A 76-year-old lady presents to the surgery with her son, who is concerned by his mother’s increasing agitation and irritability. You have known her for some years. She is a retired school principal, widowed, and is currently living with this son who acts as carer. She has a history of ischaemic heart disease, rheumatoid arthritis and a recent diagnosis of dementia, likely with a mixed Alzheimer’s and vascular aetiology. On examination you notice a two inch by four inch scarlet-coloured bruise in her epigastrium and a one inch by one inch greenish yellow bruise on the dorsum of her left arm. Could this be elder abuse, and what should be done about it?

Definition and prevalence

Elder abuse is defined as a single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person, or violates their human and civil rights.¹

International experience suggests a prevalence rate in the community of 3-10%.² An Irish survey by the National Council for Protection of Older People estimated a prevalence of 4%, ie. 18,000 people affected.³ The true prevalence may be higher – when asked, 52% of a small group of Irish carers for people with dementia admitted some form of abuse.⁴ Direct questioning of elderly patients may also underestimate abuse.⁵

Furthermore, the Irish population is ageing – the number of people over 65 will reach 33% of the population by 2041.⁶ Elderly people who are physically abused or who experience caregiver neglect have three times the mortality of those never abused.⁷ Abuse represents a widespread problem with serious consequences: for these reasons elder abuse was recognised as a ‘hot topic’ at the 2011 annual general meeting of the ICGP.

Types of abuse

There are a number of recognised types of elder abuse. Neglect may consist of ignoring physical or emotional needs, while psychological abuse includes acts of humiliation, infantilisation, or controlling the patient. Physical abuse may take the form of hitting or restraining the patient, while sexual abuse includes unwanted intimate contact and/or rape. Financial abuse pertains to accessing a person’s accounts without their permission, or pressuring them to spend money not in their own interests. Internationally, the commonest types of abuse are neglect, followed by psychological abuse and financial abuse.⁸

There is a similar pattern in Ireland, with neglect and financial abuse being most common. Sexual abuse is least common.³

Barriers to detection of abuse

Ninety percent of US physicians feel that elder mistreatment is difficult to detect.⁹ This can be for a number of reasons: older adults are unlikely to report abuse.¹⁰ Patients may be embarrassed, afraid of the consequences for their carer, or may fear the consequences when the carer finds out about disclosure. They may also worry about possible relocation to long-term care. Communication may also be impaired by cognitive impairment. 

Psychological abuse is especially difficult to detect: when it presents as apathy or depression it may be mistaken for a grief reaction or cognitive impairment. Where neglect or verbal abuse is suspected it is often difficult to ascertain what is a normal or appropriate relationship for this carer and the elder, as it could be an interpersonal disagreement. However, it is important to be vigilant since early detection and intervention can substantially decrease the associated morbidity and mortality. 

There are a number of screening tools available for elder abuse but they suffer from limitations, including time taken to administer and training for their use.¹¹ Knowledge of risk situations is the strongest factor predicting a diagnosis of abuse by GPs, with those who read articles on elder abuse being four times more likely to diagnose abuse than those who did not.¹² Older adults are two to three times more likely to visit their GP than younger individuals,¹³ suggesting that an awareness of risk factors and prevalence is imperative.

Risk factors for abuse

Risk factors may be classified according to patient, carer, or the environment. There is some evidence that risk factors differ according to the type of abuse being perpetrated. 

With respect to patients, dementia, depression, malnutrition, female sex and age > 85 are risk factors for mistreatment.^7,14 Social isolation or emotional dependence of the care receiver, especially in the setting of dementia, may be indicators.^5,7 Physical disability has been shown to correlate with abuse as the subject has an impaired ability to defend themselves.^7,15

In terms of carers, mental health problems including anxiety, alcohol or substance abuse, poor premorbid relationship and a lack of understanding of the elder’s medical condition can all contribute. Abusers are more likely to find the behaviour of their dependant a problem than non-abusers.¹⁶

Lastly, regarding environment, poor social supports are consistently associated with abusive situations.¹⁷ In over 50% of cases reported to the national elder abuse network, the alleged abuser lived with the client. Family members such as an adult child, spouse or other relative were most likely to be the perpetrator.¹⁸ In institutional settings, high staff turnover and poor staff attitudes towards the patients have been associated with abuse.¹⁹

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Signs of abuse

Neglect can manifest as dehydration, malnutrition, poor hygiene or pressure sores. Patients may be under or over- medicated. Signs of physical abuse include bruising or cuts (particularly to the head) or lacerations, fractures or burns. Patients experiencing psychological abuse may present with depression or withdrawal. 

Financial abuse may be indicated by a sudden inability to pay bills. Sexual abuse is least common, it may be hinted at by the older person, or can be detected by unusual bruising on the thighs, genitals or rectum, or the presence of sexually transmitted disease. 

Dealing with abuse

When abuse is suspected or disclosed, the patient should be interviewed sensitively, separate from the carer, to discuss the issues. Some cognitively intact patients may wish to remain in an abusive situation – this may present difficulties for treating physicians, but the wishes of cognitively intact older people should be respected. 

Often, increasing support is sufficient to allay further concerns. Where cognition is compromised, or capacity is in doubt, a clinician may make a decision in the best interests of the patient, bearing in mind that for most people their best interest is to remain in their own home with adequate supports.

Adequate documentation of disclosed information, clinical findings and subsequent plan is of utmost importance. The HSE has put in place a network of senior case workers with responsibility for known or suspected elder abuse. However, awareness is poor. In a survey of Irish general practitioners, only one third were aware of the existence of this network.²⁰

With a patient’s permission (where cognition is intact), alleged or suspected elder abuse can be reported to the local senior case worker, who will report to a regional elder abuse officer. Contact details for each area are available on the HSE website (www.hse.ie). Where cognition is compromised, involvement of elder abuse officers may help protect the patient’s interests. Interventions such as monitoring, home supports or day or respite care may then be introduced. 

While legal intervention is sometimes required, in Ireland this was the case in less than 5% of reported cases, with the majority of reported cases resulting in increased supports for the victim or the carer (74% and 51% respectively).⁶ Patients lacking capacity may have an existing enduring power of attorney activated; rarely, ward of court proceedings may be necessary. 

Management may also incorporate treatment of patients’ behavioural problems.⁴ The perpetrators must also be taught to manage their anger and counselled on more appropriate ways to respond to difficult circumstances. 

Often, empathising with carers and ensuring maximal sources of support, eg. home help, can reduce carer burden and subsequently reduce risk of abuse.

Conclusion

Elder abuse represents an uncommon but important phenomenon, which may go undetected unless clinicians are aware of the risk factors and the signs. Abuse may represent a carer in stress or a situation that requires increased support, rather than a legalistic approach. The HSE has committed to a national strategy which includes the provision of senior case workers across the country who are trained to deal with the issues in a sensitive manner.  

References

1. Department of Health and Children. Protecting our future: report form the working group on elder abuse. 2002. Available at www.ncaop.ie/publications/research/reports/73_ProtectingourFuture.pdf 
2. O’Dwyer C, O’Neill D. Developing Strategies for the Prevention, Detection and Management of Elder Abuse: The Irish Experience. Journal of Elder Abuse and Neglect 2008; 20(2): 169-180 
3. National Council for Protection of Older People: Abuse and Neglect of Older People in Ireland.2010. Available at: www.ncpop.ie/userfiles/file/Prevalence%20study%20summary%20report.pdf.
4. C Cooney, R Howard, B Lawlor. Abuse of vulnerable people with dementia by their carers: can we identify those most at risk? Int J of Geriatric Psychiatry 2006; 21: 564-571 
5. Saveman BI, Sandvide A. Swedish general practitioner’s awareness of elderly patients at risk of or actually suffering from elder abuse. Scand J Caring Sci. 2001; 15(3): 244-249
6. Clancy M, McDaid B, O’Neill D, O’Brien JG. National Profiling of elder abuse referrals. Age and Aging 2011; 40: 346-352
7. Lachs MS, Williams CS, O’Brien S et al. The mortality of elder mistreatment. JAMA 1998; 280: 428-432
8. The National Elder Abuse Incidence Study. The US Department of Health and Human Services, 1998. Available at: www.aoa.gov/AoARoot/AoA_Programs/Elder_Rights/Elder_Abuse/docs/ABuseReport_Full.pdf. 
9. O’Brien JG. Elder Abuse and the Physician. Mich Med 1986;85:618-620
10. Jones J, Dougherty J, Schelle D et al. Emergency Department protocol for the diagnosis and evaluation of geriatric abuse. Ann Emerg Med 1988; 17: 1006-1015
11. Fulmer T, Guadagno L, Bitondo Dyer C, Connolly MT. Progress in Elder Abuse Screening and Assessment Instruments. Journal of the American Geriatrics Society 2004; 52: 297-304
12. Mc Creadie C, Bennett G, Gilthorpe M et al. Elder abuse: do general practitioners know or care? Journal of the Royal Society of Medicine 2000; 93(2): 67-71
13. Progress in Elder Abuse Screening and Assessment Instruments. JAGS 52: 297-304, 2004
14. Dyer CB, Pavlik VN, Murphy KP et al. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatric Soc 2000; 48: 205-208
15. Pillemer KA, Finklehor D. The prevalence of elder abuse: a random sample survey. Gerontol 1988; 28(1): 51-57
16. Ogg J, Bennett G. Elder abuse in Britain. Br Med J 1992; 305: 998-999
17. Compton SA, Flanagan P and Gregg W. Elder Abuse in people with dementia in Northern Ireland: Prevalence and predictors in cases referred to a psychiatry of old age service 1997; 12: 632-635 
18. Wang JJ. Psychological abuse and its characteristic  correlates among elderly Taiwanese. Arch Gerontol Geriatr 2006; 42: 307-318
19. Ben Natan M, Ariela L. Study of factors that affect abuse of older people in nursing homes. Nurs Management 2010: 17(8): 20-4
20. O’Brien JG, Collins C, Ni Riain A, O’Neill D. Elder Abuse in Ireland: the role of the general practitioner. Irish Journal of Medical Science 2011: 180: S10