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Elder Abuse

  • Lana AlhalasehEmail author
  • Asma Abu-Zanat
  • Maram Alsmairat
Living reference work entry
  • 2 Downloads

Abstract

Elder abuse is generally defined as the maltreatment of individuals over the age of 60 [1]. The World Health Organization (WHO) recognizes elder abuse as “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” [2]. Instances of abuse toward older adults perpetrated by a stranger (e.g., theft, fraud) are therefore not considered elder abuse [3]. Elder abuse can be of various forms: physical; psychological/emotional, sexual; financial and material abuse; abandonment; neglect; and serious loss of dignity and respect [4].

General Principles

Definition and Background

Elder abuse is generally defined as the maltreatment of individuals over the age of 60 [1]. The World Health Organization (WHO) recognizes elder abuse as “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” [2]. Instances of abuse toward older adults perpetrated by a stranger (e.g., theft, fraud) are therefore not considered elder abuse [3]. Elder abuse can be of various forms: physical; psychological/emotional, sexual; financial and material abuse; abandonment; neglect; and serious loss of dignity and respect [4].

The American share of the older population over 65 is expected to increase from 16.6% in 2020 to 22.4% by 2050 [5]. Similarly, the global share of older people is projected to increase from 9.3% in 2020 to 15.6% in 2050 [5]. In parallel, aging of the global population will likely result in an increased prevalence of elder abuse around the world [1, 3, 6]. Global prevalence rates of overall elder abuse were reported to be 10–15.6% and 34% for self-report and third-party reports, respectively [7, 8]. Geographical differences were seen in those prevalence estimates with the highest rates in Asia at 20.2%, moderate numbers in Europe at 15.4%, and a lower reported prevalence in the Americas at 11.7% [1, 8]. However, these estimates may be inaccurate due to the lack of clear definitions, reporting guidelines, and reliance on self-reports from those who are able to participate in surveys. This may exclude vulnerable patients who are at greater risk for mistreatment [1]. Thus, a busy family physician caring for older adults is likely to encounter victims of elder abuse on a regular basis.

Disturbingly, only 1 in 23 cases of elder abuse were reported to Adult Protective Services (APS) agencies and fewer than 2% of reports and neglect came from physicians, suggesting that physicians may lack training, experience, education, and adequate guidelines for the assessment and management of abuse [9, 10].

Elder abuse causes fear, depression, stress, isolation, sleep disorders, disability, and increases the risk for suicide and death. Victims of abuse have a mortality rate three times higher than non-victims [3, 9, 11].

Despite growing awareness and concern regarding elder abuse, the US Preventive Services Task Force (USPSTF) concluded in 2018 that the current evidence was insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older or vulnerable adults. Further, The USPSTF found no valid reliable screening tools in the primary care setting to identify abuse of older or vulnerable adults without recognizable signs and symptoms of abuse [12]. The American Medical Association, on the other hand, encourages physicians to inquire about abuse routinely. The National Center on Elder Abuse suggested that primary care settings may provide a valuable opportunity for elder abuse screening as elders are frequently seen for common conditions associated with aging [13, 14]. Despite the discordance in screening guidelines, physicians might be confronted with situations that arouse suspicions of abuse [15].

This chapter discusses the definitions of abuse, risk factors for abuse associated with both the elderly and their caregivers, barriers that elderly patients and their physicians face when dealing with abuse issues, assessment of suspected elderly abuse victims, reporting guidelines, and prevention strategies.

Categories of Abuse

The Centers for Disease Control and Prevention (CDC) and a diverse group of elder abuse experts collaboratively produced version 1.0 of uniform definitions and recommended core data elements of the major types of elder abuse as follows [4, 9]:

Physical abuse: The intentional use of physical force that results in acute or chronic illness, bodily injury, physical pain, functional impairment, distress, or death. This includes pushing, slapping, kicking, spitting, hitting, misusing medications, force feeding, and using restraints. These physical acts may cause bruising, cuts, lacerations, sprains, hair loss, missing teeth, fractures, burns, and other traumatic injuries.

Sexual abuse: Forced and/or unwanted sexual interaction (touching and non-touching acts) of any kind with an older adult. It includes rape, unwanted touching, sexual advances, or innuendo. Victims may suffer from trauma around the anus, vagina, breasts, and mouth.

Emotional/psychological abuse: Verbal or nonverbal behavior that results in the infliction of anguish, mental pain, fear, or distress. It includes humiliation/disrespect, threats, harassment, isolation, or coercive control. Threats to institutionalize or withhold medication, nutrition, or hydration are also included in this category. Victims often display feelings of depression, withdrawal, and apathy.

Financial abuse/exploitation: The illegal, unauthorized, or improper use of an older individual’s resources. This includes, but is not limited to, depriving an older individual of rightful access to, information about, or use of personal benefits, resources, belongings, or assets. It consists of overpayment for goods or services; unexplained changes in power of attorney, wills, or legal documents; missing checks or money; or missing belongings.

Neglect: Failure to protect an elder from harm or the failure to meet needs for essential medical care, nutrition, hydration, hygiene, clothing, basic activities of daily living or shelter, which results in a serious risk of compromised health and/or safety, relative to age, health status, and cultural norms. Neglect may be intentional or unintentional, and it might also occur within retirement homes, assisted living facilities, nursing homes, and hospitals [15] .

Self-neglect: Is frequently omitted or reported separately in statistical summaries. It has been described as “the behavior of an elderly person that threatens his/her own health and safety.” It is not unique to seniors and it might be reflective of problems that fall outside the realm of elder abuse [15].

There is some disagreement in the literature as to the most common form of elder abuse. Nonetheless, recent meta-analyses have shown that emotional abuse was the most common, followed by financial abuse, neglect, and then physical abuse [1, 7, 8]. Sexual abuse was the least often reported, likely due to failure to screen for or lack of disclosure by victims [1, 7, 8]. Cultural or regional differences might have been found in incidence and reporting of the abuse subtypes due to differences in cultural norms that in turn could influence abuse perception and outcomes. However, a possible association between elder abuse, culture, and ethnicity is inconsistent across the literature [16].

Risk Factors

Evidence supports a multifactorial etiology of elder abuse involving victim vulnerability and perpetrator risk factors, and factors related to their relationship and the environment [1, 3, 17].

Victim vulnerability factors: Dependency, poor physical health, cognitive impairment, low socioeconomic status, gender, age, and race/ethnicity are some of the most commonly cited vulnerability factors [1, 18]. Dependency can be functional, financial, social, or emotional in nature [3]. Physical and cognitive disability have been associated with a greater risk of elder abuse as they impair their ability to seek help, impair decision-making capabilities, and limit autonomy [19]. Patients with dementia are more likely to be victims of financial exploitation [9, 20]. Women are more likely to be victims of abuse as they have a longer lifespan that might increase their risk of dependence and cognitive impairment in old age [1, 7, 18]. Elder abuse is also more common in minority older adults compared to whites [21]. In particular, older lesbian, gay, bisexual, and trans (LGBT) people are more likely to have known vulnerability factors, such as loneliness, lower likelihood to be partnered and to have children, which puts them at higher risk of abuse compared to their heterosexual peers [22].

Perpetrator risk factors: Perpetrators are most likely to be adult children or spouses, and they are more likely to be males, to have a history of substance abuse, to have mental or physical health problems, to be socially isolated, to have financial problems with dependence on the victim, and to be experiencing major stress especially caregiver burnout and poor coping skills [1, 15, 18].

Relating to the relationship: A conflictual relationship between the victim and the perpetrator has been consistently identified as a vulnerability factor for elder abuse [3].

Relating to the environment: Lack of social support, living with a larger number of household members other than a spouse, and living in a facility rather than in the community are associated with higher rates of abuse [1, 3].

A good screening history by the family physician is needed to uncover a possibility of a neuropsychiatric disease in the victim, and to reveal a potential perpetrator especially if the caregiver becomes exhausted and overwhelmed over time.

Challenges to Identification

Patient-Related Challenges

Victims of elder abuse usually face many obstacles when disclosing abuse because it is being perpetrated primarily behind closed doors and by family members. Some patients have physical or cognitive barriers or are socially isolated which not only renders them at risk of abuse but also makes their recognition challenging [23]. Other barriers to seeking help include fear of consequences for self and the perpetrator, especially if it is a close family member; victims might be afraid of retaliation or worsening of the abuse and their relationship with their family, of being abandoned, isolated, or institutionalized [24]. They also might be physically frail or have socioeconomic dependency on the perpetrator in addition to feelings of shame and embarrassment, self-blame, low self-esteem, helplessness, and the stigma associated with seeking help [9]. Also, they may have doubts about the capacity and adequacy of services to help them, a lack of trust in professionals, and accessibility were some other barriers reported [23, 24].

Physician-Related Challenges

The challenges doctors face in detecting elder abuse are mainly due to lack of awareness about elder abuse and its prevalence [25]. Many physicians may not be able to detect the signs of elder abuse, much less how to screen for it, and especially ascribing the subtle signs of abuse to the vicissitudes of “normal” aging [26]. Ageism acts as a type of prejudice that both justifies abusive behavior against older people and leads to overlooking the consequences it has on them. It impedes the prevention and early identification of elder abuse [26, 27]. Fear of legal and ethical consequences are not to be disregarded especially when the victim is not willing to share information with the authorities [25, 28]. Training family physicians to screen for risk factors contributes to early detection and intervention and thus prevents further abuse [9].

Assessment

History and Physical Examination

Family physicians may have well-established relationships with older adults and their families that allow them to recognize potential abuse provided that they maintain a high level of suspicion. They should work with multidisciplinary teams to ensure thorough assessment, intervention, and follow-up of elderly patients [29].

During the consultation, it is helpful to interview the patient and caregiver together and separately to detect disparities offering clues to the diagnosis [30]. Interviewing the victim alone helps mitigate the fear of retaliation and shame that might otherwise hinder disclosure [10]. If a language barrier exists, a professional translator should be used rather than the caregivers or family members [30].

A complete history is the key; it should start with open-ended questions such as “Can you tell me what happened?” and further questions should be neutral and nonjudgmental to encourage patients and caregivers to provide detailed information [10]. The history should focus on current health status, living arrangements, emotional stressors, social support, medication review, and financial status [30]. All vulnerability and risk factors for abuse should, also, be inquired about as well as the patient’s functional status, cognition, care needs, and safety of the home environment [10, 30]. Screening for depression and social isolation should not be overlooked [31].

Behavioral signs that may offer clues that suggest elder abuse include poor eye contact, anxiety, low self-esteem, and helplessness [30]. A caregiver who often interrupts the patient to answer questions for him or her or appears reluctant to leave the patient alone might be a potential perpetrator [30, 32]. Nonetheless, interruptions during history taking may be compensatory for the patient’s cognitive impairment and do not always indicate abuse [10]. Moreover, physicians should be able to differentiate signs of injuries from disease processes and normal aging. These include allergic reactions, osteoporotic fractures, vaginal bleeding due to atrophy, and anorexia caused by mental illness [10, 19].

The physical examination should be comprehensive, with the patient completely undressed in order to perform a full dermatological evaluation including fingernails and toenails [30]. The clinical manifestations of elder abuse are difficult to identify and vary by type of abuse. However, general signs suggestive of abuse and neglect might include signs of dehydration and malnutrition, poor hygiene and physical care, and signs of psychological distress [19].

Patterns of injury such as ligature marks, multiple burns and bruises, of different sizes and ages, found on the abdomen, neck, posterior legs, or medial arms, as well as the presence of unusual or unexplained fractures are suggestive of physical abuse, whereas sexually transmitted infections, unexplained vaginal/rectal bleeding or pain in the oral or anal–genital regions are suggestive of sexual assault that mandates forensic examination [10, 16]. Mobility assessment helps ascertain the actual cause of injuries from reported falls, while cognitive assessment using the Mini-Cog test helps screen for a possible dementia [10, 19, 33].

The comprehensiveness of the physical examination should be coupled with a meticulous documentation of all findings including the patient’s statements, behavior, appearance, and body charts or clinical photographs of the location and morphology of injuries [10, 29].

Radiographs should be obtained when possible if fractures are suspected along with a CT scan if the patient has suffered a head injury. If clinical findings suggest malnutrition, then laboratory testing (e.g., complete blood count, blood urea nitrogen, creatinine, total protein, and albumin levels) should be requested to document consistent findings [19]. Serum drug levels help uncover possible poisoning, under treatment or inappropriate use of medications [10].

Management and Reporting Guidelines

Despite the presence of several tools that have been validated for elder abuse evaluation and management, there is currently no gold standard tool [14, 32]. The Elder Abuse Suspicion Index (EASI) was validated in a primary care setting to screen for abuse in cognitively intact patients. The EASI has five patient-answered items, plus one physician question with a marginal sensitivity of 0.47 and a specificity of 0.75 [14, 15, 34]. Figure 1 shows a suggested algorithm for the management of suspected elder abuse.
Fig. 1

Management of suspected elder abuse (Adapted from Refs. [10] and [29])

A positive screen for elder abuse does not unequivocally indicate abuse, but it mandates referral for complete multidisciplinary functional assessments that may include home visits by local social workers, concerned family or friends, or Adult Protective Services (APS) authorities [1, 10]. Importantly, clinicians do not have to prove that elder mistreatment has occurred; they need only document a reasonable cause to suspect that it has [29]. After that, physicians need to ensure safety of the victim and report the case. Reporting is not federally mandated but is regulated by state governments; nearly all states have enacted mandatory reporting laws whereas pertinent statutes may vary [29]. Failure to report, however, can be considered negligence and is potentially punishable by fines, imprisonment, or loss of license [19]. Providing educational material for patients and families that includes a description of the warning signs of caregiver stress and available community supportive services is also an effective reporting approach. Even when law enforcement becomes involved, family physicians still bear significant responsibility for follow-up medical care of patients [10].

Online resources available to assist physicians with elder abuse include Eldercare Locator (https://eldercare.acl.gov/Public/Index.aspx), the Administration on Aging, American Medical Association, and the National Centre on Elder Abuse [10, 14].

Prevention

Elder abuse is a complex, multifaceted problem, and preventive strategies should be applied at many levels including public education and awareness. Early multidisciplinary intervention and education on resources and community support can be implemented to preserve elders’ emotional well-being [9, 35, 36]. Home care clinicians can play an important role in prevention through astute observation of patients, their behaviors, and environment which alerts clinicians to potential abuse [9].

Conclusion

Family physicians may have well-established relationships with older adults and their families that allow them to recognize potential abuse and neglect [29]. They are likely to encounter elder abuse in their practice, hence early identification and intervention are essential to avoid catastrophic events and to save lives.

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Copyright information

© Springer Science+Business Media LLC 2020

Authors and Affiliations

  • Lana Alhalaseh
    • 1
    Email author
  • Asma Abu-Zanat
    • 2
  • Maram Alsmairat
    • 2
  1. 1.The University of JordanAammanJordan
  2. 2.Department of Family and Community MedicineUniversity of JordanAammanJordan

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