Abuse of older or dependent patients by their caregivers has received increasing attention over the past decade and deserves the attention of family physicians. Scientific studies provide better understanding and a more secure basis for interventions, but the results are still complex and sometimes contradictory. A review by Lachs and Pillemer used international databases from medical, social service, legal, and other disciplines to clarify risk factors for abuse of older adults and suggest diagnostic and intervention strategies for the family physician.
The consensus definition for elder abuse is: intentional actions that cause harm or a serious risk of harm to a vulnerable elder by a caregiver or person who stands in a trust relationship with the elder, or failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.
Within these concepts, there is a range of actions covering active and passive harm that constitute abuse to the dependent elder. These acts include: (1) physical abuse, acts done with the intention of causing pain or injury; (2) psychologic abuse, acts intended to cause emotional distress; (3) sexual abuse; (4) material exploitation, any misappropriation of the money or property of the elder; and (5) neglect, all aspects of failing to meet the needs of a dependent older adult (see accompanying table).
Research on older adults living in domestic settings in several European countries, Canada, and the United States consistently indicates that between 2 and 10 percent are abused. Five risk factors for abuse have been identified, but more may emerge as research continues. Apart from financial abuse victims, who tend to live alone, abused elders are likely to share living arrangements with family members or others. Individuals with dementia are more likely to be abused than other elders. The disruptive or aggressive behaviors that can be part of a dementing illness are believed to contribute to this association by increasing stress on caregivers. Social isolation of older adults and caregivers also is an important risk factor for abuse. Such isolation increases stress within the relationship and reduces social sanctioning or intervention to prevent unacceptable behavior. Mental illness, substance abuse, or other psychologic pathology in the caregiver is a significant risk factor for elder abuse. Depression and alcohol abuse in the caregiver are particularly important risk factors. Finally, many abusers are heavily dependent on their victims. The elder may have substantial financial resources, leading the abuser to maintain a family relationship that may have been hostile for many years. The degree of dependency of the elder does not appear to be an independent risk factor for abuse, but some studies suggest that patterns of intergenerational violence within a family could be significant. Elder abuse can occur with or without apparent risk factors and in situations that appear benign to the external observer.
|Context of elder abuse||Potential interventions|
|Abuse potentially related to stress from caring for impaired family member||Respite services; adult day care; caregiver education programs (e.g., on what constitutes abuse); recruitment of other family members, informal, or paid caregivers to share burden of care; psychotherapy for caregiver; treatment for depression; social integration of caregiver to reduce isolation|
|Violence related to substance or alcohol abuse||Referral to alcohol or drug alcohol abuse rehabilitation programs as appropriate|
|Violence related to behavior problems associated with mental health||Treatment referral|
|Long-standing spousal violence||Marital counseling; support groups; shelter; orders of protection; victim advocacy|
|Abuse by aggressive dementia patient||Geriatric medical assessment of causes underlying behavior (e.g., new or established medical conditions)|
|Financial exploitation by family members||Guardianship proceeding, power of attorney (transfer of legal authority); protective services|
|Financial exploitation by paid caregiver||Referral to legal services; involvement of law enforcement; protective services|
Opinions vary about whether to recommend for or against screening for elder abuse in routine office visits, but various screening protocols have been developed and tested for reliability and validity. The situation often is complicated by the unwillingness or inability of the victim to disclose the abuse. The authors conclude that a generally increased threshold of suspicion by physicians of elder abuse is more likely than formal screening to increase detection in primary care.
Symptoms of elder abuse may be overlooked because they mimic other illnesses common in older adults. Clinical manifestations of elder abuse can include fracture, contusion, laceration, nonadherence to medications, weight loss, passivity, or depression. Once suspected, a comprehensive physical and psychosocial assessment is indicated. The patients should be examined in private, away from caregivers and other health care staff, because disclosure of abuse may be difficult, shameful, or dangerous. An empathetic, nonjudgmental approach is recommended if a physician must interact with an alleged abuser.
The potential importance of intervention is shown by a few outcome studies that show a threefold increase in mortality over three years in abused elders. In one follow-up study, 9 percent of abused elders were alive 13 years after detection, compared with 41 percent of the control group. Evidence-based recommendations for management and follow-up cannot be made at this time. The authors suggest a systematic approach that recognizes the patient’s right to self-determination if he or she has the capacity to exercise it. The plan requires using all appropriate community resources and is implemented by a multidisciplinary team.
editor’s note: Most states require physicians and a wide range of other professionals to report elder abuse on suspicion. Each state has different reporting guidelines (http://www.elderabusecenter.org/default.cfm). We are often reluctant to consider the possibility. If we do, we are just as haunted by the potential outcomes if we are wrong as if we are correct. If the patient is being abused, taking action could eliminate their one remaining support and could alienate a parent from a child. However pathologic the relationship, severing that tie is always serious. We may also have responsibilities toward the abuser, who may in many ways be a covictim of a horrible situation. The key is “on suspicion.” Just as in child abuse, our responsibility is to make an objective report of the facts that led us to suspect abuse to adult protective services and let them investigate the case. Reporting is confidential. Physicians should not delay reporting until conclusive “proof” is available: to do that may cost a patient his or her life.—a.d.w.