Kaleigh Hubert, BS, BA

In its simplest form, elder abuse refers to the intentional infliction of injury or neglect of an older adult by a caregiver. The 5 primary types of elder abuse include neglect, physical, financial, psychological/emotional, and sexual, with a subtype of social abuse that falls under psychological/emotional abuse.

Differentiating abuse from the normal sequelae of physiologic aging can be difficult; therefore, early identification and awareness of risk factors is key, as well as detailed documentation of the patient encounter. As soon as abuse is suspected, clinicians should report it to Adult Protective Services (APS) for further investigation. In terms of prevention, regular screening for elder abuse is still up for debate, but as the incidence of elder abuse continues to rise so should research and preventive efforts to combat this growing public health concern.
What is ‘elder abuse’?According to the Elder Abuse Prevention, Identification, and Treatment Act of 1985, elder abuse is:
…willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness.¹

There are 2 main components to this definition:
   • an older adult has suffered injury or deprivation
   • another person is responsible for causing or failing to prevent it.²

Although definitions vary, it generally is accepted that, for elder abuse to occur, it must take place within a relationship of trust.³

An ‘older adult’ is a person age ≥65, representing 14% of the U.S. population.⁴
According to U.S. Census Bureau data, there were 40 million older adults in 20105;
recent data project that this number will rise to 90 million by 2060 as Baby Boomers age.⁶ Studies suggest that as many as 10% of older adults in the United States experience elder abuse each year²; one study estimated that 6% of older adults in the community experienced significant abuse in the past month.⁷

Although elder abuse can occur in any setting, it takes place most often in the community. A survey of state APSs in 2000 showed that 60.7% of abuse was domestic; only 8.3% of incidents occurred in institutional settings.⁸ The annual direct medical costs associated with elder abuse injury in the United States are estimated at $5.3 billion, which is likely to increase with anticipated growth of the geriatric population.⁹

Although the number of older adults and the incidence of elder abuse are on the rise, as few as 1 in 14 cases is reported to authorities¹⁰; health care providers are some of the least likely of involved parties to report suspected abuse. One study found that 63% of physicians never asked about elder abuse, and only 31% reported encountering it in the previous 12 months.¹¹ A busy clinician—ie, one who sees 20 to 40 geriatric patients a day—has a high likelihood of encountering at least 1 victim of elder abuse,² yet many cases go unrecognized.
Types of abuseElder abuse comprises 5 categories¹²:
   • neglect (58.5% of cases)
   • physical (15.7%)
   • financial (12.3%)
   • psychological and emotional (7.3%)
   • sexual (0.04%).

Social abuse is considered a subtype of psychological and emotional abuse. All “other” types of abuse constitute 5.1% cases; 0.06% are of unknown type.¹²

Neglect is (1) failure of the caregiver to provide life necessities or (2) the responsible person’s refusal to permit others to provide appropriate care.³ This is one of the most common types of elder abuse in residential facilities. Signs of neglect include dehydration, depression, fecal impaction, and malnutrition (Table).⁴ The prevalence of dehydration in nursing home patients is reported to be as high as 35%, which may be the result of passive or active withholding of liquids (ie, decreasing hydration to reduce the need to change the resident’s clothing or bedding).⁴ Other forms of neglect include medication misuse (overdosing or underdosing) and self-neglect, which occurs among people living alone and often is listed as a subtype of neglect, but is controversial because it does not involve another person.
 

Physical abuse is a non-accidental act that results in physical pain or injury,³ including bruises, fractures, and burns. Physical abuse is among the most common types of abuse in nursing homes; it has been suggested that approximately 4.8% of residents experience physical abuse that results in a police investigations.¹³ New research describes resident-on-resident abuse as one of the most prevalent causes of physical abuse.¹⁴ Dementia and cognitive decline complicate resident-on-resident abuse, particularly from the standpoint of treating aggression.

Financial exploitation is the illegal or improper use, or mismanagement, of a person’s money, property, or financial resources³—often, to his (her) detriment. Estimates are that 1 of every 20 older adults has been subject to financial abuse at some point in their life.¹⁵ There should be a high index of suspicion for financial exploitation when one notices unexplained changes in power of attorney, wills, or other legal documents; missing checks, money, or belongings.¹⁶ In the past, adult children were most likely to be financial abusers; in recent years, however, the abuser is more often a spouse—especially a second spouse.¹⁷ Bankers, accountants, and other financial advisors are among those trained to identify risk factors for financial abuse; they are encouraged to caution clients about this possibility.¹⁸

 

Psychological and emotional abuse occurs when a caregiver inflicts mental stress on an older adult by actions and threats that cause fear, violence, isolation, deprivation, or feelings of shame and powerlessness.³ Examples are threatening to put the older adult in a nursing home or verbally abusing him (her). Suspect this type of abuse when a caregiver refuses to leave the older adult or speaks for him, or if the older adult expresses fear in the presence of the caregiver.⁴ This type of abuse also is prevalent in nursing homes and other long-term care facilities.¹⁹

Sexual abuse involves nonconsensual touching or sexual activities (rape, language, exploitive behavior) that are threatened or forced on an older adult.¹⁶ Sexual abuse is more common in frail or dependent persons.³ Physical exam findings—particularly dysuria, tender genitalia, and evidence of sexually transmitted infections⁴—are required to identify sexual abuse, along with signs of depression and display of fear.

Social abuse can be considered a subtype of psychological and emotional abuse, in which a caregiver denies an older adult contact with family and friends or deprives him from access to transportation. Other examples include not allowing the older adult to use the telephone, monitoring phone calls, and claiming that his friends or family are “interfering.”²⁰ Intentionally embarrassing an older adult in front of others also can be considered social abuse.

Technology, particularly smart phones and social media, can complicate and exacerbate elder abuse:
   • In July 2013, employees of a Wisconsin nursing home were found with videos and photographs of residents bathing and of a nude resident who had a bowel obstruction being mocked.²¹
   • In May 2014, employees of a nursing home in Massachusetts recorded themselves physically and verbally abusing several older adults with Alzheimer’s disease, including one episode of the employees “hitting the woman on her arms, flicking her ears and then pinching the woman’s nose closed.” The employees also possessed a photograph of her naked.²²
   • In June 2015, an employee of a nursing home in Indiana was accused of taking
photos of a resident naked and sharing them on the messaging application Snapchat,²³ in which images disappear 10 seconds after they are viewed.

As technology evolves, caregivers are finding more cunning ways to abuse older adults. Considering current events and trends in this area, technology as a gateway to elder abuse should be of growing concern.
Risk factorsA 2013 literature review on elder abuse reported that the most important risk factors are related to relationship (family disharmony, poor or conflicting relationships) and environment (a low level of social support),³ although other variables can play a role. Regardless of these findings, it is important to recognize that (1) elder abuse is not a necessary consequence in a family with many risk factors and (2) elder abuse can occur in the absence of any risk factors.

As a whole, women are at a higher risk of abuse, particularly when combined with loneliness, poor social support, cohabitation (especially family members), substance abuse, cognitive impairment, and dementia and other mental health problems.⁴ Other risk factors include functional deficiency, poor physical health or frailty, low income or wealth, and trauma or past abuse.³

Lower income, poor health, low social support, and belonging to a non-white racial group put an older adult at risk for neglect; female sex is a specific risk factor for sexual assault.¹⁵ One study found that, among older adults who suffered physical, mental, or cognitive impairment, 1 of every 4 was at risk of abuse.⁷

Mental illness. Dementia puts an older adult at higher risk because of increased
caregiver stress resulting from disruptive and aggressive behaviors²; the same is true when the older adult suffers another mental illness, such as anxiety, depression, schizophrenia or bipolar disorder. Presumably, older adults with any of these disorders are at risk of financial and psychological and emotional abuse because of their decreased social support, lack of independence, and inability to hold a job—leaving their caregiver to shoulder more responsibilities and with more opportunities to inflict abuse. In addition, an older adult suffering from depression can feel helpless and unworthy, possibly making him more susceptible to psychological and emotional abuse, and less likely to seek help.

More research is needed to establish racial and ethnic differences in the risk of abuse. Some research states that older adults who are a member of a minority are at greater risk of abuse; however, the difference dissipates after adjusting for variables such as income and social support.²⁴ Cultural confounders, such as varying interpretations of the same set of interactions between older adults, need to be examined further.

 

Sexual orientation. Identifying one’s self as a lesbian, gay, bisexual, or transgender (LGBT) person is an additional risk factor for elder abuse. In 1997, a report described a nursing home employee who refused to bathe a resident because he didn’t want to “touch the lesbian.”²⁵ Despite evolving attitudes in society toward support and acceptance of sexual orientation, fear of homophobia still prevents some LGBT older adults from seeking help when they have been abused because of their orientation—especially ones who have internalized that
homophobia and feel that they are unworthy of seeking help.²⁵

In addition, health care providers and nursing home staff members might neglect the particular care needs of LGBT older adults, intentionally or unintentionally. APS staff and providers must be cognizant of underlying biases and exhibit respect when assisting LGBT clients.

Approximately 75% of caregivers of older adults are family members; 70% are female²⁶; and most are adult children, spouses, and partners of those receiving care.²⁷ Male caregivers age ≥40 are more likely to be the abuser, however, especially when they possess any of these risk factors: fatigue, burnout, medical illness, mental illness, lack of financial and support services, family history of abusive behavior, and substance abuse.4 People who commit elder abuse also tend to be significantly dependent on the person they are abusing.² In some cases, and especially when the abuser is financially needy, caregivers turn to elder abuse to obtain resources from the victim.²

From your standpoint as a practitioner, it is important to determine the root cause of elder abuse. According to one review,²⁸ family members with mental illness or a history of substance abuse, or who are stressed by the burden of caregiving, abuse older adults at a higher rate than family members who are not affected in those ways. Depression in particular is a common characteristic of abusers,² often secondary to the stress of caring for an older adult.

Abuse caused by stress can be addressed by referral to a support group and counseling for the caregiver; psychiatric conditions, such as depression, might be better treated with pharmacotherapy. Evaluate for depression and posttraumatic stress disorder (PTSD) in both the abuser and the abused,²⁹ and for other mental health issues that might compound the situation. It is possible for you to have 2 patients: the older adult and his caregiver. Regardless of the challenge,keep in mind that the older adult’s safety is your priority.
Consequences for the abusedThe abused adult is at risk of a number of serious physical and psychological consequences.³⁰ They tend to have a shorter lifespan, after adjusting for other variables associated with increased mortality.

The reason for shortened lifespan is multifactorial³⁰:
   • Bruises, abrasions, and fractures may take longer to heal because of diminished skin and bone regeneration.
   • Diseases that affect the heart, lungs, and kidneys might prevent the person from bouncing back from major stressors caused by abuse, such as blood loss, severe injury, and pain.
   • Injury from abuse can exacerbate an underlying illness.
   • Elder abuse also is associated with increased emergency department use, hospitalization (including readmission within 30 days), and nursing home placement.³¹

Elder abuse can lead to depression, shame, and guilt; increased isolation; and
increased risk of alcohol abuse and substance use.³¹ A study found that victims of
elder abuse are significantly more depressed than non-victims.³²

In the same study, being a victim of abuse was found to be the second-strongest
predictor of depression, after the state of one’s health.³² Other potential psychiatric
consequences of abuse that need further study include increased risk of developing
fear and anxiety disorders; learned helplessness; and PTSD.³³ According to LoFaso,
“depression and anxiety can consume their days and leave them emotionally and
physically frail.”29 Such feelings make these older adults less likely to resolve abuse or break off relations with the abuser.³²

Because mental illness can be a risk factor for, and a consequence of, elder abuse,
be aware of such complications and address them appropriately. Keep in mind that older adults are more likely to visit a primary care practitioner than a psychiatrist for a routine health check-up or evaluation of initial cognition-related problems; however, they are more likely to see a psychiatrist for advanced neuropsychiatric problems such as dementia, paranoia, delusions, hallucinations, and insomnia. Adequate education on elder abuse should not be limited to a single medical specialty because it can present in several clinical settings.
Identifying abuseIdentification of elder abuse in the home poses a greater challenge to clinicians than abuse in an institutional setting because it is not directly observable. Compounding this is the lack of unified standards for identifying and dealing with elder abuse. It is first necessary for you to determine the likelihood that abuse or neglect occurred, which can be difficult because the signs of elder abuse and manifestations of normal aging often are similar. You also must establish whether (1) the abused person will accept intervention and (2) the abused person who refuses intervention has the capacity to make that decision. Both of these conditions will guide your approach to management.²

 

Obtain the history from several sources; review the records; and carefully examine patterns of injury, in particular assessing functional status and level of dependency on the caregiver. Explanations that do not match injuries signal the need for further investigation and examination.

To help differentiate elder abuse from normal physiologic aging, look at the skin for bruises, rashes that do not heal, and ulcers—all of which could be signs of abuse or neglect. Keep in mind that bruising generally is more common in older adults because of the slower turnover rate of epidermal cells; physiologic bruising tends to occur on dorsal aspects of the hands and arms.⁴ In contrast, bruising secondary to neglect or physical abuse can manifest as a subgaleal hematoma (caused by traumatic hair pulling), tracking in the peritoneum after genital trauma, Battle’s sign, and raccoon eyes, among other findings.⁴

In addition, larger bruises (>5 cm in diameter) are more likely the result of elder abuse.³⁴ To complicate matters, many older persons are taking anticoagulant therapy, making bruising more likely. In addition, be on the lookout for burns during the physical exam. Evidence suggests that at least 10% of burns caused by battery and assault occur in the context of elder abuse; most burn facilities do not have formal guidelines for screening for abuse and neglect, however.³⁵ According to one retrospective study, the most common causes of burns in older adults are hot water scalds and radiator contact, and the mortality rate of older burn patients in general is higher than among the overall population.³⁶

Falls and fractures are common among older adults, regardless of whether they are
abused, because of polypharmacy, underlying medical conditions, and functional
limitations. Many abusers, however, use these factors to cover up intentional injury
that might have resulted in the older person falling, including overmedication (a form of physical abuse) and withholding a necessary walking aid (a form of neglect). Maintain a high index of suspicion of elder abuse when (1) the caregiver’s and the older adult’s stories of an injury don’t add up and (2) physical findings that might have been caused by abuse are present.

A number of psychiatric and cognitive symptoms suggest other types of elder abuse. Take note of emotional upset, agitation, and unusual behaviors³⁷—especially if you can follow the patient over time to observe marked changes in the presentation. Likewise, be aware of proposed alterations in guardianship, which should be evaluated by a forensic psychiatrist with analysis of medical history, social attachments, home environment, self-care, and finances.³⁸ Such evaluation should provide clues to the motivation behind a change of guardianship and will help to determine if elder abuse should be suspected.

Brandi et al³⁷ provided an informative table that identifies pertinent signs, symptoms, and other findings that clinicians should be aware of to support a suspicion of elder abuse (Table).

Documentation is of utmost importance in evaluating potential elder abuse; keep in mind that the medical record might be used in an investigation of abuse by social workers, law enforcement, and prosecutors. Your records should be legible, clearly indicate who the main caregiver is and what his (her) responsibilities are, and specify who is present at your encounter with the patient.⁴ Document your observations of patient behavior, reactions to questions, and family dynamics and conflicts¹⁶; make note of warning signs such as fear, silence, and inability to interview the patient alone.

In addition to written documentation, take photographs of injuries, with a ruler in the image to record their size. Serial photographs are helpful; so are photographs from a variety of distances (close-up, regional, wholebody) to capture detail and place the wound in the context of a specific area of the body.⁴

Safety is paramount. Given the findings of the history and physical exam, it is necessary to determine whether it is safe for the patient to return home with the caregiver, or if alternate accommodations or resources, such as a social worker or a support group, are required. Include details of planned follow-up in your evaluation, and offer consideration of possible psychiatric disorders that can develop as a result of such abuse.
ReportingElder abuse is a criminal offense in all states.³⁹ A clinician who has reasonable suspicion that elder abuse occurred must report it, regardless of whether the proof of abuse is concrete.⁴⁰ At a point of reasonable suspicion, immediately contact APS, law enforcement, and a social worker. Adult Protective Services, modeled after Child Protective Services, is typically administered by local and state health
departments.⁴¹

After a report is filed with APS, an assigned social worker makes an in-person home visit to investigate the allegation and determine whether elder abuse is substantiated, partially substantiated, or unsubstantiated.¹⁶ In most states, elder abuse reporting is not anonymous because follow-up may be needed to provide additional evidence, especially if the report was made by a health care provider.¹⁶

 

No federal standard exists for states to follow when defining and addressing elder abuse, which can complicate identification and reporting of abuse. Laws governing elder abuse do not allow states to determine the fate of the older adult, who can decide for himself (herself) whether to use or waive protective services.⁴² Older adults might choose not to report abuse because of shame, intimidation, or fear,⁴³ or to protect a caregiver, who often is a family member.

Elder abuse reports can come from a variety of sources; convincing evidence is, as noted, unnecessary to report it. Health care providers are mandated reporters, but
it is believed that the number of clinicians who report elder abuse based on suspicion is far below what it should be. One study found that 94% of physicians said that they either were unable to prove that the abuse had occurred or decided not to report it.¹¹ Another study found that only 1.4% of elder abuse cases reported to APS come from physicians.⁴⁴

There are several possible reasons for underreporting elder abuse, including (1) the difficulty of distinguishing elder abuse and neglect from sequelae of normal aging and (2) the fact that cognitive and functional impairment of the abused person makes it difficult, even impossible, to establish the narrative of how the abuse happened. Nursing homes in particular provide a high level of oversight because residents have an average of ≥3 functional deficits.⁴ Other reasons for underreporting—some of which are difficult to understand, and excuse, in a clinician—are:
   • subtlety of signs
   • victim denial
   • ignorance of reporting procedures
   • inadequate training
   • lack of information about resources
   • concern about losing physician–patient rapport
   • concern about involvement in the legal system
   • time limitations
   • doubt about the effectiveness of APS.¹⁶
 

Assessing capacityThe older adult’s wishes must be respected unless a health care provider or the legal system determines that he lacks functional capacity to make decisions.¹⁶

How is capacity evaluated? A capacity evaluation has 3 components:
   • Comprehension is a person’s factual understanding of the situation, including
consequences and alternatives
   • Free choice is a person’s voluntary decision to accept or reject a proposed treatment, free of coercion (in this setting, free choice is the older adult’s decision whether to report the abuse)
   • Reliability is a person’s ability to provide a consistent choice over time.⁴⁵

Most capacity evaluations are conducted by clinical interview. No single, brief test is used universally, and there is the possibility of inter-rater variability.⁴⁵ Examples of tests used to assess capacity are the Folstein Mini-Mental Status Examination and the MacArthur Competence Assessment Tool-Treatment⁴⁵; the latter is a structured interview that incorporates information specific to the individual patient’s decision-making situation.⁴⁶ Regardless of the approach, the psychiatrist-evaluator ensures that the older adult has been given the appropriate information
to provide informed consent about the situation.⁴⁷

If the evaluator determines that a person lacks capacity to make decisions, efforts should be made to determine if the cause of that impairment is reversible.⁴⁷ Older adults who have dementia or other underlying psychiatric condition that impairs cognition might benefit from more education on their situation; ones who appear fearful of consequences should be introduced to a trusted advisor to assist in making competent judgments.⁴⁷

If the older adult is found to lack capacity, a substitute decision-maker must be sought.⁴⁷ Many states have statutes specifying the order in which family members are contacted.⁴⁸ The need to appoint an advisor can become knotty because the suspected abuser often is a family member; clinicians and others involved in identifying a decision-maker to speak on behalf of an older adult should choose carefully.
Prevention and screeningKey to reducing the prevalence of elder abuse in the community is formulating
strategies for prevention and screening. The American Medical Association recommends that clinicians “incorporate routine questions related to elder abuse and neglect into daily practice.”⁴⁹ Older adults might not admit to abuse or neglect unless they are asked; speak to patients at eye level, keep questions simple, direct, and nonjudgmental, and assure them (1) that discussions are confidential and (2) that their safety is your primary goal.^50,51

Comprehensive approaches to questioning patients are available and often recommended for screening for elder abuse.⁴ However, screening in the office setting often involves short, directly administered questionnaires.⁴⁹ For example, the Health and Safety Screen developed at the University of Maine comprises 6 questions⁵²:
   • Has anyone close to you called you names or insulted you recently?
   • Are you afraid of anyone in your life?
   • Are you able to use the telephone anytime you want to?
   • Has anyone forced you to do things you didn’t want to do?
   • Has anyone taken things or money that belong to you without your OK?
   • Has anyone close to you tried to hurt you or harm you recently?

 

Because of time constraints and lack of a universal standard, there is debate whether regular elder abuse screening is time-effective. It often is recommended, therefore, that clinicians in primary care (1) refer older adults with risk factors for abuse to geriatric medical teams trained in these measures and (2) perform periodic follow-up on such patients⁴ (Figure).

Because of limitations to regular screenings, the best method of prevention might be to raise awareness of elder abuse among clinicians and in the community. For example:
   • New York City Elder Abuse Center encourages collaboration among health, mental health, and community justice organizations.²⁸ The program involves a number of resources for addressing elder abuse, such as promoting staff awareness of risk factors for, and signs of, abuse, and screening for mental health problems in the abused.
   • The Elder Justice Act, enacted in 2010 to combat elder abuse, provides federal funds and resources to prevent, detect, treat, and intervene to stop abuse and, when appropriate, to prosecute abusers.⁵³

This Web Exclusive Table provides a 7-point summary reference guide for understanding and preventing elder abuse in your practice.

BOTTOM LINEIdentification of elder abuse can be difficult because signs and symptoms of abuse closely resemble physiologic aging. Older adults with identifiable risk factors should be screened for abuse; time constraints make universal screening impossible at this time. In the future, multidisciplinary approaches likely will make elder abuse more easily identifiable through the combined work of health care providers, law enforcement agencies, banks, and other institutions—with the ultimate goal of protecting older adults in the community from abuse.

Related Resources
• Frazão SL, Correia AM, Norton P, et al. Physical abuse against elderly persons in institutional settings. J Forensic Leg Med. 2015;36:54-60.
• Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.

 

Disclosures
Ms. Hubert reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Gupta is a member of the speakers’ bureau of Alkermes, Allergan, Avanir Pharmaceuticals, Takeda Pharmaceutical, Lundbeck, Otsuka Pharmaceutical, and Sunovion Pharmaceuticals.

In its simplest form, elder abuse refers to the intentional infliction of injury or neglect of an older adult by a caregiver. The 5 primary types of elder abuse include neglect, physical, financial, psychological/emotional, and sexual, with a subtype of social abuse that falls under psychological/emotional abuse.

Differentiating abuse from the normal sequelae of physiologic aging can be difficult; therefore, early identification and awareness of risk factors is key, as well as detailed documentation of the patient encounter. As soon as abuse is suspected, clinicians should report it to Adult Protective Services (APS) for further investigation. In terms of prevention, regular screening for elder abuse is still up for debate, but as the incidence of elder abuse continues to rise so should research and preventive efforts to combat this growing public health concern.
What is ‘elder abuse’?According to the Elder Abuse Prevention, Identification, and Treatment Act of 1985, elder abuse is:
…willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness.¹

There are 2 main components to this definition:
   • an older adult has suffered injury or deprivation
   • another person is responsible for causing or failing to prevent it.²

Although definitions vary, it generally is accepted that, for elder abuse to occur, it must take place within a relationship of trust.³

An ‘older adult’ is a person age ≥65, representing 14% of the U.S. population.⁴
According to U.S. Census Bureau data, there were 40 million older adults in 20105;
recent data project that this number will rise to 90 million by 2060 as Baby Boomers age.⁶ Studies suggest that as many as 10% of older adults in the United States experience elder abuse each year²; one study estimated that 6% of older adults in the community experienced significant abuse in the past month.⁷

Although elder abuse can occur in any setting, it takes place most often in the community. A survey of state APSs in 2000 showed that 60.7% of abuse was domestic; only 8.3% of incidents occurred in institutional settings.⁸ The annual direct medical costs associated with elder abuse injury in the United States are estimated at $5.3 billion, which is likely to increase with anticipated growth of the geriatric population.⁹

Although the number of older adults and the incidence of elder abuse are on the rise, as few as 1 in 14 cases is reported to authorities¹⁰; health care providers are some of the least likely of involved parties to report suspected abuse. One study found that 63% of physicians never asked about elder abuse, and only 31% reported encountering it in the previous 12 months.¹¹ A busy clinician—ie, one who sees 20 to 40 geriatric patients a day—has a high likelihood of encountering at least 1 victim of elder abuse,² yet many cases go unrecognized.
Types of abuseElder abuse comprises 5 categories¹²:
   • neglect (58.5% of cases)
   • physical (15.7%)
   • financial (12.3%)
   • psychological and emotional (7.3%)
   • sexual (0.04%).

Social abuse is considered a subtype of psychological and emotional abuse. All “other” types of abuse constitute 5.1% cases; 0.06% are of unknown type.¹²

Neglect is (1) failure of the caregiver to provide life necessities or (2) the responsible person’s refusal to permit others to provide appropriate care.³ This is one of the most common types of elder abuse in residential facilities. Signs of neglect include dehydration, depression, fecal impaction, and malnutrition (Table).⁴ The prevalence of dehydration in nursing home patients is reported to be as high as 35%, which may be the result of passive or active withholding of liquids (ie, decreasing hydration to reduce the need to change the resident’s clothing or bedding).⁴ Other forms of neglect include medication misuse (overdosing or underdosing) and self-neglect, which occurs among people living alone and often is listed as a subtype of neglect, but is controversial because it does not involve another person.
 

Physical abuse is a non-accidental act that results in physical pain or injury,³ including bruises, fractures, and burns. Physical abuse is among the most common types of abuse in nursing homes; it has been suggested that approximately 4.8% of residents experience physical abuse that results in a police investigations.¹³ New research describes resident-on-resident abuse as one of the most prevalent causes of physical abuse.¹⁴ Dementia and cognitive decline complicate resident-on-resident abuse, particularly from the standpoint of treating aggression.

Financial exploitation is the illegal or improper use, or mismanagement, of a person’s money, property, or financial resources³—often, to his (her) detriment. Estimates are that 1 of every 20 older adults has been subject to financial abuse at some point in their life.¹⁵ There should be a high index of suspicion for financial exploitation when one notices unexplained changes in power of attorney, wills, or other legal documents; missing checks, money, or belongings.¹⁶ In the past, adult children were most likely to be financial abusers; in recent years, however, the abuser is more often a spouse—especially a second spouse.¹⁷ Bankers, accountants, and other financial advisors are among those trained to identify risk factors for financial abuse; they are encouraged to caution clients about this possibility.¹⁸

 

Psychological and emotional abuse occurs when a caregiver inflicts mental stress on an older adult by actions and threats that cause fear, violence, isolation, deprivation, or feelings of shame and powerlessness.³ Examples are threatening to put the older adult in a nursing home or verbally abusing him (her). Suspect this type of abuse when a caregiver refuses to leave the older adult or speaks for him, or if the older adult expresses fear in the presence of the caregiver.⁴ This type of abuse also is prevalent in nursing homes and other long-term care facilities.¹⁹

Sexual abuse involves nonconsensual touching or sexual activities (rape, language, exploitive behavior) that are threatened or forced on an older adult.¹⁶ Sexual abuse is more common in frail or dependent persons.³ Physical exam findings—particularly dysuria, tender genitalia, and evidence of sexually transmitted infections⁴—are required to identify sexual abuse, along with signs of depression and display of fear.

Social abuse can be considered a subtype of psychological and emotional abuse, in which a caregiver denies an older adult contact with family and friends or deprives him from access to transportation. Other examples include not allowing the older adult to use the telephone, monitoring phone calls, and claiming that his friends or family are “interfering.”²⁰ Intentionally embarrassing an older adult in front of others also can be considered social abuse.

Technology, particularly smart phones and social media, can complicate and exacerbate elder abuse:
   • In July 2013, employees of a Wisconsin nursing home were found with videos and photographs of residents bathing and of a nude resident who had a bowel obstruction being mocked.²¹
   • In May 2014, employees of a nursing home in Massachusetts recorded themselves physically and verbally abusing several older adults with Alzheimer’s disease, including one episode of the employees “hitting the woman on her arms, flicking her ears and then pinching the woman’s nose closed.” The employees also possessed a photograph of her naked.²²
   • In June 2015, an employee of a nursing home in Indiana was accused of taking
photos of a resident naked and sharing them on the messaging application Snapchat,²³ in which images disappear 10 seconds after they are viewed.

As technology evolves, caregivers are finding more cunning ways to abuse older adults. Considering current events and trends in this area, technology as a gateway to elder abuse should be of growing concern.
Risk factorsA 2013 literature review on elder abuse reported that the most important risk factors are related to relationship (family disharmony, poor or conflicting relationships) and environment (a low level of social support),³ although other variables can play a role. Regardless of these findings, it is important to recognize that (1) elder abuse is not a necessary consequence in a family with many risk factors and (2) elder abuse can occur in the absence of any risk factors.

As a whole, women are at a higher risk of abuse, particularly when combined with loneliness, poor social support, cohabitation (especially family members), substance abuse, cognitive impairment, and dementia and other mental health problems.⁴ Other risk factors include functional deficiency, poor physical health or frailty, low income or wealth, and trauma or past abuse.³

Lower income, poor health, low social support, and belonging to a non-white racial group put an older adult at risk for neglect; female sex is a specific risk factor for sexual assault.¹⁵ One study found that, among older adults who suffered physical, mental, or cognitive impairment, 1 of every 4 was at risk of abuse.⁷

Mental illness. Dementia puts an older adult at higher risk because of increased
caregiver stress resulting from disruptive and aggressive behaviors²; the same is true when the older adult suffers another mental illness, such as anxiety, depression, schizophrenia or bipolar disorder. Presumably, older adults with any of these disorders are at risk of financial and psychological and emotional abuse because of their decreased social support, lack of independence, and inability to hold a job—leaving their caregiver to shoulder more responsibilities and with more opportunities to inflict abuse. In addition, an older adult suffering from depression can feel helpless and unworthy, possibly making him more susceptible to psychological and emotional abuse, and less likely to seek help.

More research is needed to establish racial and ethnic differences in the risk of abuse. Some research states that older adults who are a member of a minority are at greater risk of abuse; however, the difference dissipates after adjusting for variables such as income and social support.²⁴ Cultural confounders, such as varying interpretations of the same set of interactions between older adults, need to be examined further.

 

Sexual orientation. Identifying one’s self as a lesbian, gay, bisexual, or transgender (LGBT) person is an additional risk factor for elder abuse. In 1997, a report described a nursing home employee who refused to bathe a resident because he didn’t want to “touch the lesbian.”²⁵ Despite evolving attitudes in society toward support and acceptance of sexual orientation, fear of homophobia still prevents some LGBT older adults from seeking help when they have been abused because of their orientation—especially ones who have internalized that
homophobia and feel that they are unworthy of seeking help.²⁵

In addition, health care providers and nursing home staff members might neglect the particular care needs of LGBT older adults, intentionally or unintentionally. APS staff and providers must be cognizant of underlying biases and exhibit respect when assisting LGBT clients.

Approximately 75% of caregivers of older adults are family members; 70% are female²⁶; and most are adult children, spouses, and partners of those receiving care.²⁷ Male caregivers age ≥40 are more likely to be the abuser, however, especially when they possess any of these risk factors: fatigue, burnout, medical illness, mental illness, lack of financial and support services, family history of abusive behavior, and substance abuse.4 People who commit elder abuse also tend to be significantly dependent on the person they are abusing.² In some cases, and especially when the abuser is financially needy, caregivers turn to elder abuse to obtain resources from the victim.²

From your standpoint as a practitioner, it is important to determine the root cause of elder abuse. According to one review,²⁸ family members with mental illness or a history of substance abuse, or who are stressed by the burden of caregiving, abuse older adults at a higher rate than family members who are not affected in those ways. Depression in particular is a common characteristic of abusers,² often secondary to the stress of caring for an older adult.

Abuse caused by stress can be addressed by referral to a support group and counseling for the caregiver; psychiatric conditions, such as depression, might be better treated with pharmacotherapy. Evaluate for depression and posttraumatic stress disorder (PTSD) in both the abuser and the abused,²⁹ and for other mental health issues that might compound the situation. It is possible for you to have 2 patients: the older adult and his caregiver. Regardless of the challenge,keep in mind that the older adult’s safety is your priority.
Consequences for the abusedThe abused adult is at risk of a number of serious physical and psychological consequences.³⁰ They tend to have a shorter lifespan, after adjusting for other variables associated with increased mortality.

The reason for shortened lifespan is multifactorial³⁰:
   • Bruises, abrasions, and fractures may take longer to heal because of diminished skin and bone regeneration.
   • Diseases that affect the heart, lungs, and kidneys might prevent the person from bouncing back from major stressors caused by abuse, such as blood loss, severe injury, and pain.
   • Injury from abuse can exacerbate an underlying illness.
   • Elder abuse also is associated with increased emergency department use, hospitalization (including readmission within 30 days), and nursing home placement.³¹

Elder abuse can lead to depression, shame, and guilt; increased isolation; and
increased risk of alcohol abuse and substance use.³¹ A study found that victims of
elder abuse are significantly more depressed than non-victims.³²

In the same study, being a victim of abuse was found to be the second-strongest
predictor of depression, after the state of one’s health.³² Other potential psychiatric
consequences of abuse that need further study include increased risk of developing
fear and anxiety disorders; learned helplessness; and PTSD.³³ According to LoFaso,
“depression and anxiety can consume their days and leave them emotionally and
physically frail.”29 Such feelings make these older adults less likely to resolve abuse or break off relations with the abuser.³²

Because mental illness can be a risk factor for, and a consequence of, elder abuse,
be aware of such complications and address them appropriately. Keep in mind that older adults are more likely to visit a primary care practitioner than a psychiatrist for a routine health check-up or evaluation of initial cognition-related problems; however, they are more likely to see a psychiatrist for advanced neuropsychiatric problems such as dementia, paranoia, delusions, hallucinations, and insomnia. Adequate education on elder abuse should not be limited to a single medical specialty because it can present in several clinical settings.
Identifying abuseIdentification of elder abuse in the home poses a greater challenge to clinicians than abuse in an institutional setting because it is not directly observable. Compounding this is the lack of unified standards for identifying and dealing with elder abuse. It is first necessary for you to determine the likelihood that abuse or neglect occurred, which can be difficult because the signs of elder abuse and manifestations of normal aging often are similar. You also must establish whether (1) the abused person will accept intervention and (2) the abused person who refuses intervention has the capacity to make that decision. Both of these conditions will guide your approach to management.²

 

Obtain the history from several sources; review the records; and carefully examine patterns of injury, in particular assessing functional status and level of dependency on the caregiver. Explanations that do not match injuries signal the need for further investigation and examination.

To help differentiate elder abuse from normal physiologic aging, look at the skin for bruises, rashes that do not heal, and ulcers—all of which could be signs of abuse or neglect. Keep in mind that bruising generally is more common in older adults because of the slower turnover rate of epidermal cells; physiologic bruising tends to occur on dorsal aspects of the hands and arms.⁴ In contrast, bruising secondary to neglect or physical abuse can manifest as a subgaleal hematoma (caused by traumatic hair pulling), tracking in the peritoneum after genital trauma, Battle’s sign, and raccoon eyes, among other findings.⁴

In addition, larger bruises (>5 cm in diameter) are more likely the result of elder abuse.³⁴ To complicate matters, many older persons are taking anticoagulant therapy, making bruising more likely. In addition, be on the lookout for burns during the physical exam. Evidence suggests that at least 10% of burns caused by battery and assault occur in the context of elder abuse; most burn facilities do not have formal guidelines for screening for abuse and neglect, however.³⁵ According to one retrospective study, the most common causes of burns in older adults are hot water scalds and radiator contact, and the mortality rate of older burn patients in general is higher than among the overall population.³⁶

Falls and fractures are common among older adults, regardless of whether they are
abused, because of polypharmacy, underlying medical conditions, and functional
limitations. Many abusers, however, use these factors to cover up intentional injury
that might have resulted in the older person falling, including overmedication (a form of physical abuse) and withholding a necessary walking aid (a form of neglect). Maintain a high index of suspicion of elder abuse when (1) the caregiver’s and the older adult’s stories of an injury don’t add up and (2) physical findings that might have been caused by abuse are present.

A number of psychiatric and cognitive symptoms suggest other types of elder abuse. Take note of emotional upset, agitation, and unusual behaviors³⁷—especially if you can follow the patient over time to observe marked changes in the presentation. Likewise, be aware of proposed alterations in guardianship, which should be evaluated by a forensic psychiatrist with analysis of medical history, social attachments, home environment, self-care, and finances.³⁸ Such evaluation should provide clues to the motivation behind a change of guardianship and will help to determine if elder abuse should be suspected.

Brandi et al³⁷ provided an informative table that identifies pertinent signs, symptoms, and other findings that clinicians should be aware of to support a suspicion of elder abuse (Table).

Documentation is of utmost importance in evaluating potential elder abuse; keep in mind that the medical record might be used in an investigation of abuse by social workers, law enforcement, and prosecutors. Your records should be legible, clearly indicate who the main caregiver is and what his (her) responsibilities are, and specify who is present at your encounter with the patient.⁴ Document your observations of patient behavior, reactions to questions, and family dynamics and conflicts¹⁶; make note of warning signs such as fear, silence, and inability to interview the patient alone.

In addition to written documentation, take photographs of injuries, with a ruler in the image to record their size. Serial photographs are helpful; so are photographs from a variety of distances (close-up, regional, wholebody) to capture detail and place the wound in the context of a specific area of the body.⁴

Safety is paramount. Given the findings of the history and physical exam, it is necessary to determine whether it is safe for the patient to return home with the caregiver, or if alternate accommodations or resources, such as a social worker or a support group, are required. Include details of planned follow-up in your evaluation, and offer consideration of possible psychiatric disorders that can develop as a result of such abuse.
ReportingElder abuse is a criminal offense in all states.³⁹ A clinician who has reasonable suspicion that elder abuse occurred must report it, regardless of whether the proof of abuse is concrete.⁴⁰ At a point of reasonable suspicion, immediately contact APS, law enforcement, and a social worker. Adult Protective Services, modeled after Child Protective Services, is typically administered by local and state health
departments.⁴¹

After a report is filed with APS, an assigned social worker makes an in-person home visit to investigate the allegation and determine whether elder abuse is substantiated, partially substantiated, or unsubstantiated.¹⁶ In most states, elder abuse reporting is not anonymous because follow-up may be needed to provide additional evidence, especially if the report was made by a health care provider.¹⁶

 

No federal standard exists for states to follow when defining and addressing elder abuse, which can complicate identification and reporting of abuse. Laws governing elder abuse do not allow states to determine the fate of the older adult, who can decide for himself (herself) whether to use or waive protective services.⁴² Older adults might choose not to report abuse because of shame, intimidation, or fear,⁴³ or to protect a caregiver, who often is a family member.

Elder abuse reports can come from a variety of sources; convincing evidence is, as noted, unnecessary to report it. Health care providers are mandated reporters, but
it is believed that the number of clinicians who report elder abuse based on suspicion is far below what it should be. One study found that 94% of physicians said that they either were unable to prove that the abuse had occurred or decided not to report it.¹¹ Another study found that only 1.4% of elder abuse cases reported to APS come from physicians.⁴⁴

There are several possible reasons for underreporting elder abuse, including (1) the difficulty of distinguishing elder abuse and neglect from sequelae of normal aging and (2) the fact that cognitive and functional impairment of the abused person makes it difficult, even impossible, to establish the narrative of how the abuse happened. Nursing homes in particular provide a high level of oversight because residents have an average of ≥3 functional deficits.⁴ Other reasons for underreporting—some of which are difficult to understand, and excuse, in a clinician—are:
   • subtlety of signs
   • victim denial
   • ignorance of reporting procedures
   • inadequate training
   • lack of information about resources
   • concern about losing physician–patient rapport
   • concern about involvement in the legal system
   • time limitations
   • doubt about the effectiveness of APS.¹⁶
 

Assessing capacityThe older adult’s wishes must be respected unless a health care provider or the legal system determines that he lacks functional capacity to make decisions.¹⁶

How is capacity evaluated? A capacity evaluation has 3 components:
   • Comprehension is a person’s factual understanding of the situation, including
consequences and alternatives
   • Free choice is a person’s voluntary decision to accept or reject a proposed treatment, free of coercion (in this setting, free choice is the older adult’s decision whether to report the abuse)
   • Reliability is a person’s ability to provide a consistent choice over time.⁴⁵

Most capacity evaluations are conducted by clinical interview. No single, brief test is used universally, and there is the possibility of inter-rater variability.⁴⁵ Examples of tests used to assess capacity are the Folstein Mini-Mental Status Examination and the MacArthur Competence Assessment Tool-Treatment⁴⁵; the latter is a structured interview that incorporates information specific to the individual patient’s decision-making situation.⁴⁶ Regardless of the approach, the psychiatrist-evaluator ensures that the older adult has been given the appropriate information
to provide informed consent about the situation.⁴⁷

If the evaluator determines that a person lacks capacity to make decisions, efforts should be made to determine if the cause of that impairment is reversible.⁴⁷ Older adults who have dementia or other underlying psychiatric condition that impairs cognition might benefit from more education on their situation; ones who appear fearful of consequences should be introduced to a trusted advisor to assist in making competent judgments.⁴⁷

If the older adult is found to lack capacity, a substitute decision-maker must be sought.⁴⁷ Many states have statutes specifying the order in which family members are contacted.⁴⁸ The need to appoint an advisor can become knotty because the suspected abuser often is a family member; clinicians and others involved in identifying a decision-maker to speak on behalf of an older adult should choose carefully.
Prevention and screeningKey to reducing the prevalence of elder abuse in the community is formulating
strategies for prevention and screening. The American Medical Association recommends that clinicians “incorporate routine questions related to elder abuse and neglect into daily practice.”⁴⁹ Older adults might not admit to abuse or neglect unless they are asked; speak to patients at eye level, keep questions simple, direct, and nonjudgmental, and assure them (1) that discussions are confidential and (2) that their safety is your primary goal.^50,51

Comprehensive approaches to questioning patients are available and often recommended for screening for elder abuse.⁴ However, screening in the office setting often involves short, directly administered questionnaires.⁴⁹ For example, the Health and Safety Screen developed at the University of Maine comprises 6 questions⁵²:
   • Has anyone close to you called you names or insulted you recently?
   • Are you afraid of anyone in your life?
   • Are you able to use the telephone anytime you want to?
   • Has anyone forced you to do things you didn’t want to do?
   • Has anyone taken things or money that belong to you without your OK?
   • Has anyone close to you tried to hurt you or harm you recently?

 

Because of time constraints and lack of a universal standard, there is debate whether regular elder abuse screening is time-effective. It often is recommended, therefore, that clinicians in primary care (1) refer older adults with risk factors for abuse to geriatric medical teams trained in these measures and (2) perform periodic follow-up on such patients⁴ (Figure).

Because of limitations to regular screenings, the best method of prevention might be to raise awareness of elder abuse among clinicians and in the community. For example:
   • New York City Elder Abuse Center encourages collaboration among health, mental health, and community justice organizations.²⁸ The program involves a number of resources for addressing elder abuse, such as promoting staff awareness of risk factors for, and signs of, abuse, and screening for mental health problems in the abused.
   • The Elder Justice Act, enacted in 2010 to combat elder abuse, provides federal funds and resources to prevent, detect, treat, and intervene to stop abuse and, when appropriate, to prosecute abusers.⁵³

This Web Exclusive Table provides a 7-point summary reference guide for understanding and preventing elder abuse in your practice.

BOTTOM LINEIdentification of elder abuse can be difficult because signs and symptoms of abuse closely resemble physiologic aging. Older adults with identifiable risk factors should be screened for abuse; time constraints make universal screening impossible at this time. In the future, multidisciplinary approaches likely will make elder abuse more easily identifiable through the combined work of health care providers, law enforcement agencies, banks, and other institutions—with the ultimate goal of protecting older adults in the community from abuse.

Related Resources
• Frazão SL, Correia AM, Norton P, et al. Physical abuse against elderly persons in institutional settings. J Forensic Leg Med. 2015;36:54-60.
• Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.

 

Disclosures
Ms. Hubert reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Gupta is a member of the speakers’ bureau of Alkermes, Allergan, Avanir Pharmaceuticals, Takeda Pharmaceutical, Lundbeck, Otsuka Pharmaceutical, and Sunovion Pharmaceuticals.

In its simplest form, elder abuse refers to the intentional infliction of injury or neglect of an older adult by a caregiver. The 5 primary types of elder abuse include neglect, physical, financial, psychological/emotional, and sexual, with a subtype of social abuse that falls under psychological/emotional abuse.

Differentiating abuse from the normal sequelae of physiologic aging can be difficult; therefore, early identification and awareness of risk factors is key, as well as detailed documentation of the patient encounter. As soon as abuse is suspected, clinicians should report it to Adult Protective Services (APS) for further investigation. In terms of prevention, regular screening for elder abuse is still up for debate, but as the incidence of elder abuse continues to rise so should research and preventive efforts to combat this growing public health concern.
What is ‘elder abuse’?According to the Elder Abuse Prevention, Identification, and Treatment Act of 1985, elder abuse is:
…willful infliction of injury, unreasonable confinement, intimidation or cruel punishment with resulting physical harm or pain or mental anguish or the willful deprivation by a caretaker of goods or services which are necessary to avoid physical harm, mental anguish or mental illness.¹

There are 2 main components to this definition:
   • an older adult has suffered injury or deprivation
   • another person is responsible for causing or failing to prevent it.²

Although definitions vary, it generally is accepted that, for elder abuse to occur, it must take place within a relationship of trust.³

An ‘older adult’ is a person age ≥65, representing 14% of the U.S. population.⁴
According to U.S. Census Bureau data, there were 40 million older adults in 20105;
recent data project that this number will rise to 90 million by 2060 as Baby Boomers age.⁶ Studies suggest that as many as 10% of older adults in the United States experience elder abuse each year²; one study estimated that 6% of older adults in the community experienced significant abuse in the past month.⁷

Although elder abuse can occur in any setting, it takes place most often in the community. A survey of state APSs in 2000 showed that 60.7% of abuse was domestic; only 8.3% of incidents occurred in institutional settings.⁸ The annual direct medical costs associated with elder abuse injury in the United States are estimated at $5.3 billion, which is likely to increase with anticipated growth of the geriatric population.⁹

Although the number of older adults and the incidence of elder abuse are on the rise, as few as 1 in 14 cases is reported to authorities¹⁰; health care providers are some of the least likely of involved parties to report suspected abuse. One study found that 63% of physicians never asked about elder abuse, and only 31% reported encountering it in the previous 12 months.¹¹ A busy clinician—ie, one who sees 20 to 40 geriatric patients a day—has a high likelihood of encountering at least 1 victim of elder abuse,² yet many cases go unrecognized.
Types of abuseElder abuse comprises 5 categories¹²:
   • neglect (58.5% of cases)
   • physical (15.7%)
   • financial (12.3%)
   • psychological and emotional (7.3%)
   • sexual (0.04%).

Social abuse is considered a subtype of psychological and emotional abuse. All “other” types of abuse constitute 5.1% cases; 0.06% are of unknown type.¹²

Neglect is (1) failure of the caregiver to provide life necessities or (2) the responsible person’s refusal to permit others to provide appropriate care.³ This is one of the most common types of elder abuse in residential facilities. Signs of neglect include dehydration, depression, fecal impaction, and malnutrition (Table).⁴ The prevalence of dehydration in nursing home patients is reported to be as high as 35%, which may be the result of passive or active withholding of liquids (ie, decreasing hydration to reduce the need to change the resident’s clothing or bedding).⁴ Other forms of neglect include medication misuse (overdosing or underdosing) and self-neglect, which occurs among people living alone and often is listed as a subtype of neglect, but is controversial because it does not involve another person.
 

Physical abuse is a non-accidental act that results in physical pain or injury,³ including bruises, fractures, and burns. Physical abuse is among the most common types of abuse in nursing homes; it has been suggested that approximately 4.8% of residents experience physical abuse that results in a police investigations.¹³ New research describes resident-on-resident abuse as one of the most prevalent causes of physical abuse.¹⁴ Dementia and cognitive decline complicate resident-on-resident abuse, particularly from the standpoint of treating aggression.

Financial exploitation is the illegal or improper use, or mismanagement, of a person’s money, property, or financial resources³—often, to his (her) detriment. Estimates are that 1 of every 20 older adults has been subject to financial abuse at some point in their life.¹⁵ There should be a high index of suspicion for financial exploitation when one notices unexplained changes in power of attorney, wills, or other legal documents; missing checks, money, or belongings.¹⁶ In the past, adult children were most likely to be financial abusers; in recent years, however, the abuser is more often a spouse—especially a second spouse.¹⁷ Bankers, accountants, and other financial advisors are among those trained to identify risk factors for financial abuse; they are encouraged to caution clients about this possibility.¹⁸

 

Psychological and emotional abuse occurs when a caregiver inflicts mental stress on an older adult by actions and threats that cause fear, violence, isolation, deprivation, or feelings of shame and powerlessness.³ Examples are threatening to put the older adult in a nursing home or verbally abusing him (her). Suspect this type of abuse when a caregiver refuses to leave the older adult or speaks for him, or if the older adult expresses fear in the presence of the caregiver.⁴ This type of abuse also is prevalent in nursing homes and other long-term care facilities.¹⁹

Sexual abuse involves nonconsensual touching or sexual activities (rape, language, exploitive behavior) that are threatened or forced on an older adult.¹⁶ Sexual abuse is more common in frail or dependent persons.³ Physical exam findings—particularly dysuria, tender genitalia, and evidence of sexually transmitted infections⁴—are required to identify sexual abuse, along with signs of depression and display of fear.

Social abuse can be considered a subtype of psychological and emotional abuse, in which a caregiver denies an older adult contact with family and friends or deprives him from access to transportation. Other examples include not allowing the older adult to use the telephone, monitoring phone calls, and claiming that his friends or family are “interfering.”²⁰ Intentionally embarrassing an older adult in front of others also can be considered social abuse.

Technology, particularly smart phones and social media, can complicate and exacerbate elder abuse:
   • In July 2013, employees of a Wisconsin nursing home were found with videos and photographs of residents bathing and of a nude resident who had a bowel obstruction being mocked.²¹
   • In May 2014, employees of a nursing home in Massachusetts recorded themselves physically and verbally abusing several older adults with Alzheimer’s disease, including one episode of the employees “hitting the woman on her arms, flicking her ears and then pinching the woman’s nose closed.” The employees also possessed a photograph of her naked.²²
   • In June 2015, an employee of a nursing home in Indiana was accused of taking
photos of a resident naked and sharing them on the messaging application Snapchat,²³ in which images disappear 10 seconds after they are viewed.

As technology evolves, caregivers are finding more cunning ways to abuse older adults. Considering current events and trends in this area, technology as a gateway to elder abuse should be of growing concern.
Risk factorsA 2013 literature review on elder abuse reported that the most important risk factors are related to relationship (family disharmony, poor or conflicting relationships) and environment (a low level of social support),³ although other variables can play a role. Regardless of these findings, it is important to recognize that (1) elder abuse is not a necessary consequence in a family with many risk factors and (2) elder abuse can occur in the absence of any risk factors.

As a whole, women are at a higher risk of abuse, particularly when combined with loneliness, poor social support, cohabitation (especially family members), substance abuse, cognitive impairment, and dementia and other mental health problems.⁴ Other risk factors include functional deficiency, poor physical health or frailty, low income or wealth, and trauma or past abuse.³

Lower income, poor health, low social support, and belonging to a non-white racial group put an older adult at risk for neglect; female sex is a specific risk factor for sexual assault.¹⁵ One study found that, among older adults who suffered physical, mental, or cognitive impairment, 1 of every 4 was at risk of abuse.⁷

Mental illness. Dementia puts an older adult at higher risk because of increased
caregiver stress resulting from disruptive and aggressive behaviors²; the same is true when the older adult suffers another mental illness, such as anxiety, depression, schizophrenia or bipolar disorder. Presumably, older adults with any of these disorders are at risk of financial and psychological and emotional abuse because of their decreased social support, lack of independence, and inability to hold a job—leaving their caregiver to shoulder more responsibilities and with more opportunities to inflict abuse. In addition, an older adult suffering from depression can feel helpless and unworthy, possibly making him more susceptible to psychological and emotional abuse, and less likely to seek help.

More research is needed to establish racial and ethnic differences in the risk of abuse. Some research states that older adults who are a member of a minority are at greater risk of abuse; however, the difference dissipates after adjusting for variables such as income and social support.²⁴ Cultural confounders, such as varying interpretations of the same set of interactions between older adults, need to be examined further.

 

Sexual orientation. Identifying one’s self as a lesbian, gay, bisexual, or transgender (LGBT) person is an additional risk factor for elder abuse. In 1997, a report described a nursing home employee who refused to bathe a resident because he didn’t want to “touch the lesbian.”²⁵ Despite evolving attitudes in society toward support and acceptance of sexual orientation, fear of homophobia still prevents some LGBT older adults from seeking help when they have been abused because of their orientation—especially ones who have internalized that
homophobia and feel that they are unworthy of seeking help.²⁵

In addition, health care providers and nursing home staff members might neglect the particular care needs of LGBT older adults, intentionally or unintentionally. APS staff and providers must be cognizant of underlying biases and exhibit respect when assisting LGBT clients.

Approximately 75% of caregivers of older adults are family members; 70% are female²⁶; and most are adult children, spouses, and partners of those receiving care.²⁷ Male caregivers age ≥40 are more likely to be the abuser, however, especially when they possess any of these risk factors: fatigue, burnout, medical illness, mental illness, lack of financial and support services, family history of abusive behavior, and substance abuse.4 People who commit elder abuse also tend to be significantly dependent on the person they are abusing.² In some cases, and especially when the abuser is financially needy, caregivers turn to elder abuse to obtain resources from the victim.²

From your standpoint as a practitioner, it is important to determine the root cause of elder abuse. According to one review,²⁸ family members with mental illness or a history of substance abuse, or who are stressed by the burden of caregiving, abuse older adults at a higher rate than family members who are not affected in those ways. Depression in particular is a common characteristic of abusers,² often secondary to the stress of caring for an older adult.

Abuse caused by stress can be addressed by referral to a support group and counseling for the caregiver; psychiatric conditions, such as depression, might be better treated with pharmacotherapy. Evaluate for depression and posttraumatic stress disorder (PTSD) in both the abuser and the abused,²⁹ and for other mental health issues that might compound the situation. It is possible for you to have 2 patients: the older adult and his caregiver. Regardless of the challenge,keep in mind that the older adult’s safety is your priority.
Consequences for the abusedThe abused adult is at risk of a number of serious physical and psychological consequences.³⁰ They tend to have a shorter lifespan, after adjusting for other variables associated with increased mortality.

The reason for shortened lifespan is multifactorial³⁰:
   • Bruises, abrasions, and fractures may take longer to heal because of diminished skin and bone regeneration.
   • Diseases that affect the heart, lungs, and kidneys might prevent the person from bouncing back from major stressors caused by abuse, such as blood loss, severe injury, and pain.
   • Injury from abuse can exacerbate an underlying illness.
   • Elder abuse also is associated with increased emergency department use, hospitalization (including readmission within 30 days), and nursing home placement.³¹

Elder abuse can lead to depression, shame, and guilt; increased isolation; and
increased risk of alcohol abuse and substance use.³¹ A study found that victims of
elder abuse are significantly more depressed than non-victims.³²

In the same study, being a victim of abuse was found to be the second-strongest
predictor of depression, after the state of one’s health.³² Other potential psychiatric
consequences of abuse that need further study include increased risk of developing
fear and anxiety disorders; learned helplessness; and PTSD.³³ According to LoFaso,
“depression and anxiety can consume their days and leave them emotionally and
physically frail.”29 Such feelings make these older adults less likely to resolve abuse or break off relations with the abuser.³²

Because mental illness can be a risk factor for, and a consequence of, elder abuse,
be aware of such complications and address them appropriately. Keep in mind that older adults are more likely to visit a primary care practitioner than a psychiatrist for a routine health check-up or evaluation of initial cognition-related problems; however, they are more likely to see a psychiatrist for advanced neuropsychiatric problems such as dementia, paranoia, delusions, hallucinations, and insomnia. Adequate education on elder abuse should not be limited to a single medical specialty because it can present in several clinical settings.
Identifying abuseIdentification of elder abuse in the home poses a greater challenge to clinicians than abuse in an institutional setting because it is not directly observable. Compounding this is the lack of unified standards for identifying and dealing with elder abuse. It is first necessary for you to determine the likelihood that abuse or neglect occurred, which can be difficult because the signs of elder abuse and manifestations of normal aging often are similar. You also must establish whether (1) the abused person will accept intervention and (2) the abused person who refuses intervention has the capacity to make that decision. Both of these conditions will guide your approach to management.²

 

Obtain the history from several sources; review the records; and carefully examine patterns of injury, in particular assessing functional status and level of dependency on the caregiver. Explanations that do not match injuries signal the need for further investigation and examination.

To help differentiate elder abuse from normal physiologic aging, look at the skin for bruises, rashes that do not heal, and ulcers—all of which could be signs of abuse or neglect. Keep in mind that bruising generally is more common in older adults because of the slower turnover rate of epidermal cells; physiologic bruising tends to occur on dorsal aspects of the hands and arms.⁴ In contrast, bruising secondary to neglect or physical abuse can manifest as a subgaleal hematoma (caused by traumatic hair pulling), tracking in the peritoneum after genital trauma, Battle’s sign, and raccoon eyes, among other findings.⁴

In addition, larger bruises (>5 cm in diameter) are more likely the result of elder abuse.³⁴ To complicate matters, many older persons are taking anticoagulant therapy, making bruising more likely. In addition, be on the lookout for burns during the physical exam. Evidence suggests that at least 10% of burns caused by battery and assault occur in the context of elder abuse; most burn facilities do not have formal guidelines for screening for abuse and neglect, however.³⁵ According to one retrospective study, the most common causes of burns in older adults are hot water scalds and radiator contact, and the mortality rate of older burn patients in general is higher than among the overall population.³⁶

Falls and fractures are common among older adults, regardless of whether they are
abused, because of polypharmacy, underlying medical conditions, and functional
limitations. Many abusers, however, use these factors to cover up intentional injury
that might have resulted in the older person falling, including overmedication (a form of physical abuse) and withholding a necessary walking aid (a form of neglect). Maintain a high index of suspicion of elder abuse when (1) the caregiver’s and the older adult’s stories of an injury don’t add up and (2) physical findings that might have been caused by abuse are present.

A number of psychiatric and cognitive symptoms suggest other types of elder abuse. Take note of emotional upset, agitation, and unusual behaviors³⁷—especially if you can follow the patient over time to observe marked changes in the presentation. Likewise, be aware of proposed alterations in guardianship, which should be evaluated by a forensic psychiatrist with analysis of medical history, social attachments, home environment, self-care, and finances.³⁸ Such evaluation should provide clues to the motivation behind a change of guardianship and will help to determine if elder abuse should be suspected.

Brandi et al³⁷ provided an informative table that identifies pertinent signs, symptoms, and other findings that clinicians should be aware of to support a suspicion of elder abuse (Table).

Documentation is of utmost importance in evaluating potential elder abuse; keep in mind that the medical record might be used in an investigation of abuse by social workers, law enforcement, and prosecutors. Your records should be legible, clearly indicate who the main caregiver is and what his (her) responsibilities are, and specify who is present at your encounter with the patient.⁴ Document your observations of patient behavior, reactions to questions, and family dynamics and conflicts¹⁶; make note of warning signs such as fear, silence, and inability to interview the patient alone.

In addition to written documentation, take photographs of injuries, with a ruler in the image to record their size. Serial photographs are helpful; so are photographs from a variety of distances (close-up, regional, wholebody) to capture detail and place the wound in the context of a specific area of the body.⁴

Safety is paramount. Given the findings of the history and physical exam, it is necessary to determine whether it is safe for the patient to return home with the caregiver, or if alternate accommodations or resources, such as a social worker or a support group, are required. Include details of planned follow-up in your evaluation, and offer consideration of possible psychiatric disorders that can develop as a result of such abuse.
ReportingElder abuse is a criminal offense in all states.³⁹ A clinician who has reasonable suspicion that elder abuse occurred must report it, regardless of whether the proof of abuse is concrete.⁴⁰ At a point of reasonable suspicion, immediately contact APS, law enforcement, and a social worker. Adult Protective Services, modeled after Child Protective Services, is typically administered by local and state health
departments.⁴¹

After a report is filed with APS, an assigned social worker makes an in-person home visit to investigate the allegation and determine whether elder abuse is substantiated, partially substantiated, or unsubstantiated.¹⁶ In most states, elder abuse reporting is not anonymous because follow-up may be needed to provide additional evidence, especially if the report was made by a health care provider.¹⁶

 

No federal standard exists for states to follow when defining and addressing elder abuse, which can complicate identification and reporting of abuse. Laws governing elder abuse do not allow states to determine the fate of the older adult, who can decide for himself (herself) whether to use or waive protective services.⁴² Older adults might choose not to report abuse because of shame, intimidation, or fear,⁴³ or to protect a caregiver, who often is a family member.

Elder abuse reports can come from a variety of sources; convincing evidence is, as noted, unnecessary to report it. Health care providers are mandated reporters, but
it is believed that the number of clinicians who report elder abuse based on suspicion is far below what it should be. One study found that 94% of physicians said that they either were unable to prove that the abuse had occurred or decided not to report it.¹¹ Another study found that only 1.4% of elder abuse cases reported to APS come from physicians.⁴⁴

There are several possible reasons for underreporting elder abuse, including (1) the difficulty of distinguishing elder abuse and neglect from sequelae of normal aging and (2) the fact that cognitive and functional impairment of the abused person makes it difficult, even impossible, to establish the narrative of how the abuse happened. Nursing homes in particular provide a high level of oversight because residents have an average of ≥3 functional deficits.⁴ Other reasons for underreporting—some of which are difficult to understand, and excuse, in a clinician—are:
   • subtlety of signs
   • victim denial
   • ignorance of reporting procedures
   • inadequate training
   • lack of information about resources
   • concern about losing physician–patient rapport
   • concern about involvement in the legal system
   • time limitations
   • doubt about the effectiveness of APS.¹⁶
 

Assessing capacityThe older adult’s wishes must be respected unless a health care provider or the legal system determines that he lacks functional capacity to make decisions.¹⁶

How is capacity evaluated? A capacity evaluation has 3 components:
   • Comprehension is a person’s factual understanding of the situation, including
consequences and alternatives
   • Free choice is a person’s voluntary decision to accept or reject a proposed treatment, free of coercion (in this setting, free choice is the older adult’s decision whether to report the abuse)
   • Reliability is a person’s ability to provide a consistent choice over time.⁴⁵

Most capacity evaluations are conducted by clinical interview. No single, brief test is used universally, and there is the possibility of inter-rater variability.⁴⁵ Examples of tests used to assess capacity are the Folstein Mini-Mental Status Examination and the MacArthur Competence Assessment Tool-Treatment⁴⁵; the latter is a structured interview that incorporates information specific to the individual patient’s decision-making situation.⁴⁶ Regardless of the approach, the psychiatrist-evaluator ensures that the older adult has been given the appropriate information
to provide informed consent about the situation.⁴⁷

If the evaluator determines that a person lacks capacity to make decisions, efforts should be made to determine if the cause of that impairment is reversible.⁴⁷ Older adults who have dementia or other underlying psychiatric condition that impairs cognition might benefit from more education on their situation; ones who appear fearful of consequences should be introduced to a trusted advisor to assist in making competent judgments.⁴⁷

If the older adult is found to lack capacity, a substitute decision-maker must be sought.⁴⁷ Many states have statutes specifying the order in which family members are contacted.⁴⁸ The need to appoint an advisor can become knotty because the suspected abuser often is a family member; clinicians and others involved in identifying a decision-maker to speak on behalf of an older adult should choose carefully.
Prevention and screeningKey to reducing the prevalence of elder abuse in the community is formulating
strategies for prevention and screening. The American Medical Association recommends that clinicians “incorporate routine questions related to elder abuse and neglect into daily practice.”⁴⁹ Older adults might not admit to abuse or neglect unless they are asked; speak to patients at eye level, keep questions simple, direct, and nonjudgmental, and assure them (1) that discussions are confidential and (2) that their safety is your primary goal.^50,51

Comprehensive approaches to questioning patients are available and often recommended for screening for elder abuse.⁴ However, screening in the office setting often involves short, directly administered questionnaires.⁴⁹ For example, the Health and Safety Screen developed at the University of Maine comprises 6 questions⁵²:
   • Has anyone close to you called you names or insulted you recently?
   • Are you afraid of anyone in your life?
   • Are you able to use the telephone anytime you want to?
   • Has anyone forced you to do things you didn’t want to do?
   • Has anyone taken things or money that belong to you without your OK?
   • Has anyone close to you tried to hurt you or harm you recently?

 

Because of time constraints and lack of a universal standard, there is debate whether regular elder abuse screening is time-effective. It often is recommended, therefore, that clinicians in primary care (1) refer older adults with risk factors for abuse to geriatric medical teams trained in these measures and (2) perform periodic follow-up on such patients⁴ (Figure).

Because of limitations to regular screenings, the best method of prevention might be to raise awareness of elder abuse among clinicians and in the community. For example:
   • New York City Elder Abuse Center encourages collaboration among health, mental health, and community justice organizations.²⁸ The program involves a number of resources for addressing elder abuse, such as promoting staff awareness of risk factors for, and signs of, abuse, and screening for mental health problems in the abused.
   • The Elder Justice Act, enacted in 2010 to combat elder abuse, provides federal funds and resources to prevent, detect, treat, and intervene to stop abuse and, when appropriate, to prosecute abusers.⁵³

This Web Exclusive Table provides a 7-point summary reference guide for understanding and preventing elder abuse in your practice.

BOTTOM LINEIdentification of elder abuse can be difficult because signs and symptoms of abuse closely resemble physiologic aging. Older adults with identifiable risk factors should be screened for abuse; time constraints make universal screening impossible at this time. In the future, multidisciplinary approaches likely will make elder abuse more easily identifiable through the combined work of health care providers, law enforcement agencies, banks, and other institutions—with the ultimate goal of protecting older adults in the community from abuse.

Related Resources
• Frazão SL, Correia AM, Norton P, et al. Physical abuse against elderly persons in institutional settings. J Forensic Leg Med. 2015;36:54-60.
• Sorrentino R. Performing capacity evaluations: what’s expected from your consult. Current Psychiatry. 2014;13(1):41-44.

 

Disclosures
Ms. Hubert reports no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Gupta is a member of the speakers’ bureau of Alkermes, Allergan, Avanir Pharmaceuticals, Takeda Pharmaceutical, Lundbeck, Otsuka Pharmaceutical, and Sunovion Pharmaceuticals.