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Educational Objectives

After reading this article, you will be familiar with:

• The different subtypes of elder abuse.
• The implications of elder abuse for your practice
• Ways of recognizing and combating elder abuse. • The physician’s responsibilities.

Who will benefit from reading this article?
Psychiatrists, neurologists, primary care physicians, geriatricians, nurse practitioners, and other health care professionals. Continuing medical education credit is available for most specialists. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing board.

Elder abuse—behaviors toward the elderly that are malignant and damaging—has
become a major public health issue. In Boston, more than 3 of 100 persons aged 65 years and older have been victims of elder abuse, and tens of thousands of cases are reported to Adult Protective Services Agencies annually in the United States.1 These numbers, which do not include financial elder abuse, can be expected to increase as the population of older persons increases.[1,2] Between 2000 and 2030 the population aged 65 years and older in the United States is projected to increase from 12.4% to 19.6%. Even more dramatically, the number of persons aged 80 years or older is anticipated to more than double from 9.3 million to 19.3 million.[3]

Elder abuse is a concern for all practitioners who care for elderly patients or their family members. An elderly person’s fears of aging and dependence may be heightened by stories and news accounts of abuse. Medical and psychiatric care is fundamental in the identification, treatment, and mitigation of clinical effects of elder abuse, and physician documentation often provides evidence crucial for investigations of elder abuse. All practitioners need to be aware of the ethical and statutory requirements for reporting abuse or suspected abuse. In addition, elder abuse has broader effects that radiate through society—to family members, caregivers, institutions, and courts (issues beyond the scope of this article).

Here I review aspects and concepts of elder abuse and the implications for clinical and forensic practice. I will begin with an illustrative case vignette.

Case Vignette

Mrs A was a long-widowed 86-year-old woman whose favorite nephew was unable to reach her by phone. He had been turned away at her door by Mr X, who said he was her conservator and thus responsible for Mrs A. 

A social worker from Adult Protective Services was also rebuffed. Mrs A’s nephew sought the assistance of an elder law attorney, who obtained a court order for a medical and psychiatric evaluation of Mrs A.

Mrs A proved to be a sweet but frightened woman who clearly had lost a lot of weight. She was very weak and had been functionally confined by Mr X, with no access to a telephone. She appeared desperate for contact and conversation. Her short-term memory was impaired, and she did poorly on tests of mental control; she scored 21 on the Mini Mental State Examination (MMSE). Medical examination confirmed multiple bruises, malnutrition, and other untreated medical conditions.

Based on her impaired capacity and physical deterioration, with obvious evidence of injury, neglect, and abuse, and her overt fear of Mr X, a petition to the court finally removed Mr X as conservator. The lengthy process eventually consumed nearly two-thirds of Mrs A’s estate. (As conservator, Mr X was able to use her funds to oppose the actions against him.) Mrs A was
finally able to live out her life in comfort and safety and with the attention of family and friends.

Definitions and typology

The American Medical Association defines elder abuse and/or neglect as “an act of commission or omission that results in harm or threatened harm to the health or welfare of an older adult,” whether intentional or unintentional. Several subtypes are recognized.[4]

Physical abuse refers to the use of force that can result in injury, pain, or impairment. In addition, inappropriate use of drugs, restraints, or punishment, or the imposition of medical procedures without informed consent can be considered physical abuse. Because physical abuse may result in injuries, prompt and careful physical examination is required. However, because the elderly are prone to falls and can easily fracture bones or tear skin, establishing abuse can be a clinical challenge. The problem is compounded in the case of lesions such as ulcers that can be either signs of serious neglect or difficult-to-avoid complications of wasting illnesses.

Sexual abuse includes rape and any other nonconsensual sexual contact, as well as other types of assault, exposure, nudity, etc. Sexual abuse of elders is an especially grave concern when unrelated caregivers attend patients with minimal or no supervision.[5]

Emotional or psychological abuse refers to any verbal or nonverbal acts that result in anguish, pain, or other distress (eg, insults, threats, humiliation, harassment). Isolation from friends, family, and/or community can be considered psychological abuse and also potentially facilitates an abuser’s other goals, including secrecy. Adverse influence specifically related to psychological elder abuse may manifest in multiple ways. It can be verbal. Statements such as “no one else cares about you,” are often accompanied by efforts to isolate the victim by controlling access to mail, phone, or transportation. Such verbal abuse also creates “evidence” that family, friends, or neighbors do not, in fact, care. By creating doubt and fear through the withholding or providing of basic needs (eg, food, hygiene, medications) and brow-beating the elderly person, the abuser can extract favors or concessions.

Manipulation of prescription medications, especially for pain, or controlling access to alcohol or cigarettes can also be a very effective means of control. Medically knowledgable abusers can control mental states by having their victim be relatively alert for a doctor’s visit but obtunded at other times.