Hidden in the Shadows: Detecting and Addressing Elder Abuse

Iris hemorrhage and a large bruise around the eye area on mature adult
The number of potentially abused elders is staggering: in 2015, older adults — defined as people age 65 or above constituted nearly 15% of the US population — up by 1.6 million from 2014.

Elder abuse can be defined as “intentional or neglectful acts by a caregiver or ‘trusted’ individual that lead to, or may lead to, harm of a vulnerable elder.”1 It is often a “hidden offence, often perpetrated against vulnerable people, many with memory impairment, by those on whom they depend.”2

Elder abuse is common, with one study suggesting that it may affect as many as 1 in 4 vulnerable older people.3 According to the National Council on Aging, approximately 1 in 10 Americans older than 60 years has been the victim of abuse, including physical abuse, psychological or verbal abuse, sexual abuse, financial exploitation, or neglect.4

Given the rapidly burgeoning population of older adults in the United States, the number of potentially abused elders is staggering: in 2015, older adults — defined as people age 65 years or above (47.8 million) constituted nearly 15% of the US population — up by 1.6 million from 2014.5 It is projected that by 2060, the number will reach 98.2 million, comprising nearly one-fourth of US residents5 as the “Baby Boomers” age and as life expectancy is expected to increase.6 Of these, 19.7 million will be age 85 years or older.5

Elder abuse can take place in both community and institutional settings; however, some research suggests that it is more common in the community.7 A 2000 survey showed that 60.7% of elder abuse took place in domestic settings, whereas 8.3% took place in institutional facilities.8

It is difficult to estimate the true prevalence of elder abuse as it is often “unreported, undetected, and underestimated by professionals.”2,3 Only 1 in 14 cases is reported to authorities.4 Moreover, healthcare providers “tend to underestimate the prevalence of elder abuse and only a minority ask their older patients about it routinely.”9 One study found that 63% of physicians never asked their patients about elder abuse, and only a third reported having encountered it in the previous 12 months.10 Less than 2% of reports of elder abuse and neglect to state Adult Protective Services (APS) come from physicians.1

“Physicians and other healthcare providers — particularly those who specialize in the care of older people — are likely to encounter elder abuse regularly and therefore play an important role in its detection and management,” according to Claudia Cooper, MD, professor of psychiatry of older age, Division of Psychiatry, Faculty of Brain Sciences, University College London, United Kingdom.

Psychiatrists may become involved when psychiatric illness is an outcome of the abuse or because psychiatric illness makes elders more vulnerable to abuse, she told Psychiatry Advisor.

The Evolving Understanding of Elder Abuse

Elder abuse is not a new phenomenon, but it did not garner public or research attention until relatively recently.6 Awareness of “granny battering” a term coined in the 1970s,2 has increased, and in 1980, the House Select Committee on Aging heard testimony about elder abuse in the United States.6 A 1974 amendment to the Social Security Act created APS, which was originally designed to protect adults with physical and/or mental limitations, but its mission was later expanded to encompass elder abuse as well.6

As awareness of elder abuse evolved, lawmakers and service providers turned to the child abuse model with its mandatory reporting laws, “[requiring] the reporting of incidences of abuse through specific channels, the designation of certain professionals to report if incidences of abuse are learned, and penalties for violations… and allowing a third party to intervene if there is suspected child or elder abuse.”6

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Types of Elder Abuse

“Elder abuse” is a broad term encompassing 5 categories: neglect/abandonment, physical, financial, psychological, and sexual abuses.1,7

Neglect can be defined as intentional or unintentional “failure of the caregiver to provide life necessities” or the refusal of the caregiver “to permit others to provide appropriate care.”1,7 Neglect is one of the most common types of elder abuse in residential facilities.7 Signs of neglect include dehydration, depression, fecal impaction, malnutrition, and medication misuse.7

Psychological/emotional abuse is the “infliction of mental anguish”1 and includes verbal aggression, threats of physical harm, threats of institutionalization, and humiliating or degrading statements.7 It should be suspected when a caregiver refuses to leave the older adult or speaks for him/her, or if the older adult expresses fear in the presence of the caregiver.7

Social abuse, a subtype of psychological/emotional abuse, takes place when a caregiver “denies an older adult contact with family or friends, deprives [him/her] of access to transportation”, restricts or monitors phone calls, or intentionally embarrasses older adults in front of others.7

Sexual abuse involves “nonconsensual touching or sexual activities that are threatened or forced upon an older adult.” It is more common in frail or dependent elders.7

Physical abuse refers to a “non-accidental act that results in physical pain or injury, including bruises, fractures, and burns.”7 Restraint is also considered a form of physical abuse.1

Financial exploitation, the “illegal or importer use, or mismanagement of a person’s money, property, or financial resources,”7 includes theft or unauthorized use of credit or debit cards, and coercion to deprive the elder of assets.1

Suspicion should arise when in the setting of unexplained changes in power of attorney, wills or other legal documents, missing checks, money, or belongings.7 Although adult children, grandchildren, or other caregivers have typically been considered the abusers, recently it has become recognized that a spouse — especially in a second marriage — can also be an abuser.7

These forms of abuse are not mutually exclusive; an elder who experiences one type of abuse will often be the victim of another.6