Abuse of Older People

Abuse of older people, also known as elder abuse, occurs when there is harm or distress to older adults from an action or lack of action by an individual expected to be trusted. Abuse of older people comes in different forms including physical abuse, psychological or emotional abuse, sexual abuse, financial abuse, and neglect. Abuse of older people is often underreported, and with the aging population, will increase as a public health concern. It is imperative that healthcare providers recognize signs of abuse of older people and how to assess and evaluate the situation. Cases of abuse of older people should be evaluated for safety risks to the individual to determine a plan of care. In cases of suspected abuse of older people, it is important to understand the reporting requirements to Adult Protective Services. When abuse of older people is suspected, it can be helpful to work with interprofessional team members to identify services that may be available to the individual and caregivers.

Erika Zimmons, DO, MS, AGSF | erika.zimmons@umassmemorial.org

The author has no conflicts of interest or financial disclosures.  

INTRODUCTION

Abuse of older people, also known as elder abuse or elder mistreatment, is defined by the World Health Organization, as “a single or repeated act or lack of appropriate action occurring with any relationship in which there is an expectation of trust that causes harm or distress to an older person (aged 60 years and older).”¹ Based on a national survey of cognitively intact community dwelling individuals over the age of 60 years, abuse of older people in the United States is estimated to occur in 1 out of 10 older adults each year.² This is likely an underestimate as cases of abuse of older people are underreported. Prevalence rates vary among studies based on population and research methods. One study of community-dwelling older adults ages 57 to 85 years asked individuals about their experience with verbal, financial, and physical mistreatment. Nine percent of respondents reported verbal mistreatment, 3.5% financial mistreatment, and 0.2% physical mistreatment by a family member.³ Another study in the United States of individuals over 60 years old found that the 1-year prevalence for emotional abuse was 4.6%, physical abuse 1.6%, sexual abuse 0.6%, potential neglect 5.1%, and financial abuse 5.2%.² Abuse of older people may occur in the home or institutional setting and may be caused by adult caregivers, family members, or other individuals. In the long-term care setting, abuse may result not only from caregivers but also from interactions with other residents of the facility.

There are five types of abuse of older people.^4,5 Physical abuse takes place when there is intentional action that causes pain or injury. Examples may include hitting, kicking, or inappropriate use of restraints. Sexual abuse happens when there is sexual contact that is not consensual or if it occurs with someone who is not able to give consent. This may occur with unwanted touching, sexual advances, or exposure. Neglect occurs when there is failure to take care of the needs of an older adult that may result in harm. Examples of neglect include withholding food, clothing, medications, or not ensuring that a person has their personal hygiene maintained or physical aides available. Older adults may also experience emotional/psychological abuse, which happens when there are verbal or nonverbal acts that cause pain or distress. Cases of this type of abuse include verbal harassment, threats of punishment, treating an older adult like an infant, or isolating an older adult from others. Another type of abuse is financial abuse. This occurs when there is an improper use of the older adult’s property or money and may include stealing, forging a signature, or pressuring an older adult to sign documents or change a will. Financial abuse may also include making financial decisions that are not in the best interest of the individual.

Patients may also experience self-neglect. This happens when an older adult does not perform or refuses assistance with essential self-care tasks. Self-neglect may include not eating, not taking medications, not performing personal hygiene, or not maintaining a safe home environment. Individuals may have limited contact with others outside of the home.

There are several different risk factors for abuse of older people as highlighted in Table 1.^6,7 Functional dependence on another person and cognitive impairment are significant risk factors for abuse of older people.⁸ Individuals may have caregivers who are not trained or equipped to provide the care that the older adult needs. There are several risk factors for perpetrators of abuse of older people such as caregiver burden or stress, psychiatric illness, and substance misuse.^7,8 Relationship risk factors, such as family disharmony or relationships in conflict, may also lead to abuse of older people.⁸

TABLE 1: Risk factors for abuse of older people

Risk Factors in Older Adults Cognitive impairment/dementia Poor physical health Functional dependence Low socioeconomic status Substance abuse Social isolation/poor social support
Risk Factors in Perpetrators of Abuse Mental illness Substance abuse Abuser dependency on the older adult, e.g., for housing or financial assistance

 

Abuse of older people can produce several repercussions and may result in physical or psychological consequences for the older adult. There may be increased rates of depression and anxiety among older people subjected to abuse.⁹ Older people who experience abuse are more likely to be hospitalized. A study of community-dwelling individuals over the age of 65 years who were reported to Adult Protective Services for concerns of abuse of older people found that after adjusting for comorbidities, socioeconomic variables, and cognitive and physical function, there was a higher rate of hospitalization among those with reported abuse of older people (rate ratio, 2.00 [95% confidence interval, 1.45-2.75]).¹⁰ Individuals who are referred to Adult Protective Services with concerns for abuse of older people are more likely to be admitted to a nursing facility.¹¹ Older people who experience abuse also have a higher rate of disability and a higher mortality rate than those who do not undergo abuse of older people.^12,13 A study of community-dwelling individuals over the age of 65 years who were referred to Adult Protective Services examined mortality rates over at least a 9-year follow-up period associated with abuse of older people. The study found a shorter survival for individuals who had experienced abuse of older people (9%) than those who were found to have self-neglect (17%) and compared to other members of the study who did not have contact with Adult Protective Services (40%).¹³

EVALUATION FOR ABUSE OF OLDER PEOPLE

Screening

There is no uniform consensus on screening for abuse of older people by all organizations. The US Preventative Services Task Force notes there is insufficient evidence to recommend screening all older adults for abuse of older people.¹⁴  On the other hand, the American Academy of Neurology and American College of Obstetricians and Gynecologists do recommend screening for abuse of older people.^15,16 The American Medical Association recommends inquiry about family violence, which includes abuse of older people.¹⁷ A number of screening tools for abuse of older people have been developed.¹⁸ One such screening tool is the Elder Abuse Suspicion Index (EASI), which can be used for cognitively intact individuals in the primary care setting. This instrument includes five questions that the patient answers, plus one question that the physician answers. At least one “yes” answer on questions 2 through 6 indicates a need for further assessment. The EASI generally takes less than 2 minutes to perform and has an estimated sensitivity of 0.47 and specificity of 0.75.¹⁹

History and Exam

Evaluation for abuse of older people involves looking holistically at the patient and caregiver.  Osteopathic family physicians are trained to evaluate and treat the whole person, including mind, body, and spirit. Utilizing the whole-person and social situation evaluation can be helpful in identifying older adults at risk for or undergoing abuse.  

During medical visits, healthcare providers can observe the interactions between the caregiver and older adult. When possible, older adults should be interviewed individually so they can speak freely. The interview should begin with open-ended questions and then move to more specific questions based on answers. It may be particularly challenging to get an accurate history and evaluation if the older adult has cognitive impairment. It is also important to understand the older adult’s functional status and who is responsible for helping to care for them if there are functional deficits. It may be helpful to better understand the skill level of the caregiver in order to see if their skill set matches with the older adult’s needs. It is also important to identify caregiver stress.

During a medical exam, a healthcare provider can look for unexplained injuries or injuries that do not match the patient’s history. In abuse of older people, there may be a delay between the injury or onset of medical illness and seeking medical treatment. An older adult experiencing abuse may visit multiple clinicians or emergency departments for similar injuries. A healthcare provider should consider whether abuse may be playing a role if there is inconsistent compliance with medications, appointments, or following instructions. A complete physical exam for abuse of older people includes a skin and musculoskeletal exam. Signs of abuse of older people are noted in Table 2.^20-23

TABLE 2: Signs of abuse of older people

Physical Abuse Bruising in atypical locations, eg, lateral arms, back, face, ears, or neck Burns Injuries suggestive of the shape of belts, fingers, or another object Wrist or ankle lesions suggestive of restraints Multiple fractures or bruises at different states

Sexual Abuse Genital, rectal, or oral trauma Evidence of sexually transmitted infection

Neglect Malnutrition Dehydration Pressure injuries Poor hygiene or soiled incontinence products Dirty clothing Poor oral hygiene

 

Chronic medical conditions may mimic abuse of older people. For example, fractures may occur from osteoporosis or metabolic bone disease, or an individual may have a skin manifestation due to chronic disease or medications, such as anticoagulants.²⁰ Dehydration may be caused by medications or uncontrolled medical conditions. A gastrointestinal disease process, malabsorption, or malignancy may cause an individual to lose weight and appear malnourished.

Psychological assessment is also beneficial in the evaluation for suspected abuse of older people. The healthcare provider may identify signs of increased anxiety, fear, or anger that can suggest a need for further assessment. Cognitive assessment is also helpful to determine if the older adult has the capacity to make decisions and advocate for themselves.

If there are concerns about financial abuse, a healthcare provider may see signs of a disparity between assets and the individual’s living situation or appearance. For example, financial abuse might be suspected if a caregiver is suddenly able to acquire items when they appear to have limited financial assets. Another example may be if a caregiver is unwilling to allow access to the home of an older adult. If an older adult has a progressive cognitive impartment, they will ultimately have difficulty with managing their finances. Healthcare providers can assist these patients by proactively discussing options for financial management with the patient and caregivers.

Laboratory and Imaging Studies

Laboratory findings may be beneficial in some evaluations for abuse of older people. For example, findings of dehydration or malnutrition may suggest neglect if another medical reason is not apparent. Laboratory evaluation of prescription medications or illicit drugs may help to determine if patients are receiving medications they should not be receiving or if some medications are being withheld. Imaging studies may be valuable if there is concern for fractures or injury.

If a healthcare provider performs a home visit for a patient undergoing abuse or self-neglect, they may note that there is not enough food in the refrigerator, excessive clutter, or insect infestation.

INTERVENTIONS FOR SUSPECTED ABUSE OF OLDER PEOPLE

It is important to understand the reporting regulations for abuse of older people in each individual state. Healthcare providers are often required to report to Adult Protective Services or state agencies associated with aging. Healthcare providers can find more information about the specific state requirements at the U.S. Department of Justice website (https://www.justice.gov/elderjustice/elder-justice-statutes-0).²⁴ The National Center on Elder Abuse (https://ncea.acl.gov) provides useful information about signs of abuse of older people and what to do if abuse is suspected, including how to report concerns of abuse.²⁵

If abuse of older people is suspected, the healthcare provider should consider whether there is an immediate risk to the individual and if they are able to safely return to their current living environment.⁵ Determination of a safety plan is important. If a patient is not safe to return home, they may require hospitalization until a safe alternative is determined.

When abuse of older people is suspected, osteopathic family physicians may find it particularly beneficial to work with interprofessional team members to provide a holistic management plan. Social workers and case managers may be valuable in determining if there are additional resources that may be available to the individual and caregiver. Setting the individual up for support services such as Meals on Wheels, transportation, or extra services in the home may be helpful. Healthcare providers may access information about local resources and services at eldercare.gov.²⁶ The osteopathic family physician and team members may also work with an individual on managing depression and anxiety that may accompany the abuse. Healthcare providers may also need to determine the individual’s capacity to make decisions and, in particular, identify if the individual has the ability to refuse services and care.

In cases of suspected abuse of older people, documentation should occur as accurately and completely as possible. Using the patient’s own words within the medical documentation can be helpful. Detailed documentation of injuries, including size, location, and stage of healing, should be performed.

CONCLUSION

Abuse of older people is often underreported. Clinicians have the opportunity to recognize and intervene in abuse of older people. Resources may be provided by working with interprofessional team members and community agencies such as Adult Protective Services.

REFERENCES

1. World Health Organization. Abuse of older people. Accessed May 27, 2024.  https://apps.who.int/violence-info/abuse-of-older-people/
2. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health. 2010;100(2):292–297. doi:10.2105/AJPH.2009.163089 
3. Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States: prevalence estimates from a nationally representative study. J Gerontol B Pscyhol Sci Soc Sci. 2008;63(4):S248–S254. doi:10.1093/geronb/63.4
4. Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373(20):1947–1956. doi:10.1056/NEJMra1404688
5. Hoover RM, Polson M. Detecting elder abuse and neglect: assessment and intervention. Am Fam Physician. 2014;89(6):453–460. https://www.aafp.org/pubs/afp/issues/2014/0315/p453.html
6. Dong XQ. Elder abuse: systematic review and implications for practice. J Am Geriatr Soc. 2015;63(6):1214–1238. doi:10.1111/jgs.13454
7. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder abuse: global situation, risk factors, and prevention strategies. Gerontologist. 2016;56(suppl 2)):S194–S205. doi:10.1093/geront/gnw004
8. Johannesen M, LoGuidice D. Elder abuse: a systematic review of risk factors in community-dwelling elders. Age Ageing. 2013;42(3):292–298. doi:10.1093/ageing/
9. Begle AM, Strachan M, Cisler JS, Amstadter AB, Hernandez M, Acierno R. Elder mistreatment and emotional symptoms among older adults in a largely rural population: the South Carolina Elder Mistreatment Study. J Interpers Violence. 2011;26(11):2321–2332. doi:10.1177/0886260510383037                                         
10. Dong XQ, Simon M. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med. 2013;173(10):911–917. doi:10.1001/jamainternmed.2013.238
11. Lachs MS, Williams CS, O’Brien S, Pillemer KA. Adult protective service use and nursing home placement. Gerontologist. 2002:42(6):734–739. doi:10.1093/geront/42.6.734
12. Schofield M, Powers JR, Loxton D. Mortality and disability outcomes of self-reported elder abuse: a 12-year prospective investigation. J Am Geriatr Soc. 2013;61(5):679–685. doi:10.1111/jgs.12212
13. Lachs M, Williams C, O’Brien S, Pillemer K, Charlson M. The mortality of elder mistreatment. JAMA. 1998;280(5):428–432. doi:10.1001/jama.280.5.428
14. US Preventive Services Task Force; Curry SJ, Krist AH, et al. Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults. US Preventive Services Task Force Final Recommendation Statement. JAMA. 2018;320(16):1678–1687. doi:10.1001/jama.2018.14741
15. Schulman EA, DePold Holher A. The American Academy of Neurology position statement on abuse and violence. Neurology. 2012;78(6):433–435. doi:10.1212/WNL.0b013e318245d21c
16. ACOG Committee on Health Care for Underserved Women. Elder abuse and women’s health. Obstet Gynecol. 2021;137(3):e89–e93. doi: 10.1097/AOG.0000000000004298               
17. American Medical Association. Family and intimate partner violence policy. Accessed June 4, 2024. https://policysearch.ama-assn.org/policyfinder/detail/*?uri=%2FAMADoc%2FHOD.xml-0-4664.xml
18. Gallione C, Dal Molin A, Cristina FVB, Ferns H, Mattioli M, Suardi B. Screening tools for identification of elder abuse: a systematic review. J Clin Nurs. 2017;26(15-16):2154–2176. doi:10.1111/jocn.13721
19. Yaffe MJ, Wolfson C, Lithwick M, Weiss D. Development and validation of a tool to improve physician identification of elder abuse: the Elder Abuse Suspicion Index (EASI). J Elder Abuse Negl. 2008;20(3):276–300. doi:10.1080/08946560801973168
20. Chang ALS, Wong JW, Endo JO, Norman RA. Geriatrics dermatology: Part II. Risk factors and cutaneous signs of elder mistreatment for the dermatologist. J Am Acad Dermatol. 2013;68(4):533.e1–533.e10. doi:10.1016/j.jaad.2013.01.001
21. Chen AL, Koval KJ. Elder abuse: the role of the orthopaedic surgeon in diagnosis and management. J Am Acad Orthop Surg. 2002;10(1):25–31. doi:10.5435/00124635-200201000-00005
22. Murphy K, Waa S, Jaffer H, Sauter A, Chan A. A literature review of findings in physical elder abuse. Can Assoc Radiol J. 2013;64 (1):10–14. doi:10.1016/j.carj.2012.12.001
23. Wiglesworth A, Austin R, Corona M, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191–1196. doi:10.1111/j.1532-5415.2009.02330.x
24. U.S. Department of Justice. State elder abuse statutes. Accessed on June 4, 2024. https://www.justice.gov/elderjustice/elder-justice-statutes-0 
25. National Center on Elder Abuse. Accessed on June 4, 2024. https://ncea.acl.gov/home#gsc.tab=0 
26. Administration for Community Living. Eldercare locator. Accessed on September 2, 2024 https://eldercare.acl.gov/Public/Index.aspx