ELDER ABUSE

Elder abuse (also referred to as vulnerable adult abuse or older adult abuse) is defined as an intentional or neglectful act by a caregiver or trusted individual that leads to or may lead to harm of a vulnerable older adult. Elder abuse is a problem estimated to affect up to 1.2 million older adults annually in the United States. Only 1 in 10 cases of elder abuse, however, are ever reported (Kane et al., 2018).

Various types of elder abuse include:

  • Physical abuse: Use of force to threaten or physically injure an older person, including acts such as hitting, kicking, pushing, slapping, and burning
  • Emotional/psychological abuse: Verbal or nonverbal attacks, threats, rejection, isolation, or belittling acts that cause mental anguish, fear, or distress
  • Sexual abuse: Sexual contact that is forced, tricked, threatened, or otherwise coerced, including sexual harassment
  • Exploitation: Theft, fraud, misuse or neglect of authority, and use of undue influence as a lever to gain control over an older person’s money or property
  • Neglect: Failure or refusal to provide for an older person’s basic needs of food, water, shelter, clothing, hygiene, essential medical care, safety, or emotional needs
  • Abandonment: Leaving an older adult who needs help alone without planning for their care
    (NCEA, 2020)

Elder abuse can lead to early death, harm one’s physical and psychological health, destroy social and family ties, and cause devastating financial loss (CDC, 2020g).

Risk Factors

Factors that may increase an older adult’s risk of being an abuse victim include:

  • Low social support and social isolation
  • Cognitive impairment
  • Experience of previous traumatic events
  • Functional impairment and poor physical health
  • Being female
  • Living with a large number of household members other than a spouse
  • Lower income or poverty

Factors associated with financial exploitation include:

  • Lack of access for public assistance and resources
  • Need for ADL assistance
  • Poor self-rated health
  • Lack of spouse/partner
    (NCEA, 2020)

A combination of individual, relational, community, and societal factors contribute to the risk of becoming a perpetrator of elder abuse.

  • Individual level:
    • Current diagnosis of mental illness
    • Current abuse of alcohol
    • High levels of hostility
    • Poor or inadequate preparation or training for caregiving responsibilities
    • Assumption of caregiving responsibilities at an early age
    • Inadequate coping skills
    • Exposure to abuse as a child
  • Relationship level:
    • High financial and emotional dependence upon a vulnerable adult
    • Past exposure of disruptive behavior
    • Lack of social and/or formal support
  • Community level:
    • Limited, inaccessible, or unavailable formal services such as respite care
  • Societal level:
    • High tolerance and acceptance of aggressive behavior
    • Family members are expected to care for elders without seeking help from others
    • Persons are encouraged to endure suffering and remain silent
    • Negative beliefs about aging and elders

Specific characteristics of institutional settings that increase the risk include:

  • Unsympathetic or negative attitudes towards residents
  • Chronic staffing problems
  • Lack of administrative oversight, staff burnout, and stressful working conditions
    (CDC, 2020g)

Assessment for Elder Abuse

Routine screening for elder abuse is not recommended by the U.S. Preventive Services Task Force, but it is recommended that ongoing awareness of this growing problem be considered during all patient care interactions.

SCREENING QUESTIONS

Office or emergency room visits may be the only time the patient can have safe, confidential contact with someone other than the abuser. If the patient is able to understand and respond to questions, the patient can be interviewed alone in a quiet, private location. Interviewing can be difficult if the patient is cognitively impaired or if the caregiver is the suspected abuser. It is best performed by someone with expertise in geriatrics and/or a social worker or other mental health professional.

Examples of indirect screening questions include:

  • Do you feel safe where you live?
  • Who prepares your food?
  • Does someone help you with your medication?
  • Who takes care of your checkbook?

Examples of direct screening questions include:

  • Does anyone at home hurt you?
  • Do they scold or threaten you?
  • Do they touch you without your consent?
  • Do they make you do things you don’t want to do?
  • Do they take anything that’s yours without asking?
  • Have you signed documents that you did not understand?
  • Are you afraid of anyone at home?
  • Are you alone a lot?
  • Has anyone ever failed to help you take care of yourself when you needed help?

Follow-up questions assess safety issues and explore mistreatment, asking what, how, when, how often, etc.:

  • Who is the perpetrator?
  • How do you (the patient) cope?
  • What are your alternative living options?
  • Who are alternative caregivers?
  • What can be done to prevent future abuse?
    (Stanford Medicine, 2020)

In cases of suspected or known abuse, further screening can be done with validated tools such as the Elder Assessment Instrument (EAI), a 41-item tool comprised of seven sections that reviews signs, symptoms, and subjective complaints of elder abuse, neglect, exploitation, and abandonment. There is no actual scoring done, but the person is referred to social services for the following:

  • Evidence of mistreatment
  • Subjective complaint of mistreatment by the older adult
  • Clinician belief there is a high risk for probable abuse

Many older adults are reluctant and/or ashamed to report mistreatment, or they are afraid if they do, it will get back to the abuser and make the situation worse (Fulmer, 2020).

RED FLAGS FOR ABUSE

Clinicians must be aware of the signs and symptoms that signal an older adult may be experiencing abuse. Such red flags include:

Physical abuse clues (especially if there has been a delay in seeking treatment):

  • Unexplained or implausible injuries
  • Multiple ED visits; healthcare “shopping”
  • Broken bones, dislocations, sprains
  • Multiple injuries in various stages of healing
  • Traumatic, patchy hair loss
  • Broken glasses
  • Swelling, pinch marks, hand slap or finger marks
  • Bruises, especially when not over bony prominences
  • Scratches, cuts, lacerations, punctures
  • Burns from a cigarette, immersion line, or in the shape of hot object such as an iron
  • Restraint marks on axilla, wrists, or ankles
  • Aspiration/choking from forced feeding

Sexual abuse clues:

  • Bruises on breasts or genital area
  • Genital infections or venereal disease
  • Vaginal or anal bleeding

Possible signs of neglect (also self-neglect):

  • Pressure injuries, especially if not cared for
  • Signs of suboptimal living conditions, such as poor hygiene, torn or dirty clothes, inappropriate or inadequate clothing
  • Poor state of dentition
  • Malnutrition, weight loss, temporal wasting, low serum albumin and cholesterol
  • Dehydration, cracked lips, sunken eyes, impaction (water withheld to decrease incontinence episodes), poor skin turgor, elevated BUN and sodium
  • Contractures
  • General deterioration in health
  • Failure to keep medical appointments
  • Physical or laboratory evidence of over- or underdosing
  • Lack of needed healthcare appliances or supplies
  • Lack of physical aids such as dentures, glasses, or hearing aids
  • Failure to address issues of safety
  • Inability to manage activities of daily living

Possible indicators of economic abuse:

  • Caregiver refusal to spend money on care items or services
  • Lack of appropriate clothing or grooming for the level of income
  • Patient complains of missing clothing, jewelry, or valuable items
  • Lonely patient with new “best friend” at office visits
  • Sudden appearance of previously uninvolved relatives
  • Unpaid medical bills when caregiver is supposed to be handling them
  • Checks, new will, power of attorney, or healthcare directives “signed” by a patient who is incapable of doing so
    (Stanford Medicine, 2020)

Reporting

The laws in most states mandate healthcare professionals to report suspected abuse or neglect of vulnerable elders. Additionally, under the laws of some states, “any person” is required to report a suspicion of mistreatment. All healthcare professionals are advised to familiarize themselves with reporting laws and procedures applicable to their state and/or local area.

If an older adult is in immediate, life-threatening danger, call 911. Anyone who suspects that an older adult is being mistreated should also contact the long-term care ombudsman, police, or Adult Protective Services (APS) office in their jurisdiction to report the suspected abuse.

While federal law does not specifically address elder abuse, all 50 states and the District of Columbia provide APS programs. The National Center on Elder Abuse (NCEA) offers resources, and more information is also available from Eldercare Locator (see “Resources” at the end of this course).

Punishments for elder abuse range widely between states. In some states, elder abuse is considered a first-degree felony (NHAC, 2020).