Elder abuse is any action — or lack of appropriate action — occurring in a relationship where there is an expectation of trust that causes harm or distress to an older person, according to the World Health Organization.
One sixth of community-dwelling older adults are affected by elder abuse, with rates climbing in the United States and globally. The ramifications are alarming, says Ecler Jaqua, MD, MBA, associate professor, family and geriatric medicine and medical director, San Antonio Regional Hospital Center of Aging, Rancho Cucamonga, California.
Equally disturbing is that it’s frequently unrecognized, with only 1 in 24 cases reported to authorities and <2% reported by physicians. “This is unfortunate because we’re the main ‘point people,’ often the first or only professionals, in a position to detect and maybe intervene,” Jaqua told Medscape Medical News.
The consequences are devastating, said Tony Rosen, MD, MPH, emergency medicine physician, Weill Cornell Medicine and NewYork-Presbyterian Hospital, New York. “Elder abuse may lead to increased mortality, increased depression, and exacerbations of chronic illness.”
Be Aware of Risk Factors
Cognitive and functional impairment are among the strongest risk factors for experiencing elder abuse, with prevalence among individuals
with dementia significantly higher than in those without dementia. Other risk factors include difficult family dynamics, diminished community support, challenging behaviors (resisting care, aggression, or agitation), mental illness, substance abuse, lower income, frailty, trauma, or past abuse. Older women, minorities, and lesbian, gay, bisexual, or transgender individuals are also at higher risk.
Factors found in perpetrators include mental illness, inexperience, reluctance to assume a caregiver role, substance abuse, financial difficulties, and a conflictual relationship. Among community-dwelling older adults, the most common perpetrators of elder abuse are family members.
Detecting Elder Abuse in the Clinical Setting
Elder abuse is typically divided into five categories:
- Neglect/abandonment: Failure to meet or allow others to provide the elder’s basic needs (food, clothing, shelter, medical care, hygiene, social interactions)
- Physical: Infliction of physical pain, injury
- Psychological/emotional: Infliction of emotional pain (e.g., threatening violence or institutionalization, verbal aggression, humiliating statements)
- Sexual: Nonconsensual sexual talk, contact, activity
- Financial: Illegal/improper use of elder’s funds/resources
“Having a high index of suspicion is very helpful,” Amy Shaw, MD, a geriatrician at Weill Cornell Medicine and NewYork-Presbyterian Hospital, New York, told Medscape Medical News.
Begin with observing potential red flags in the patient-caregiver interaction, Shaw and Rosen advised.
- Patient seeming uneasy around caregiver
- Caregiver seeming angry/resentful
- Hostility between patient and caregiver
- Caregiver not allowing patient to speak
- Caregiver not understanding patient’s medical issues or type of care required
- Missed appointments
- Differing caregiver and patient reports
- Caregiver has taken patient to multiple doctors/hospitals (there may be an innocuous explanation, or it may suggest elder abuse)
- Delayed presentation for care — e.g., after injury
Clues in the Physical Examination
Rosen recommended looking for unexplained bruises not found over bony prominences, burns, fractures, infected areas of open wounds, soiled diapers, long fingernails or toenails with dirt underneath, poor hygiene, and signs of malnutrition.
Uncontrolled chronic medical conditions can suggest the caregiver isn’t attending to the patient’s needs, Shaw noted — for example, if the patient isn’t taking prescribed medications or is taking them incorrectly.
Concerning findings suggesting sexual abuse include difficulty walking/sitting, genital pain/itching, vaginal/anal bleeding, and damaged/bloody underclothing. Dehydration, failure to thrive, unexplained weight loss, and repeated falls may signal neglect. But remember, certain conditions can mimic neglect or abuse in elders. For example, poor wound healing can be associated with diabetes.
Screening for Elder Abuse
The US Preventive Services Task Force doesn’t recommend routine screening of all older adults for elder abuse. Nevertheless, Jaqua screens her older patients because elder abuse is so common. It’s certainly important to screen if you suspect elder abuse.
“Never screen with the caregiver present,” Jaqua warned. “You have to ask the caregiver to step out in a nice way, but it’s a clue if the caregiver won’t allow the patient to be alone with you.”
Jaqua starts with open-ended questions such as, “Has anyone ever hurt or threatened you? Do you feel safe at home? Where do you live? Are you afraid of anyone in your life?”
Screening tools can be incorporated into the visit. Although several tools are available, Jaqua uses the Elder Abuse Suspicion Index (EASI), validated for family physicians in an ambulatory setting in older adults with a Mini-Mental State Examination score of ≥23.
“Explain to patients why you’re asking these questions,” Shaw advised. “You can say, ‘Some older adults are mistreated, so we ask these questions routinely.’” A positive screen doesn’t definitively confirm elder abuse but suggests follow-up is indicated.
Some patients may not want to disclose elder abuse, Jaqua noted. “They may fear caregiver retaliation or being forced to go to a nursing home. They may not want to get their caregiver in trouble — especially a family member like a spouse, child, or grandchild.” Reassure the patient you’re interested in their safety and want them to be able to live with dignity, “and there are people (such as social workers) who can help make that happen.”
Reporting Elder Abuse
Concerns should be thoroughly documented, including the history, complete physical exam, and results of any screening tests. Include statements made by the patient, documentation of marks of physical abuse (potentially including photographs), the caregiver’s name, and the patient’s living situation.
“No absolute proof is needed to make a report to APS [Adult Protective Services] or law enforcement, only reasonable suspicion,” Jaqua said. “As unpleasant as it is, and of course the caregiver won’t like it — the patient may not like it either — it’s better to be safe than sorry and err on the side of caution.”
Laws regarding reporting suspected elder abuse are “less uniform and clear than those regarding child abuse,” Shaw noted. “Laws vary from state to state, so it’s important to be familiar with the reporting laws of the state in which you practice. In some cases, it may be necessary to call not only APS but also law enforcement.”
Rosen elaborated. “While CPS [Child Protective Services] must step in immediately after a report, APS typically has 72 hours to initiate an investigation. Cooperating with APS is considered ‘voluntary,’ so if the patient or caregiver don’t answer the door or refuse services, APS may close the case. That’s why law enforcement might need to be involved, especially in life-threatening situations.”
Ideally, decisions shouldn’t be made in a vacuum but should include social workers and case managers. Physicians treating older patients outside a hospital or health system should develop a relationship with geriatric social workers and case managers in the community. Rosen recommended findhelp.org, which offers a guide to community-based resources. “Even rural communities may have more resources than you realize.”
For patients with decision-making capacity, the physician’s role is to assist with safety planning. “This is no different from working with any adult who is experiencing domestic abuse,” Rosen commented. “That person has the right to decide whether or not to stay in the relationship.” But reporting is necessary if the patient is frail, disabled, or lacks decision-making capacity.
Information about reporting elder abuse can be found at these websites:.
- US Department of Justice
- US Department of Health and Human Services
- National Adult Protective Services Association
Detecting Financial Abuse
Physicians can play an important role in detecting financial abuse. Elders may be exploited not only by caregivers but also by scammers. According to the FBI, older individuals seem “disproportionately” affected by fraud, including cryptocurrency and tech support scams.
Questions to ask patients include:
- Has money/property been taken from you without your consent?
- Have your credit/debit cards been used without your consent?
- Has anyone called/emailed you asking you to send or wire money to them?
- At the end of the month, do you have enough money for food, rent, utilities, or other necessities?
Victims may be unwilling to disclose exploitation because of embarrassment, so use a nonjudgmental tone, Jaqua advised.
Considerations regarding a physician’s role in detecting and intervening in financial abuse can be found in a paper by Lachs and Pillemer in The New England Journal of Medicine.
Caregivers Also Have Needs
Caregivers often neglect themselves because of caregiving demands. They need “resources, respite, and time to attend to their own needs, such as medical appointments or financial commitments,” Jaqua said.
Rosen advised recommending organizations that provide information and support for caregivers.
- Alzheimer’s Association
- National Alliance for Caregiving
- National Institute on Aging
- CaringBridge
- Family Caregiver Alliance
- Aging Life Care Association
- Eldercare Locator
Complex Cases
Patients with dementia may lack the capacity to describe what’s happening to them, Jaqua said. “You’ll need to rely more heavily on your own observations, physical exam, interactions with the caregiver, and other clues not provided verbally by the patient.”
It’s challenging when a patient with dementia describes being abused by a caregiver but no evidence corroborates that abuse and you don’t see concerning behaviors on the caregiver’s part, Jaqua noted. “It’s helpful to have a longstanding relationship with the patient and caregiver, which provides a baseline of their ‘usual’ interactions. It’s more challenging with a new patient.” Make sure you have the right diagnosis, and ask the patient to return for additional appointments to assess the situation over time.
Optimal care can be provided by involving a multidisciplinary team of social workers and other healthcare and sometimes non-healthcare professionals (e.g., forensic accountants).
The time available during a primary care appointment is compressed, with many other issues to address. Multidisciplinary collaboration can extend the umbrella of care, ensuring the myriad needs of these patients are being met, Shaw said.
For example, members of the team might help the patient qualify for Medicaid, involve non-abusive family members, and increase homecare hours, which might help with neglect. And forensic accountants might assist with financial abuse, in collaboration with financial institutions and law enforcement.
Rosen receives funding from the National Institutes of Health. Shaw and Jaqua disclose no relevant financial relationships.
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