Am Fam Physician. 1999;59(10):2804-2808
Elder mistreatment is a widespread problem in our society that is often under-recognized by physicians. As a result of growing public outcry over the past 20 years, all states now have abuse laws that are specific to older adults; most states have mandated reporting by all health care professionals. The term “mistreatment” includes physical abuse and neglect, psychologic abuse, financial exploitation and violation of rights. Poor health, physical or cognitive impairment, alcohol abuse and a history of domestic violence are some of the risk factors for elder mistreatment. Diagnosis of elder mistreatment depends on acquiring a detailed history from the patient and the caregiver. It also involves performing a comprehensive physical examination. Only through awareness, a healthy suspicion and the performing of certain procedures are physicians able to detect elder mistreatment. Once it is suspected, elder mistreatment should be reported to adult protective services.
It is estimated that over 2 million older adults are mistreated each year in the United States. Elder mistreatment first gained attention as a medical and social problem about 20 years ago, when the term “granny battering” first appeared in a British medical journal.1 Since that time, elder mistreatment has become a matter of concern not only in the United States, but throughout the world. This heightened awareness has followed a growing awareness of child and spousal abuse. Nevertheless, because of differing definitions, poor detection and under-reporting, the extent of elder mistreatment is unknown. These same factors make the collection of data difficult and its accuracy questionable. Published studies estimate that the prevalence of elder mistreatment ranges from 1 to 5 percent.2
Most health care professionals are reluctant to address domestic violence. However, physicians are in an ideal position to detect and manage mistreatment, as they may be the only person outside the family/caregiver role who regularly sees the older adult. In addition, the physician is the most likely person to order the testing, hospital admissions and support services that are sometimes needed to correct elder mistreatment. This article will review the clinical, ethical and legal issues regarding elder mistreatment. The various forms of elder mistreatment are defined, including ways to identify patient and caregiver risk factors, and history and physical findings that suggest a diagnosis of elder mistreatment. Finally, a systematic approach to patient evaluation, documentation and reporting of suspected cases will be reviewed.
Elder Mistreatment: Definitions and Classifications
In an effort to increase physicians' awareness, facilitate accurate detection and promote further research, the American Medical Association published a position paper on elder mistreatment in 1987.3 This paper proposed a standard definition:“ ‘Abuse’ shall mean an act or omission which results in harm or threatened harm to the health or welfare of an elderly person. Abuse includes intentional infliction of physical or mental injury; sexual abuse; or withholding of necessary food, clothing, and medical care to meet the physical and mental needs of an elderly person by one having the care, custody or responsibility of an elderly person.”
Elder mistreatment may take many forms. Types of elder mistreatment are often classified as physical abuse and neglect, psychologic abuse, financial exploitation and violation of rights. Table 1 lists the various types of elder mistreatment. A major obstacle to prevention of and intervention for elder mistreatment is a lack of awareness on the part of physicians and other health care professionals. Table 2 lists many of the reasons for under-reporting of elder mistreatment.
| Type of mistreatment | Definition |
|---|---|
| Physical abuse | An act that may result in pain, injury, impairment or illness |
| Example: punching, kicking, shoving | |
| Physical neglect | Failure of a caregiver (or the elderly person) to provide goods or services that are necessary for optimal function or to avoid harm |
| Psychologic abuse | Conduct that causes mental anguish in an elderly person. |
| Example: verbal harassment or degradation | |
| Financial exploitation | Misappropriation of an elderly person's assets for the benefit of another person |
| Violation of rights | Deprivation of any inalienable right (personal liberty, personal property, assembly, speech, privacy, vote) |
| Example: taking personal items from an elderly person |
| Little or no training in recognizing mistreatment |
| Unfavorable attitude toward older adults (ageism) |
| Little information in medical literature about elder mistreatment |
| Reluctance to attribute signs of mistreatment (disbelief) |
| Isolation of victims (patient not seen often by physicians/health care providers) |
| Subtle presentation (i.e., poor hygiene or dehydration) |
| Reluctance/fear of confronting the offender |
| Reluctance to report mistreatment that is only suspected |
| Mistreated person requests that abuse not be reported (patient/physician privilege) |
| Lack of knowledge about proper reporting procedure |
| Fear of jeopardizing relationship with hospital or nursing facility |
Risk Factors and Prevention
Cognitive impairment and the need for assistance with activities of daily living are important risk factors for elder mistreatment.4 Caregiver burnout and frustration can lead to elder mistreatment.5 Substance abuse by the caregiver or the patient, especially abuse of alcohol, significantly increases the risk of physical violence and neglect.6 Psychologic and character pathology in the caregiver and patient are also major risk factors. Table 3 lists the commonly accepted risk factors for elder mistreatment.4–6
Prevention of elder mistreatment is difficult and depends as much on the social support network as on the medical network. Preventing elder mistreatment involves identifying high-risk patients and caregivers, and attempting to address the underlying issues. Screening patients and caregivers before placement can be helpful, when it is feasible. Helping patients obtain county or state assistance can also help reduce some high-risk situations.7
| Older age |
| Lack of access to resources |
| Low income |
| Social isolation |
| Minority status |
| Low level of education |
| Functional debility |
| Substance abuse by caregiver or by elderly person |
| Psychologic disorders and character pathology |
| Previous history of family violence |
| Caregiver burnout and frustration |
| Cognitive impairment |
Approach to the Patient
HISTORY
Recognizing mistreatment is often difficult. The older adult may be unable to provide information because of cognitive impairment. The history is sometimes difficult to obtain from the victim, for fear of retaliation by the abuser. This retaliation can come in the form of physical punishment or threats of violence and abandonment. Older adults are often fearful of being placed in a nursing facility, and some may prefer to be abused in their own home rather than be moved to such a facility.
The mistreated older adult often presents with somatic complaints. Physicians should ask older patients about rough handling, confinement and verbal or emotional abuse. Subtle or confusing complaints may actually be indicative of mistreatment. It is important to recognize that abuse and neglect are most often discovered during routine visits at the physician's office or in the long term care facility.
Generally, the patient should be interviewed without the caregiver(s) present. Cognitive impairment may limit the ability to obtain an accurate history. It is important to ask general questions about conditions in the home or nursing facility. The physician should try to obtain an accurate view of the patient's daily life, including meals, medication, shopping and social outlets.
It is also important to ask the patient about the nature and quality of the relationship with the caregiver. It may be helpful to ask questions such as, “How do you and (name of caregiver) get along?” and “Is (name of caregiver) taking good care of you?” It is critical to assess the patient's mental status for indicators of depression or alcohol and substance abuse. A discussion of the patient's financial situation may be appropriate. If issues of mistreatment are raised, the caregiver should be interviewed as well. The physician must be careful not to overinterpret or to make suggestive comments, especially when the patient is cognitively impaired. Table 4 lists the essential features of a history for identifying a mistreated elder patient.
| Medical problems/diagnoses |
| Detailed description of home environment (adequacy of food, shelter, supplies, etc.) |
| Accurate description of events related to injury or trauma (instances of rough handling, confinement, verbal or emotional abuse) |
| History of prior violence |
| Description of prior injuries and events surrounding them |
| Description of berating, threats or emotional abuse |
| Improper care of medical problems, untreated injuries, poor hygiene, prolonged period before presenting for medical attention |
| Depression or other mental illness |
| Extent of confusion or dementia |
| Drug or alcohol abuse |
| Quality/nature of relationships with caregivers |
Physical Examination and Laboratory Tests
The physical examination is often used as legal evidence of mistreatment. Table 5 lists the basic features of a physical examination in assessing a mistreated elder patient.8 Laboratory and imaging studies should be performed to confirm any suspicious findings in the history and physical examination. The presence of dehydration and malnutrition can be established with simple laboratory tests such as a complete blood count and measurement of blood urea nitrogen, creatinine, total protein and albumin levels. Radiographic studies provide evidence of old and new fractures.9 Unfortunately, proving that a fracture was caused by abuse can be difficult.
| Area examined | Possible signs of mistreatment |
|---|---|
| Head | Traumatic alopecia or other evidence of direct physical violence; poor oral hygiene |
| Skin | Hematomas, welts, bite marks, burns, decubitus ulcers |
| Musculoskeletal | Fractures or signs of previous fractures |
| Neurologic | Cognitive impairment that is a risk factor for mistreatment and influences management decisions regarding competency |
| Genitorectal | Poor hygiene, inguinal rash, impaction of feces |
| General | Weight loss, dehydration, poor hygiene, unkempt appearance |
Documentation
Documentation of all findings may be entered as evidence in criminal trials or in guardianship hearings. Documentation must be complete, thorough and legible. Such circumstances dictate that there be a “chain of evidence.” This need mandates a careful collection of physical evidence, which is critical in cases of suspected sexual or physical abuse. Laboratory data and, when possible, photographs should be used for verification of written documentation.
Management
Management of elder mistreatment first involves discussing the situation with the patient, if feasible. The patient should be allowed to play a role in the ultimate resolution, if he or she is able to do so. First, the competency of the patient should be determined. Local and state social services have different methods of addressing mistreatment. Social workers from hospitals, clinics or long term care facilities are valuable resources and should be able to assist with these services.
Multidisciplinary teams can be very effective.10 These teams typically include geriatricians, social workers, case management nurses and representatives from legal, financial and adult protective services. Multidisciplinary teams are often more effective in problem-solving and provide a forum for discussion with participants involved in the care of the older adult.
Senior advocacy volunteer groups are also helpful.10 A senior advocate can provide information to the abused person and enable access to resources from community programs and social services.
Reporting
All health care providers (physicians, nurses, social workers, etc.) and administrators are mandated by law to report suspected elder mistreatment. The laws differ from state to state; physicians should determine the specific requirements in their states. Any other person may also report suspected abuse and neglect. All reporters are immune from civil liability if they act in good faith and without malice. They are also protected from termination of employment. Health care providers can be found to be negligent if they fail to report suspected mistreatment. Penalties can include fines, imprisonment or loss of licensure.
Reports of suspected elder mistreatment should be given to the state or county division of adult protective services. In the absence of such services, the reporter should contact the county extension office or the state's office of child and family services. In addition, any Area Agency on Aging would be able to provide assistance in reporting suspected mistreatment. The National Domestic Violence Hotline (telephone: 800-799-SAFE) or the Older Women's League (telephone: 800-825-3695) could also help. Contacting the police is always an option, especially in an urgent situation.
In the event that the older adult is a resident of a long term care facility, a separate mechanism often exists for investigating suspected mistreatment through the state agency that surveys these facilities. Identifying the appropriate avenue for investigation can be done through the available adult protective service agency or the state department of child and family services.11,12
Once suspected mistreatment has been reported, the responsible agency will assign a social worker to investigate the case. The social worker will provide an accurate description of the home or nursing-facility environment. After assessment, the social worker may provide insight into some possible solutions to the problem and information about available resources. Unlike cases of child abuse, if the older adult is competent to make decisions, he or she may refuse intervention. If the older adult is not competent to make decisions, a guardian can be appointed by the state. The guardian can then direct care as needed until the problem is satisfactorily resolved.