Elder Abuse

Basic Information

The average life expectancy is on the rise with persons over the age of 85 accounting for the largest-growing segment of the U.S. population. Today 13% of the U.S. population is over 65 and by the end of the next 30 years those over 65 will make up 22% of the population. As this segment of the population gets older, the family care of elder persons will be on the rise. Before we look at how abuse and neglect occur, we must first look at statistics on how the elderly live and who is most likely to assume the burden of care should assistance be needed.

Elders who require assistance turn to their spouses for help first and then to their daughters or daughters-in-law.
Two-thirds of the elderly live with a family member while one out of 3 live by themselves.
The majority of elders have children living less than 30 minutes away and have at least one weekly visit from their children.
While 80% of older men are married, older women are 5 times more likely to be widowed and 3 times more likely to live by themselves.
Five percent of those over 65 live in nursery homes.

Now let's take a look at the caregiver.

One in five persons over 45 is a caregiver to a relative.
Thirty-five percent of caregivers are spouses, often elderly themselves with their own financial and health difficulties.
Forty percent of caregivers are the elder's adult children.

Elder abuse and neglect of those over 65 years of age is thought to occur in the 3 to 4 percent range in the U.S. -- at the rate of half a million to two-and-a-half million persons. Accurate data is difficult to obtain because it is estimated that less than one in five cases of elder abuse is reported. This is because this serious problem is not always recognized by the victim, the abuser or even the health care professional. It is often a subject that is unpleasant to deal with, talk or even think about.

Certain older persons are more vulnerable than others because of lack of support in the family or community or because of financial difficulties or because of decreased cognitive impairment. Additionally those older persons who are in failing health are more susceptible to abuse and neglect because they often do not have the mental or physical resources to report the abuse, or live in denial about it, or are too fearful of losing their already fragile support system to complain about it.

Many persons are under the assumption that elder persons are abused most often by a part-time professional caregiver who comes to the home and can act in a cruel or uncaring manner when away from the watchful eyes of the rest of the family. And while this certainly can happen, it will come as a surprise to many to find that the majority of elder abusers are members of the elder's family, most often the spouse and sometimes the children or other close blood relatives.

What then is the make-up of the abuser that is most often seen? The most likely profile of the abuser includes some or all of the following:

History of mental illness
History of violence
History of alcoholism or other substance abuse
A financial dependence on the victim
Absence of other close family ties

No one definition can fit every elder abuser. Abusers can come from all socioeconomic and education levels -- in other words, all walks of life -- but male spouses who abuse their wives are more likely to have:

A high degree of economic anxiety
Low self-esteem
Destructive coping behaviors
Have had violent or controlling role models
Lower income and education
Beliefs of entitlement and the feeling that there is nothing wrong with their behavior

In most cases the abuser has taken care of the elder for many years and often feels overwhelmed by the burdens and responsibilities of taking on the long-term role of caregiver -- feeling cheated out of having a more independent, carefree life. This is known as caregiver stress. Anger builds, especially when the caregiver is financially dependent on the elder and the caregiver feels trapped and is primed to strike out in an abusive way. The potential for violence and/or neglect increases. The lack of physical abuse does not negate the grave consequences that can affect the frail, elderly person who is neglected -- isolated or not given needed attention that may be required on a daily basis. Neglect may cause the elder to become malnourished, afraid, to have accidents in which serious injury occurs, become very depressed and even turn suicidal. Neglect on the part of the caregiver is unpredictable in many cases and not easy to define, but in its passive-aggressive way can be just as damaging to the elder as physical abuse, especially over the long term.

We have defined neglect. What then constitutes abuse? Though experts on elder abuse have come up with varying definitions, a picture emerges that brings the experts into general agreement. Abuse is defined fourfold as:

physical
psychological
financial
material

Let's explore these kinds of abuses individually.

Physical abuse can include:

rape
beatings
tying the elevator to a chair or bed
burning the victim
starving the victim

While it is agreed that men and women suffer elder abuse in equal numbers (50/50) it is more difficult for women to bound back both physically and mentally. Elders who are cognitively impaired are at greater risk for physical violence.

Psychological abuse includes:

verbal abuse and humiliation, subtle or angry and overt
refusal to allow the elder access to the things that the elder enjoys whether it is people (i.e. telephoning a friend), activities (i.e. watching television) or refusing to allow access to possessions (i.e. refusing to allow the victim to choose what clothing to wear)
refusal to allow the elder to exercise legal rights

Financial abuse can include:

stealing from the victim which can occur in various ways including not allowing the elder access to funds that are rightfully hers or his
withholding all or partial amounts of money due the victim from retirement or money market funds or outright embezzlement or fraud
lying to the victim about their financial worth; this is common -- the victim feels that he or she is nearly penniless

Material abuse can include:

stealing the victim's possessions
selling the victim's property

Most elders, in poor health, have experienced all or combinations of the above kinds of abuse but neglect is by far the most common form of elder abuse.

Of course not all elder abuse occurs at the hands of a spouse, child or other family member, but data regarding abuse at the hands of professional caregivers is sketchy at best, often with denial and minimization being the response of not only the suspected abusive caregiver but also the caregiver's employer so as not to "rock the boat" and cause trouble for the employer, hospital or institution involved. It is difficult to prove abuse on the part of professional caregivers, except in the most obvious cases, as the definition of what constitutes legal abuse varies from state to state. Additionally the elder often has cognitive impairment and can become confused or forgetful during any kind of deposition or testimony.

In a rare study of abuse of the elderly in nursing homes conducted in 1989, the staff of the nursing home was surveyed and 36% reported witnessing physical abuse of the patients, while 86% reported witnessing some form of psychological abuse. Clearly this is an area where more surveys need to be taken so a more reliable data bank can be built on the abuse of the elderly in institutions. One thing is painfully clear -- whether the frail elder suffers physical abuse at the hands of a relative or a professional caregiver, over 50% of elders who are admitted into institutions as the victims of physical violence remain there. The problem of elder battering is acute -- with ramifications not only for psychological damage to the elder but for the financial costs to the elder or hospital, institution and medical staff/support for physical care and rehabilitation.

Symptoms

The abused elder may exhibit certain adverse psychological symptoms when seeing a health care provider. This presentation of symptoms can be confusing. Fear, anxiety or depression can be suggestive of personality disorders and the seeming inability on the part of the patient to remember unpleasant incidents and events or the patient exhibiting generalized confusion can even mimic Alzheimer's disease. Fear of retaliation from the abusive caregiver or societal shame can prevent the patient from admitting to any abuse.

Physical symptoms however can be strong indicators of abuse. They include:

sleeping disorders where extreme listlessness is exhibited
eating disorders
multiple bone or rib fractures
rope burns
bruises
lacerations

Also lack of nutrition in the elderly, known as the failure to thrive, can also be but is not necessarily an indicator of abuse.

Diagnosis/Treatment

Diagnosing elder abuse is the challenge to the health care provider who must diagnose within the framework of our cultural denial of the very existence of elder abuse as well as the pervasive cultural bias towards the elderly in general. Physical symptoms of abuse described above are strong indicators, especially if they are inconsistent with the patient's medical history. Observing the caregiver can also help the health care provider make a diagnosis. Signs to watch for in the caregiver include:

anger and hostility
over control
overt suspicion towards the health care provider
lack of empathy for the abused elder
complaining about the burden of caretaking

and in some cases:

obsequious, obsessive concern about the abused elder as if "something will be found out" unless the overconcern and fussiness is plainly exhibited

Of course ideal for diagnosis is the directed admission of suffering abuse by the patient. If you are an elder being abused, it is in your best interest if you can confide in a nonjudgmental, accepting, experienced health care provider about the abuse so that you can begin to receive help.

Unfortunately many patients are too afraid of repercussions from the abuser or too ashamed to admit it or in many instances have long ago failed to even recognize the abuse and just consider it the norm.

In the best of all possible worlds the health care provider will be able to assume the role of confidant -- or collaborator if you will -- and win the trust of the elder. With the abuser out of the room, the health care provider will often get the best results from asking such direct questions as "Is someone beating you?" or "Is someone stopping you from doing what you would like to do?" Eliciting direct, honest responses from oblique or indirect questioning rarely works. The abused elder tends to hedge generalities. But posed with a direct, pointed question, the abused elder is likely to respond "Yes," with relief and diagnosis can be confidently made and treatment begun.

Corroboration from a third party such as another relative or friend of the abused is often essential.

In treating the abused elder, taking a history of the patient is important to determine risk factors in the patient's life in general. For instance, it is important to know the patient's marital status and social support system. For example, divorced or separated women have more depression and poorer immune functions. Older persons in general who are the most socially isolated have twice the death rates of those who are the least socially isolated. Social networks in general are predictors of both health and mortality. Understanding the abused elder's social situation is important when planning intervention and management of abuse.

An important part in caring for the elderly in poor health is CGA (comprehensive geriatric assessment) offered as an ongoing outpatient (as well as inpatient) service to the elderly in which assessments can be made regarding those "at risk" for lack of medical care, inadequate social support and the potential for abuse. In addition, assessment of the abusive caretaker is given and social services provided for the caregiver.

CGA can be one of the services offered to the abused elder as part of a management plan to improve, eradicate or prevent an abusive situation. The health care provider of an abused elder will be able to identify local services that will be important for the victim to utilize. Making the abused elder (and if possible a concerned friend of the elder) aware of and knowledgeable about how to use appropriate social services is a primary goal.

A management team put together by the patient's health care provider of social workers, therapists, physicians and members of Legal Aid and local protection agencies will give the abused elder much-needed support. If you are concerned about an abused elder, investigate local support services such as Meals on Wheels.

Unlike thirty years ago, more and more health care providers are able to make house calls on the frail or bedridden elderly, a good way to be on the lookout for new or continuing abuse. In any case abused elders must keep follow-up appointments with their health care providers, arranging for transportation to the office from a social service if needed. There are many issues concerning abused elders that take time to resolve and they will differ in each case. Some will include explaining social services, legal issues, discussing help for or possible restraining orders against the abuser, etc.

Finally a plan should be formulated about what to do if physical violence continues to occur, i.e. how to arrange for transportation out of the house in an emergency, who to call if violence begins, where the nearest shelter is, or the most appropriate way to react in a potentially violent situation that will least provoke the abuser until help arrives or you are able to leave.

If you are suffering from elder abuse or are concerned about someone who is, please see your health care provider promptly.