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.
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