Elder mistreatment often occurs insidiously, beneath the radar of those who see the effects but do not recognize the cause. Although difficult to measure, the best estimate places the prevalence of elder abuse at 3.2 percent in the United States.1 By 2030, the number of persons in the United States older than 65 years of age is projected to be 69 million2; based on a prevalence of 3 to 4 percent, about 2.5 million will be abused or neglected.
Elder abuse is a medical issue that family physicians must address. Victims of abuse and neglect have a three times greater risk of mortality compared with non-abused persons.3 Those who survive abuse may be left with nonhealing fractures, stage IV pressure sores that lead to septicemia, and depression that can be resistant to treatment. Persons who victimize the elderly prey on those who are least able to recover from the myriad effects of abuse.
Despite a growing body of knowledge about elder mistreatment, it remains largely unreported, particularly by physicians. In one state survey, only 23 percent of family medicine and internal medicine physicians believed that elder abuse was a concern in their own patient populations.4 More than 60 percent had never or “almost never” asked elderly patients about abuse, and 69 percent had not suspected a case of elder abuse in the previous year. A separate study that reviewed four years' worth of reports in Michigan found that only 2 percent of elder abuse reports were filed by family physicians.5
As physicians, we have intimate knowledge of patients' medical, functional, and social problems. Thus, we are in a unique position to assist in the recognition of elder mistreatment. A physician visit may be an elderly person's only source of interaction outside the home. Why are we not fulfilling our potential to recognize—and perhaps prevent—mistreatment of the elderly?
In a recent study, physicians cited the following reasons for failing to report suspected elder abuse: victim denial (23 percent), uncertainty about reporting procedures (21 percent), uncertainty about reporting laws and resources (10 percent), and the fact that the abuse involved only subtle signs (44 percent).4 Educating physicians about elder abuse may help overcome these barriers. For example, many physicians do not realize that victims' family members are most often the abusers. Physicians also may not realize that bruising, which is common in older adults, may be a sign of physical abuse, especially when it appears on the head or neck.6
Physicians are mandated reporters in most states, and every state has a protective services agency responsible for investigating reports of elder abuse. In several states, mandated reporters are given immunity from criminal and civil liability as long as reports are made in good faith. Reports do not have to be substantiated for this protection. In fact, only about 50 percent of cases are substantiated.7 However, physicians may face penalties, including jail time and fines, for not reporting suspected abuse, especially if the abuse is ongoing. It has even been argued that failure to report obvious cases may qualify as negligence or malpractice.8
Almost every primary care physician will care for an older patient who is at risk of being mistreated. More research is needed to help physicians identify signs of mistreatment and understand the barriers to reporting suspected abuse. Education at all levels of medical training is required. Increased awareness and reporting of elder mistreatment will significantly improve the care of our older patients.