08. Elder Abuse

The prevalence of elder abuse is often underestimated by professionals. It is estimated that 1 in 10 adults 60 years or older is a victim of abuse and only half of detected abuse cases are reported.

Emotional abuse, neglect, and exploitation are the most common forms of abuse.

Types of Elder Abuse

Type

Definition

Examples

Physical

use of physical force that may result in injury, pain, or impairment.

hitting, pushing, shoving, shaking, pinching, inappropriate drug or physical restraints, force-feeding, physical punishment

Sexual

non-consensual sexual contact, or sexual contact with someone incapable of giving consent

unwanted touching, sexual assault or battery, explicit photographing or nudity

Emotional / Psychological

anguish, pain, or distress caused through verbal or nonverbal acts.

verbal insults, threats, humiliation, harassment, treating an older person as an infant, isolating elderly from friends/family, “silent treatment”

Neglect

refusal or failure to fulfill any part of a person’s obligations or duties to an elder.

pay for necessary home service or provide care, provide necessities such as food/shelter/clothing/hygiene/ medications/personal safety

Abandonment

desertion of the elderly by person who had assumed responsibility

 

Financial / Material Exploitation

illegal or improper use of elder’s funds, property, or assets

cashing checks without authorization, forgery, coercing elder to sign documents

Self-Neglect

behavior or elderly person that threatens own health or safety

refusal or failure to provide food/water/clothing/shelter/hygiene/medications/safety precautions. Does not apply to situations where someone who has capacity and chooses a decision that can threaten his/her health or safety.

Evaluation

Screening is important, especially in patients with dementia. However, no single screening tool is adequate to identify patients.

Questions for patient (interviewed alone if possible)

  • Are you afraid of anyone in your family?
  • Has anyone close to you tried to hurt or harm you recently?
  • Has anyone close to you called you names or put you down or made you feel bad recently?
  • Does someone in your family make you stay in bed or tell you you’re sick when you know you aren’t?
  • Has anyone forced you to do things you didn’t want to do?
  • Has anyone taken things that belong to you without your permission?

Questions for the caregiver (especially important for patients with dementia) should focus on three main areas:

  • Caregiver intrapersonal concerns (e.g. mental health, alcohol or substance use)
  • Caregiver interpersonal problems (e.g. marital/family conflicts, relationship with the care receiver)
  • Care receiver social support shortages and past abuse

Signs of abuse:

  • Physical exam: weight loss, temporal wasting, bruises / pressure marks / broken bones, poor hygiene, screen for depression, bedsores
  • Unexplained withdrawal from normal activities, sudden change in alertness
  • Sudden changes in financial situations
  • Belittling, threats from spouse
  • Strained or tense relationships, frequent arguments between caregiver and elderly person

The Elder Abuse Suspicion Index has been validated in cognitively intact patients (MMSE > 24). Positive answer for question 2-6 yields sensitivity of 0.47 and specificity of 0.75

Management

Physicians are mandated reporters in California.

  • For suspected abuse in nursing home or residential care, call the local Long-term Care Ombudsman or Bureau of MediCal Fraud and Elder Abuse
  • For suspected abuse in another setting report to Adult Protective Services (see http://ag.ca.gov/bmfea/pdfs/citizens_guide.pdf for list of California phone numbers)
  • Contact Adult Protective Services (APS) and local social services
  • If urgent, call 911

Aim efforts to reduce caregiver stress.

  • Consider respite services, adult day care, recruit other family members to assist in caregiving
  • Treat depression
  • Refer to substance use programs if applicable
  • Counseling, social work
  • Offer home visits
  • Discuss with patient and other friends/family (if available) about advance directives and power of attorney.

Resources

References

National Center on Elder Abuse

http://www.ncea.aoa.gov/ncearoot/Main_Site/index.aspx

Fulmer T, Guadagno L, Dyer CB et al. Progress in elder abuse screening and assessment instruments. J Am Geriatr Soc 2004;52:297.

Abbey L. Elder abuse and neglect: when home is not safe. Clin Geriatr Med. 2009 Feb; 25(1): 47-60.

Reis, M. & Nahmiash, D. (1998). Validation of the indicators of abuse (IOA) screen. The Gerontologist, 38 (4), 471-480.

Lachsj MS, Pillemer K. Elder abuse. The Lancet. 2004 Feb; 364(9441): 1263-1272.

Hoover RM. Polson M. Detecting elder abuse and neglect: assessment and intervention. 2014 Mar 15: 89 (6): 453-60.

Acierno R, Hernandez M, Amstadter AB et al. Prevalence and Correlates of Emotional, Physical, Sexual, and Financial Abuse and Potential Neglect in the United States: The National Elder Mistreatment Study. Am J Public Health. 2010 February; 100(2): 292–297