% being older than 85 years.3 As the aging population continues to increase, it is anticipated that the number of cases of elder abuse will also rise. Because older adults will make up a larger portion of emergency department visits in the future, emergency physicians need to have a greater knowledge of the risk factors and signs of abuse and neglect and consider them more frequently in the differential diagnosis.4
With aging, there is an increase in vulnerabilities, such as physical and cognitive decline, expended financial resources, and uncertain medical insurance. As the U.S. population ages, there is a greater need to recognize and respond to signs of elder abuse and neglect. The World Health Organization has recognized that abuse and neglect of elders are global health problems.5 Elderly individuals may be isolated from society as a result of physical illness, disability, mental illness (e.g., dementia), and age. Visits to physicians by elderly persons may provide their only contact outside the family. Elderly persons frequently visit the emergency department for medical care. Therefore emergency physicians have the opportunity to diagnose suspected elder abuse and initiate further evaluation by elder abuse teams and Adult Protective Services.6 However, one survey suggests that emergency physicians may lack awareness and adequate training about elder abuse. In this survey of 705 emergency physicians, 79% reported they had treated a case of elder abuse in the previous year, but only 50% said they had reported the abuse. Of respondents, 28% believed elder abuse is rare, and 84% rarely ask their patients directly about elder abuse. Only 31% of emergency physicians responded that they are aware of a written protocol for elder abuse in the emergency departments where they practice, and just 38% said they are familiar with their state laws pertaining to elder abuse. In addition, only 40% responded that they are aware of types of community services available for victims of elder abuse, and only 25% could recall receiving education about elder abuse during their residencies.7 It is hoped that through education and increased awareness, these numbers will increase markedly, as the emergency department often serves as the first step in the detection of an abusive or neglectful situation.
Epidemiology
It has been estimated that 2 million elders are neglected or abused annually in the United States.8 The National Elder Abuse Incidence Study found that 449,924 Americans older than age 60 years had experienced some form of mistreatment in the previous year.9 In this study the median age of victims of elder abuse was 78 years, and two thirds of victims were women. Of identified elder abuse victims, 66% were white, 19% black, and 10% Hispanic. More than two thirds of perpetrators of elder abuse were family members, primarily spouses and grown children, and the overwhelming majority of victims lived with the perpetrators. A total of 77% of victims were unable or only somewhat able to care for themselves; 60% of victims were either very confused or occasionally confused. In addition, 37% of elder abuse victims were moderately depressed, and 6% were severely depressed. The more recent National Elder Maltreatment Study interviewed 5777 adults older than age 60 years (average age 71.5 years) and found a 1-year prevalence of 4.6% for emotional abuse, 1.6% for physical abuse, 0.6% for sexual abuse, 5.1% for potential neglect, and 5.2% for financial abuse.10 This study also found that very little of the abuse was reported to authorities.
A systematic review of studies measuring the prevalence of elder abuse published in 2008 found that 6% of older people living in the community reported significant abuse within the previous month.11 When looking more specifically at vulnerable older people, the review found that one fourth of those who were dependent on others for care reported significant psychological abuse, and one fifth reported neglect. One third of family caregivers reported perpetrating abuse, and of professional caregivers in long-term care, 16% admitted to perpetrating psychological abuse, and 10% admitted to perpetrating physical abuse. In this review, very few cases were reported to Adult Protective Services. Studies have shown that as few as 1 in 14 cases of elder abuse is actually reported.12
Definitions and Types of Elder Abuse
Some of the difficulty in establishing the true incidence and prevalence of elder abuse stems from the lack of uniformity of definitions of elder abuse, both among researchers and in legislation. Definitions vary from state to state and often lack objective criteria for reliably establishing a medical diagnosis. Elder abuse is a form of family violence, along with child abuse and intimate partner violence. There are three main categories of elder abuse: domestic elder abuse, institutional elder abuse, and self-neglect or self-abuse. Domestic elder abuse includes any form of elder abuse inflicted in the elder’s home or the caregiver’s home by a family member or a caregiver. Institutional abuse includes any form of elder abuse that occurs in a residential facility for elderly persons, usually inflicted by individuals who are hired to provide care. Self-neglect or self-abuse is the result of the behavior of an elderly person and threatens the well-being of that individual. Self-neglect usually involves the refusal or failure of elderly individuals to provide themselves with basic necessities, such as food, water, shelter, medications if indicated, and appropriate personal hygiene. In 45% of cases of self-neglect, elders 80 years of age or older are involved.13 Self-neglect does not include mentally competent elderly individuals who understand the consequences of their decisions.
In addition to the three main categories, elder abuse can be grouped into six types: physical abuse, sexual abuse, emotional or psychological abuse, neglect, abandonment, and financial or material exploitation.13 In a study of substantiated cases of elder abuse, 58% involved neglect, 11% physical abuse, 15% exploitation, 15% emotional abuse, and 1% sexual abuse.14 Victims of elder abuse are often subjected to multiple types of elder abuse.
Abandonment is defined as the desertion of an elderly person by the caregiver, custodian, or an individual who is responsible for providing care. As many emergency physicians are aware, elderly patients may be abandoned in the emergency department. One survey reported that a median of 24 elderly patients were abandoned annually per emergency department, with 46% living alone and no longer being able to look after themselves and 41% being left in the emergency department by family members or a caregiver.15 Abandonment may be considered a form of neglect.
Financial or material exploitation is defined as the illegal or improper use of an elderly person’s money, property, or assets. Financial exploitation includes denying an elderly person his or her home; stealing money or belongings; and coercing an elderly individual into signing contracts, changing a will, or assigning durable power of attorney to someone against his or her wishes. It may also include coercing an elderly individual to take out a loan or sign a legally binding document when he or she does not possess the mental capacity to do so.16
Etiology of and Risk Factors for Elder Abuse
There are several theories regarding the cause of elder abuse.17 More recent focus has been directed toward the abusing relative or caregiver. The social learning or transgenerational violence theory proposes that children who grow up in an abusive household may go on to be abusive to their own children and perhaps parents. Another theory, the stressed caregiver theory, proposes that as a caregiver becomes increasingly stressed (from caregiving or other causes), elder abuse is more likely to occur. Some researchers theorize that it is the psychopathology of the abuser that leads to elder abuse. Proponents of the isolation theory contend that as elderly individuals become more socially isolated as a result of illness, disability, and age, they are at increased risk for abuse. Those who adhere to the dependency theory believe that increasing frailty is the underlying cause of elder abuse, whereas others contend that frailty only prevents many elders from protecting or defending themselves and that the true cause lies with the abuser. It is now recognized that no single theory can account for all situations of abuse or neglect. An integrated theoretic model may best describe all potential factors involved, and each circumstance may involve some components to a greater degree than others.
Numerous risk factors for elder abuse have been proposed. These factors may be divided into four main categories: caregiver risk factors for abusing, elder risk factors for being abused, environmental risk factors, and institutional abuse risk factors (Box 69-1).18,19 The National Elder Maltreatment Study evaluated correlates for each type of abuse and found that the most consistent correlates across abuse types were low social support and previous traumatic event exposure. Emergency providers should be aware of these risk factors and alert to the possibility of abuse among all elderly patients.
Clinical Features
Elderly patients are four times more likely to be brought to the emergency department by ambulance than nonelderly patients.20 When elders are brought to the emergency department by ambulance, the emergency medical technicians or paramedics may be invaluable in identifying at-risk elders on the basis of their assessment of the home situation and the family dynamics at the home. The emergency provider should question prehospital care personnel about the cleanliness and upkeep of the home; the availability of electricity, heat, water, and sanitation; infestation by rodents or vermin; and the safety of the interior of the home for the older patient.
The American Medical Association (AMA) has recommended that all health care providers routinely ask their older patients about abuse, even in the absence of signs of abuse.21 Patients should be questioned in as private a setting as possible, after the family or caregiver has left the room. If the patient has dementia or is unable to answer questions for other reasons, individuals who have knowledge about the patient, other than the caregiver, should be questioned, such as other family members, visiting home nurses and assistants, therapists, primary care physician, or neighbors. If a translator is needed, someone other than a family member or the caregiver should be used. To broach the subject of elder abuse, the interviewer begins by asking about the patient’s care in general and then focuses on abuse and specific types of abuse (Box 69-2). Factors that have been shown to have a significant association with suspected elder abuse include a brittle support system, feelings of loneliness, expression of conflict with family or friends, alcohol abuse, short-term memory problems, and psychiatric illness.22 One study determined that emergency department nurses can be trained to routinely ask older patients about neglect and appropriately refer them for care.23 There are now several instruments available to assist medical personnel in inquiring about and identifying abuse and neglect. These tools involve direct questioning of the elder, recognition of possible physical signs, or identification of risk factors. No single test has been found to be optimal, but the use of multiple approaches may be most helpful in recognizing abuse victims. If elder abuse is identified, the provider should question the patient further about the duration and frequency of the abuse, the nature of the abuse, and whether there has been intervention or assistance in the past because of the abuse.
