Abuse and Neglect

Madelyn A. Iris, Ph.D.

Identification and assessment of abuse and neglect of community-dwelling older persons is difficult and presents many challenges. Often, abuse and neglect are perpetrated by close family members, particularly spouses and/or adult children. Because elder abuse is closely linked to family issues, victims may deny or play down its seriousness to protect the abuser and maintain the image of a caring and loving family. Victims may be reluctant to identify family members as abusers for fear of involving the criminal justice system. Sometimes victims are unable to report abuse or neglect due to cognitive incapacity. Social supports for victims of abuse and neglect may not be readily available, and finally, health care professionals may minimize complaints of abuse.

Definitions

National incidence rates are difficult to determine, due to lack of consistency in definitions. Generally, the types of abuse identified are (in order of decreasing frequency or incidence):

 

Physical abuse

includes pushing and shoving, hitting, slapping, burning, etc.

Psychological or emotional abuse

includes threats, harassment, insults, denial or refusal to meet the social needs of the elderly person (e.g., by denying visitors or outings). Such abuse is difficult to define and identify, especially within the family context.

Exploitation

refers to misuse or misappropriation of financial resources and assets and ranges from misuse of income to converting assets for use by the abuser. Since many older persons rely on spouses or children to help manage financial affairs, exploitation is difficult to assess, as abusers often have authorized access to bank accounts, credit cards, deeds, etc.

Sexual abuse

is defined as sexual contact against the will of the older person and includes fondling, exposure, and rape. Reports of sexual abuse are difficult to obtain and incidence rates are probably highly underestimated. Assessing sexual abuse can be difficult, and may require a physical examination, especially in cases of rape. However, it may be extremely difficult to obtain consent for such an examination. If the victim does consent, the same procedures should be used as in all other cases of sexual assault.

Medication abuse

includes inappropriate use of medications (e.g., overuse of sedatives) or withholding prescribed medications.

Signs that raise suspicion but are NOT diagnostic:

Physical/Sexual

Unexplained trauma (lacerations, punctures, welts, bruises, fractures, burns, and evidence of the use of restraints)

Sexually transmitted diseases

Psychological/Emotional

Reluctance to speak around potential abuser

Demonstrations of fear of the abuser

Unwillingness of the abuser to leave the victim alone

Exploitation

Sudden inability of victim to pay his/her bills

Patient's statements about missing valuables (even in the presence of mild dementia)

Medication

Oversedation

Poor response to therapy

Neglect of an older person covers a wide range of situations. In all cases, signs of neglect include malnutrition or sudden weight loss, poor hygiene, deplorable living conditions, inappropriate clothing or lack of clothing, lack of compliance with a treatment protocol in a previously compliant patient, and the presence of sores, excrement, and dirt on the body. Misplaced or broken glasses, false teeth, hearing aids, or other prostheses or equipment are also indicators. Two types of neglect may occur: benign neglect and willful neglect.

1. Benign neglect occurs when the caregiver is ignorant of or unable to provide appropriate care. This may be remedied by the provision of educational and/or supportive services to assist the caregiver in his or her caregiving role.
   
2. Willful neglect is regarded as deliberate and meant to harm. It includes denying the elderly person access to resources, medical care, medications, food, etc. Willful neglect should be treated in the same manner as other types of abuse.

Risk factors

All elderly persons are potentially vulnerable to abuse, especially those with physical or mental impairments, regardless of racial background, social class, educational level, etc. Eight risk factors have been identified:

1. Poor health and functional impairment in the elderly person
   
2. Cognitive impairment in the elderly person
   
3. Substance abuse by or mental illness in the potential abuser
   
4. Dependence of the potential abuser on the victim (financial or psychological)
   
5. Shared living arrangements
   
6. External factors causing stress, especially for the potential abuser
   
7. Social isolation of the elderly person and/or the potential abuser
   
8. A history of violence in the family

Management

Health care professionals should follow a standardized protocol for assessment, intervention and treatment of elder abuse and neglect.

• Regard impaired caregiver function (for whatever reason) as a significant health risk for the patient and assess as thoroughly as you would any other health risk factor.
  
• Continually assess caregiving situations to identify the older person believed to be abused, neglected, or at risk.
  
• Provide medical evaluation and treatment for injuries or conditions resulting from abuse or neglect.

DRG 454 can be used as admitting diagnoses for inpatient assessment. This DRG corresponds to ICD codes 995.85 Other Adult Abuse and Neglect. ICD code 995.8 Other Specified Adverse Effects, Not Elsewhere Classified lists subcategories that include various types of abuse and neglect situations.

• Pursue action to alleviate the abuse or neglect, protect the safety and well-being of the victim, and assist the victim and family in reestablishing a nonabusive and caring environment.
  
• Be aware of protocols and community services that can assist with assessment and management.
  
• Attempt to establish and maintain a supportive relationship with the victim and with other family members, to ensure that harmful situations do not reoccur.
  
• Report abuse or neglect in accordance with state or local statutes.
  
• Remain objective and nonjudgemental.
  
• Advocate for the protection and rights of those who cannot do so for themselves.

Legal and ethical issues

Three issues warrant special attention:

• Most states, whether reporting is mandatory or voluntary, offer immunity and anonymity for reporters. Health care professionals should report even suspicions of abuse or neglect to the appropriate adult protective services.
  
• Elder abuse raises ethical issues of competency, privacy, and the right to refuse intervention. All older persons are deemed competent unless adjudicated otherwise through a formal competency hearing; thus, they reserve the right to refuse intervention regardless of perceived dangers. If victims refuse to participate in assessment or deny that abuse exists, despite extensive evidence to the contrary, investigators may have no legal right to intervene or overrule such decisions.

Effective January 1, 1999, the Illinois Elder Abuse and Neglect Act requires health care professional to report suspected abuse, exploitation or neglect, if the older person is thought to be unable to do so on his or her own behalf. This change implies that judgements about cognitive capacity can be made without seeking a formal adjudication in a court of law.

• Many dilemmas arise because elder abuse can be both a family systems issue as well as a criminal matter. While abuse and neglect may be most effectively dealt with through counseling or social services, some state or local statutes may define them as criminal acts, bringing the victim and abuser into the criminal justice system.

All who provide services to abused and neglected elderly must remain aware of the complex needs of this vulnerable population and access support services on behalf of their patients and clients.

For assistance in helping patients and families address issues of elder abuse and neglect, consult geriatricians, social workers, or local Departments on Agent’s Adult Protective Services.

Illinois maintains a 24 hour Elder Abuse Reporting Hotline at 1-800-252-8966.