  |  | | By Mike Magee, MD
Recently, issues of elder abuse have resurfaced in both home and institutional settings.1 As Stephanie Lederman, executive director of the American Federation for Aging Research notes, “A large segment of our population is both dependent and frail. Studies on elder abuse now alert us that seniors are also vulnerable and in need of help.”2,3
How large is the at-risk segment? One study of 2,812 adults over age 65 revealed that 6 percent, or 176, of them were seen by elderly protective services over a nine-year period. Nearly three-quarters of these cases involved self-neglect, but the remaining 27 percent were traced to the actions of others – nearly 6 percent of the elderly people experienced physical abuse, 17 percent had been neglected, and almost 5 percent suffered exploitation.4
What is elder abuse? The U.S. National Academy of Sciences defines the problem as “intentional actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder; or, failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.”5
Elder abuse not only implies that a person has suffered injury or neglect, but also that a specific individual, entrusted to provide care, is responsible. The abuse may take a variety of forms, including physical abuse, psychological abuse, sexual assault, exploitation of material resources, or neglect.
Studying elder abuse is easier said than done. For example, a simple geriatric study on how to prevent elder fractures due to falls must consider confounding issues such as polypharmacy, visual impairment from cataracts and other conditions, and depression or dementia, to name a few.6 When one then attempts to decipher naturally occurring injuries from deliberate ones, study design and verification become critical. Was an injury due to loss of balance or assault? Did weight loss occur due to chronic disease and cancer or from neglect? Was under- or over-medicating the result of forgetfulness or malevolence of the caregiver?1,6
Risk factors associated with elder abuse are increasingly clear. Most incidences occur in shared living situations where there is prolonged access by a family member, friend or entrusted surrogate. Elder dementia creates both a complex management challenge and an unreliable witness to the abuse, which complicates documentation. Social isolation creates stress that can lead to reactive abuse behavior, as well as a hidden environment to harbor abuse, neglect, or exploitation. The presence of caregiver mental illness, including depression or substance abuse, increases the likelihood of harmful behaviors, as does the use of family-member caregivers who are dependent upon and often resentful of the senior for whom they are charged to provide care.1,4
Caring for a frail, dependent and vulnerable senior is challenging under the best circumstances.
Screening elders for abuse requires high awareness and good clinical judgment. There is not a clear consensus on routine monitoring or an instrument to be used.1,4 General concern should be raised when physicians, nurses, and other members of the care team observe a poor social network, poor social functioning, and signs of conflict between a patient and a caregiver. Trust your instincts, experts say. Conduct a thorough evaluation with a focus on cognitive function, question the patient in private, and be cautious in discussions with the caregiver, extending empathy while uncovering the caregiver's training and coping skills.1
Questions for the family? Is mom or dad declining without an obvious reason? What is the level of cleanliness of the patient and the home setting? What is the patient being fed, and, under direct viewing, how gentle and effective is the process? Are there unexplained bruises, blisters, or painful areas? Is the senior’s mobility rapidly declining? What is being said to the senior, not simply with words, but also with messages and tone? And what do your instincts tell you when you make unannounced visits? Would video monitoring be helpful?
Addressing senior abuse requires a continuum of committed individuals from home to care sites and back home again, providing reliable monitoring, oversight, diagnosis, and intervention when necessary. Such a network must be built, and a good place to begin is with an informed discussion of the issue between family members and their care teams.
For Health Commentary, I’m Mike Magee.
References
1. Lachs MS, Pillemer K. Elder abuse. The Lancet. 2004; 364: 1263-1272.
2. Lederman S. Private communication. 2005.
3. National Center on Elder Abuse. Reports of Elder Abuse. 28 Feb. 2005.
4. Lachs MS, et al. The mortality of elder abuse. JAMA. 1998; 280:428-443. Cited in Lachs MS, Pillemer K.
5. National Academies of Sciences. Bonnie R, Wallace R, eds. Elder abuse: abuse, neglect, and exploitation in an aging America. Washington, D.C.: National Academy Press. 2002. Cited in Lachs MS, Pillemer K.
6. Lachs MS, Pillemer K. Abuse and neglect of elderly persons. NEJM. 1995; 333:437. Cited in Lachs MS, Pillemer K.
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