Elder Abuse

In addition, romance can be used as a tool to manipulate the elderly person. Because elderly persons may frequently experience isolation or loneliness, they may be more prone to accept professions of love and desirability at face value. The pleasure of being considered attractive does not disappear with age nor does sexual responsiveness. Even further damage can be done. When the abuser is able to “prove” his or her dedication with marriage, he then gains legal rights and privileges.

Psychological manipulation is not necessarily associated with distress on the victim’s part—
instead, an elderly person may experience comfort and caring. The victim will not give credence to the abuser’s ulterior motives. The victim may therefore collaborate in concealing the abuser’s role. Alternatively, the abuser may convince the victim that he or she is “bad,” that the abuser
“really cares,” and is the only one preventing the elderly person from “going to a home.” This has been likened to the Stockholm syndrome (a psychological response in which a hostage shows signs of loyalty to his abductor). Paradoxically, lurid publicity about elder abuse can facilitate the effectiveness of the abuser’s strategy of persuading the victim that the abuser is the only bulwark against abandonment.

Financial elder abuse and exploitation are common. Financial gain serves as motivation for abuse, which can influence and/or control the victim. Financial abuse and exploitation are more likely to be identified by friends and neighbors, family members, financial professionals, or attorneys, than by physicians. The financial abuser can:

• Obtain power of attorney and then divert funds.

• Cheat on expenses and/or wages as the dependent elder becomes more impaired.

• Manipulate the elderly person into accepting unneeded or misjudged financial “services.”

• Transfer property into his name.

• Be named as beneficiary in testamentary documents—wills or trusts.

Elder abuse issues for the practicing clinician

A clinician may learn of suspected elder abuse directly from a patient. Alternatively, the clinician may become concerned after observing an elderly patient or after a family member, concerned party, or outside agency refers an elderly person. The victim may be unaware of exploitation or be intimidated or insulted at the implication that he is “crazy” or “becoming senile” and cannot take care of himself or his affairs. Appropriate response requires sensitivity and careful attention to issues of responsibility, trust, and confidentiality. The clinician should maintain an attitude of “healthy suspicion,” even with familiar patients and caregiving situations, as the following cautionary case vignette illustrates.

Case Vignette

Dr X had cared for Mrs Y for many years, including the last decade of her life, as she slowly descended into dementia. Hired as a caregiver, Ms Z became a constant presence in Mrs Y’s life and Dr X relied on her for essentially all communication about Mrs Y. Although Dr X had recorded Mrs Y’s severe dementia, he did not question Ms Z’s salary increase and her subsequent purchase of a house with Mrs Y’s funds. Furthermore, having documented her strong desire to live out her life in her home, he did not protest when Ms Z moved Mrs Y into the new house.

After Mrs Y died, it was found that her will had been amended in the previous year and that her entire estate had been left to Ms Z. At trial, Dr X testified that although he did not believe Mrs Y was competent, he believed Ms Z “deserved” the benefits that had come her way. He was rebuked by the court for having ignored his own findings. In an attempt to safeguard decisions from the “undue” influence of caregivers such as Ms Z, special protections have been established by law.[6,7]

Identifying suspected elder abuse

Although it may lay the groundwork for a patient (or a family member) to begin to recognize an ongoing problem, simply asking an elderly person about abuse will not always identify a situation of abuse. Many cases will be overlooked. While various screening procedures have been suggested for the identification of elder abuse, none has gained general acceptance, and different approaches result in substantially different rates of identification.8 A better-accepted and more-effective method is the concept of identifying risk factors (Table).[9]

In any case of suspected elder abuse, the clinician is advised to undertake a comprehensive examination. While the psychiatrist should describe obvious relevant physical findings, a physical examination should be undertaken by an appropriate specialist. Documentation of a careful mental status examination is invaluable, both for clinical and evidentiary purposes. Mood and affective reactions may reveal difficulties even in the face of verbal denial. Careful evaluation of cognitive functions is especially essential. Vulnerability to financial abuse is elevated during the early and mild stages of dementia, when a person’s memory and cognition are declining, but when he can still sign a deed or contract, or execute a trust or will, albeit without clear understanding and appreciation.[10]