New Year’s Resolution: Discuss Elder Abuse With Your Extended Family.

Posted on | December 26, 2013 | Comments Off on New Year’s Resolution: Discuss Elder Abuse With Your Extended Family.

Mike Magee

As we approach New Year’s celebrations, reports now estimate that abuse of the world’s burgeoning elder populations affects anywhere from 4% to 10% of all seniors globally.(1) Considering that we are on the front end of exponential rises in the numbers of seniors, and considering that the abuses remain largely under the radar screen and poorly understood, there is a real and legitimate reason for concern.

What we are all conscious of in this country is that the care of elder Americans generates a large portion of our annual healthcare expenditure. Those over 65 represent 13 percent of our population but consume 40 percent of our healthcare dollars. (2,3) To address this, a landmark study a decade ago focused on defining and addressing common problems and conditions in the elderly. The approach, called ACOVE, for Assessing Care of Vulnerable Elders, was developed by the RAND Corporation in 2003.(4,5)

These approaches were based on a principle well expressed at the time by Jim Firman of the National Council on the Aging, who said, “We mistakenly define long-term care problems as medical concerns, rather than a disability concern…The care needs of most frail older people are primarily supportive: for example, help them move from here to there, help them eat and dress, and help them keep track of their medicines.”

The numbers then were alarming. A decade ago, 42 percent of those over 65-some 14 million seniors-were disabled. 12.4 million seniors were home-based, and 1.6 million were institutionalized. (6,7) Today, the numbers are more dramatic, and the problem compounded by neglect and abuse.

As Stephanie Lederman, executive director of the American Federation of Aging Research noted then, “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.” 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. (8)

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.” (9)

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. 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? (10,11)

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. (9,12)

Caring for a frail, dependent and vulnerable senior is challenging under the best circumstances. When abuse is interjected, the consequences are significant, including an increase in mortality rates. One study has documented that the three-year mortality rate for seniors who are exposed to elder abuse was 91 percent, compared to 58 percent in a matched dependent senior population that was not abused. (12)

Dr. Mark Lachs and his colleagues have noted, “It seems plausible that experiencing elder abuse is an extreme form of negative social support. In the same manner that social integration reduces mortality, it may conversely be the case that the extreme interpersonal stress resulting from elder abuse situations may confer additional death risk.” (12)

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. 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. Clinicians should trust their clinical judgment and instincts, do a complete physical assessment with a focus on cognitive function, question the patient in private, and be cautious in discussions with the caregiver, extending empathy while uncovering the individual’s mental status and coping skills. (10,11,12)

Similarly, families should trust their instincts. 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?

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 as part of your New Year’s Resolution.

For Health Commentary, I’m Mike Magee.

References:

1. Associated Press Investigative Report. December 23, 2013. Elder Abuse, Including Neglect, On The Rise As World’s Populations Age.http://nydn.us/1ed6wJm

2.Manton KG et al. Monitoring changes in the health of U.S. elderly populations: Correlates with biomedical research and clinical innovations. FASEB J. 1997;11:923-930

3.Hodgson TA, Cohen AJ. Medical expenditures for major diseases 1995. Health Care Finance Rev. 1999; 21:119-164 (PMID:11481772}.

4. Wegner NS et. al. The quality of medical care provided to vulnerable community-dwelling older patients. Annals of Internal Medicine. 2003;138:740-747

5. .RAND corporation. RAND-UCLA study finds significant shortfalls in quality of health care for vulnerable seniors. Press Release. Monday, November 3, 2003.

6.Census 2000 Brief. The 65 and over population: 2000. Available at http://www.census.gov/2010census/

7.Census 2000 Brief. Disability status:2000. Available at: http://www.census.gov/2010census/

8. Lachs MS, Williams CS, O’Brien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. JAMA. 1998;280:428-443.

9. National Center on Elder Abuse. Reports of Domestic Elder Abuse. http://www.aginginplace.org/guide-to-recognizing-elder-abuse/

10. Lachs MS, Pillemer K. Elder abuse. The Lancet. 2004;364:1263-1272.

11. Lachs MS, Pillemer K. Abuse and neglect of elderly persons. NEJM. 1995;333:70, 437

12.Lachs MS, Williams CS, O’Brien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. JAMA. 1998;280:428-443.