Elder Abuse 

Over the past 35 years, tremendous strides have been made in identifying and increasing awareness about patterns of abusive relationships. Child abuse and domestic violence have received significantly more recognition than elder abuse and continue to receive more attention in both public and medical domains, although abuse clearly occurs in persons of all ages.

With current medical advances and the adoption of healthier lifestyles, people are living longer. Older Americans now comprise the fastest growing segment of the United States population. According to the US Census Bureau, people 65 years of age and older accounted for 12.5% of the US population in 2000.^[1] By the year 2020, this group will increase by 5.5%, and by 2050, older Americans are projected to account for 25% of the population.^[1]

As a result of the sheer number of older Americans, the number of elder abuse cases will increase, and the impact of elder abuse as a public health issue will grow. Victims of violence have twice as many physician visits compared with the general US population, allowing opportunities for discovery and intervention. Due to the relative isolation of many elders who are mistreated, an unexpected visit to the emergency department may be the only opportunity for detection. Emergency physicians are in a unique position to affect diagnosis and management of this vulnerable population.

Elder mistreatment is a multidimensional phenomenon that encompasses a broad range of behaviors, events, and circumstances. Unlike random acts of violence or exploitation, elder abuse usually consists of repetitive instances of misconduct. It encompasses any act of commission or omission that results in harm or threatened harm to the health and welfare of an older adult.

The US National Academy of Sciences defines elder abuse as follows:

• Intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended), to a vulnerable elder by a caregiver or other person who stands in a trusted relationship to the elder
• Failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm.

Systematically, the terminology used to describe elder abuse is not consistent. Terms vary among researchers, and usage is not consistent in the laws of different states. Even the age at which a person is considered elderly, usually 60 or 65 years, is debated. Seven categories of elder abuse have been described by the National Center on Elder Abuse (NCEA).^[2] Categories include the following:

• Physical abuse - Any act of violence that causes pain, injury, impairment, or disease, including striking, pushing, force-feeding, and improper use of physical restraints or medication
• Emotional or psychological abuse - Conduct that causes mental anguish including threats, verbal or nonverbal insults, isolation, and humiliation. Some legal definitions require identification of at least 10 episodes of this type of behavior within a single year to constitute abuse.
• Financial or material exploitation - Misuse of an elderly person's money or assets for personal gain. Acts such as stealing (money, social security checks, possessions) or coercion (changing a will, assuming power of attorney) constitute financial abuse.
• Neglect - Failure of a caretaker to provide for the patient's basic needs. As in the previous examples of abuse, neglect can be physical, emotional, or financial. Physical neglect is failure to provide eyeglasses or dentures, preventive health care, safety precautions, or hygiene. Emotional neglect includes failure to provide social stimulation (leaving an older person alone for extended periods). Financial neglect involves failure to use the resources available to restore or maintain the well-being of the aging adult.
• Sexual abuse - Nonconsensual intimate contact or exposure or any similar activity when the patient is incapable of giving consent. Family members, friends, institutional employees, and fellow patients can commit sexual abuse.^[33]
• Self-neglect - Behavior in which seniors compromise their own health and safety, as when an aging adult refuses needed help with various daily activities. When the patient is deemed competent, many ethical questions arise regarding the patient's right of autonomy and the physician's oath of beneficence.
• Abandonment - The desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.

Further training is needed for physicians regarding elder abuse.^[34]

Frequency

United States

Due to the inconsistencies in the working definitions of elder abuse, differences in sampling and survey methods, and underreporting of cases, obtaining accurate information on the incidence of elder abuse and neglect is difficult. A 2003 report from the National Research Council suggests that 1-2 million Americans age 65 years or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection.^[3] Other studies suggest that 3-10% of elders are abused or neglected.

Many factors play a role in the underestimation of the number of abused elders. Patient factors include fear, shame, guilt, or ignorance. Healthcare providers underestimate and underreport elder abuse due to decreased recognition of the problem, lack of awareness of reporting requirements, including who to report to, and concerns about physician-patient confidentiality.

In addition, many studies routinely exclude certain populations such as persons unable to respond to a survey, speakers of languages other than English, and persons with mental illness, further complicating accurate tallies of the number of older persons who are abused. Despite difficulty in identifying the exact frequency of elder abuse, the occurrence is common enough to be encountered regularly in daily clinical practice. As a result, healthcare providers must maintain a high index of suspicion.

Mortality/Morbidity

Elders who are victim to physical abuse, caregiver neglect, or self-neglect have triple the mortality of those never reported as abused. Early detection and intervention by healthcare professionals in elder abuse cases may lead to decreased morbidity and mortality. Healthcare provider involvement is paramount, as studies have shown that only 1 in 6 victims are likely to self-report mistreatment to the appropriate legal authorities.

Race

Elder abuse occurs among members of all racial, socioeconomic, and religious backgrounds. The NCEA found the following racial and ethnic distribution among older persons who had been abused:

• White, non-Hispanic – 66.4%
• Black – 18.7%
• Hispanic – 10%
• Other – 4.9%

Sex

Women are believed to be the most common victims of abuse, perhaps because they report abuse at higher rates or because the severity of injury in women typically is greater than in men. Numerous studies, however, have found no differences based on sex.

Age

By definition, elder abuse occurs in the elderly, although there is no universally accepted definition of when old age begins. Typically, 60 or 65 years is considered the threshold of old age.