As the population ages, psychiatrists will need to take a more proactive role in preventing, diagnosing and treating elder abuse. This article looks at the definition of elder abuse and the history of reporting it, research findings on the effects of abuse on mortality, and needs for the future.
Maltreatment of vulnerable elderly individuals is a concept that can be understood in many different ways, gradations and intensities. Minimally, this concept can include active or passive physical, sexual and/or psychological abuse, neglect, self-neglect, fiduciary exploitation, and abandonment. We must assess individual tolerances for maltreatment, etiologies and reasons for enduring perpetration of abuse. We must clarify who the victims are and who the perpetrators/caregivers are, as well as the past and current relationships between them. We must distinguish between the settings in which victimization takes place: in the community, while living alone, with others or family, or in acute- or long-term care facilities.
Other essentials to understanding and preventing elder maltreatment include the history and current status of federal, state and local legislative and financial involvement, varying content of state reporting mandates, level of awareness and education of health care professionals, interdisciplinary collaborations, or lack thereof. Ongoing research findings during the past two decades have shed light on epidemiology and underreporting (Pillemer and Finkelhor, 1988); factors influencing reporting rates (Wolf and Li, 1999); outcome such as survival rates (Lachs et al., 1998); and predictive factors of caregiver characteristics, caregiving context (Pillemer and Suitor, 1998) and victim characteristics (Lachs et al., 1994).
There is increasing literature on risk factors, preventive efforts, assessments, interventions, follow-up and outcome, as well as on issues of confidentiality and privacy. The victim's capacity to participate in decision-making and the delicate balance between autonomy and the need for protection, leads us into ethical and legal arenas. The possibility of criminality on the part of the perpetrator and its judicial complexities also become important. Since these issues have been addressed in previous publications they will not be the focus of this article.
History and Definition
Social workers and nurses brought elder maltreatment to legislative attention as a major public problem in the late 1970s. It has been estimated that 2.5 million elderly people are subject to maltreatment annually (Kleinschmidt, 1997). Elder maltreatment crosses gender, socioeconomic levels and ethnic boundaries.
Low socioeconomic level is a major risk factor for self-neglect. Being female, over the age of 75, and having recent decline in physical and cognitive capacity are risk factors for any kind of maltreatment. Women in this population, most of whom have spent their lives caring for others, most frequently have inadequate resources for maintaining a semblance of quality of life in late life.
Profiles of perpetrators of elder maltreatment can include:
Similarly, none of these laws include directives as to how abusive situations should be handled after an investigation has occurred, but many include punitive measures for health care professionals who do not report such situations.
Despite these egregious situations and despite being beleaguered by a dysfunctional managed care/cost system, considerable advances have been made in the medical profession by individual physicians and professional organizations.
Review and research articles on elder maltreatment have appeared in The New England Journal of Medicine and The Journal of the American Medical Association, as well as the major journals for emergency physicians, family physicians, internists and psychiatrists. Additionally, articles have appeared in several journals of state medical societies and in the burgeoning geriatric specialty journals.Jones et al. (1997) surveyed 3,000 members of the American College of Emergency Physicians to determine their familiarity with their local reporting laws and availability of written protocols on how to proceed. Of the 24% who responded, only 31% reported having written protocols available; 25% recalled some educational content; 74% did not think there was a clear-cut medical definition of elder maltreatment; 58% did not feel confident in their own judgment; and 92% did not feel that the state supplied sufficient resources for assessment and intervention.
Beginning in 1994, Lachs and colleagues have presented several data-analyses on 2,812 community-dwelling (New Haven, Conn.) men and women who were over 65 in 1982. These studies examined the risk factors for the investigation of maltreatment by Protective Services (PS) and the relationship of mortality to maltreatment. During a nine-year follow-up, there were 184 reported cases (Lachs et al., 1997). Risk factors for maltreatment of any kind were age, poverty, functional disability and cognitive impairment. We must take into consideration that these data only reflect occurrences of maltreatment within the social welfare system of which PS is a part.
At the end of a 13-year follow-up period and after correcting for other factors associated with increased mortality, the survival of the non-investigated group was 40% and the investigated group 9%. Seventeen percent who had not suffered abuse or neglect but did not properly care for themselves were still living (Lachs et al., 1998). No associations could be studied to ascertain whether earlier intervention leading to improved quality of life could alter these results or whether after the investigation and corroboration no suitable resources were available to intervene appropriately and optimally.
Wolf and Li (1999) reported factors that influence elder abuse reporting rates to PS in 27 geographic areas in Massachusetts. High rates of reporting were associated with lower socioeconomic status, more community training of area professionals and higher agency service rating scores.
Guidelines for Professionals
Elder mistreatment guidelines for health care professionals have been prepared by various organizations, but resources for training are not universally available and denial, rationalization and minimization of the problem tend to prevail by those not directly involved with these issues. One set of guidelines, prepared by the Mount Sinai/Victim Services Agency Elder Abuse Project (N.Y.), is available from the New York Office of Children and Family Services. (Copies can be requested by e-mailing <AY3860@dfa.state.ny.us>.) The guidelines address detection, assessment, and intervention with patient and with family (voluntary and involuntary), as well as list community resources and reporting avenues. The National Elder Abuse Incidence Study, prepared by the National Center on Elder Abuse at the American Public Human Services Association in collaboration with Westat Inc., is available at <www.aoa.dhhs.gov/abuse/report/default.htm>.
If each state had an Office of Health, it is possible that the medical mental health issues of the abused elderly and their families would be better addressed. Similarly, it would change the fact that social issues are usually the initial and the final (if not only) focus of state interventions.
Ideally, multidisciplinary consultation teams should be available with all necessary disciplines represented. Such teams, however, are only available in model situations, are mostly theoretical, and are far from standard at this time in our history and level of societal attentiveness to elder maltreatment (Anetzberger et al., 2000; Wolf and Pillemer, 1994).
Where does the American Psychiatric Association stand on the issue of elder maltreatment? Under the aegis of the APA Council on Aging, a position paper on the issues was prepared, approved by the APA assembly and board of trustees, and published in The American Journal of Psychiatry (APA Council on Aging, 1995). Emotional abuses were described as threats, insults, harassment, harsh orders, infantilization, restriction of social and religious activities, financial exploitation, physical abuse, and excess stress. Psychiatric symptoms and conditions such as depressed mood, cognitive impairment, substance abuse, agitation, insomnia, lethargy, fear, anger, ambivalence, resignation, self-neglect and delirium are noted in many other psychiatric conditions, but are also quite prevalent as reactions to elder abuse.
APA recommends that psychiatrists participate in the formulation of protocols for the identification of elder abuse, neglect and exploitation; be aware and knowledgeable of local reporting laws; whenever possible participate in clinical and research multidisciplinary consulting teams; and collaborate with appropriate government and private agencies. Psychiatrists are encouraged to develop curricula for medical students, residents, and continuing medical education programs for primary care physicians and psychiatrists. These programs should include the mental status manifestations, behaviors and treatments of elder abuse, neglect and exploitation. Psychiatrists have the expertise, if appropriately trained, to develop a trusting relationship with both victim and perpetrator, thereby establishing a working alliance of which each is a part. Recommendations for interventions can then be followed while maintaining maximum autonomy.
DSM classification and CPT coding for elder maltreatment have yet to be formulated for reimbursement of mental health assessment and interventions between victims and perpetrator/caregiver or for multidisciplinary collaborations. With proper training, psychiatrists should be able to assess capacity for decision-making and should possess clinical judgment to decide how and when involuntary actions have to be implemented. The goal of such assessments is to establish a new balance of safety and optimal quality of life in late life.