Clinical Evaluation of Elder Abuse

CLINICAL EVALUATION OF ELDER ABUSE- A SILENT EPIDEMIC
by Dr. Karen Reimers, MD, FRCPC; IPA Bulletin Assistant Editor, Around the World

Elder abuse is often a silent issue in clinical settings. However, it is a global concern, affecting millions of older people worldwide, and a focus of increasing international concern. Elder abuse is a pervasive and growing problem, urgently requiring the attention of geriatric psychiatrists, hospitals, health care systems, social services, lawmakers, and communities. Elder abuse is a problem that is larger than previously thought, and without geographic boundaries. Elder abuse is becoming more widely recognized as a prevalent, identifiable and costly problem with the increasing number of aging adults in the world.

As psychiatrists caring for older adults, we have all had patients who are victims of elder abuse, though we may not be aware of it. Many older adults are ashamed of their experiences and hide the facts of their abuse from their physicians and mental health professionals. Clinicians should keep in mind the possibility of abuse, even if a vulnerable patient denies it. Perpetrators of elder abuse are often someone the elder knows and trusts.

Geriatric psychiatrists play a crucial role in the assessment of an elder’s mental functioning and in evaluating the effects of elder abuse. Do we know what these patients need from us? In addition to practical considerations, we must consider complex ethical and legal issues. This article provides an overview of elder abuse and some practical tips for clinicians on how to evaluate suspected elder abuse.

What is elder abuse?

Elder abuse is a broad term. No single definition describes elder abuse uniformly across legal jurisdictions, or across various countries, states, medical subspecialties, organizations, or research studies.

Common elements in formal definitions of elder abuse include:

• an act of commission or omission
• may be intentional or unintentional abuse or neglect
• can be perpetrated by the victim, a trusted other, a stranger, or an acquaintance
• can occur in domestic or institutional settings
• results in harm or threatened harm to the health or welfare of an older adult
• harm can be physical, psychological, social, financial, or sexual

There are several sub-types of elder abuse:

• Physical abuse refers to the use of force resulting in injury, pain, or impairment. Threats of harm may be part of physical abuse. Injuries due to neglect may also be due to abuse by a caregiver. Examples of this include bone fractures, inadequate medical care, malnutrition/cachexia or decubitus ulcers.
• Emotional (psychological) abuse results in anguish, pain, or other distress due to verbal (insults, harassment, humiliation), or non-verbal acts. It is often associated with physical abuse. Emotional abuse may be part of efforts to manipulate or isolate the elder.
• Financial abuse (elder financial exploitation) is common and may involve the disposition of a person’s estate, gifts, property transfers, and other financial acts. It may be more likely to be identified by the victim’s family or financial professionals than by physicians.
• Sexual abuse refers to non-consensual sexual contact. It includes not only rape, but other types of sexual assault, including unwanted exposure to nudity. Elders are vulnerable to sexual abuse since they are often cared for in settings where there is little supervision of the caregiver, who may be a stranger.
• Neglect is mistreatment resulting from inadequate attention, carelessness, or disregard for an individual’s needs. It can encompass physical, emotional, abandonment, financial, and self-neglect issues.

Elder abuse situations rarely come to the attention of authorities, and the scope of elder abuse has been a subject of interest and speculation for decades. Very few studies have used professional surveys or official data to examine the incidence, prevalence, or mortality-rates associated with elder abuse. Some studies suggest there may be patterns of more verbal mistreatment for women and those with physical disabilities, and more financial abuse for those without a spouse or intimate partner. In general, spouses or intimate partners appear to be more likely than adult children to perpetrate most forms of elder abuse.

Risk factors for elder abuse include cognitive impairment in the victim, physical function impairment, psychological distress, and disruptive behaviors, heavy caregiver burden, substance abuse in the perpetrator, the victim’s social isolation, and previous trauma.

Consequences of elder abuse include increased mortality, depression and psychological distress, overall poorer health and functioning, greater likelihood of institutionalization, and economic loss.

Interventions that have the potential to prevent mistreatment include caregiver interventions, money management programs, help lines, emergency shelter, and multidisciplinary teams.

Clinical evaluation of elder abuse

Concern about elder abuse may arise at home, in nursing homes, or other residential settings. Elements of abuse may become evident in the course of the clinical evaluation. There may have been recent changes or decline in functioning flagging the clinician’s attention.

Multiple screening instruments are available to assess elder abuse, but none are in widespread use in geriatric psychiatry settings.

Medical and psychiatric care is fundamental in the identification and management of elder abuse situations. The first step in evaluating elder abuse is to conduct a comprehensive geriatric psychiatric assessment, including a mental status examination with screening for mood and psychotic disorders.

The degree of cognitive impairment may be assessed using a standard brief rating scale such as the Montreal Cognitive Assessment (MoCA), the Mini-Mental State Examination (MMSE), or a clock drawing test. Executive function should be evaluated since this is the major cognitive domain associated with decision making.

Collateral information should be obtained from caregivers and concerned parties, maintaining an open mind to the possibility of abuse even with familiar patients and caregivers. The psychiatrist may need additional knowledge of key facts from outside sources to reliably assess an older person’s memory.

Careful physical examination is recommended, with an eye to possible injuries, bearing in mind that many older people are prone to falls or bedsores and they may have fractures or other injuries for reasons other than abuse. Geriatric psychiatrists suspecting elder abuse should arrange for the victim to be physically examined by an appropriate specialist. Clinicians should be alert to any inappropriate use of drugs, restraint, or punishment.

Interviewing techniques

The clinical interview provides an opportunity to the geriatric psychiatrist to gain greater knowledge of the victim’s situation. However, it may not be helpful to directly question an older adult about abuse.  Some patients may be ashamed and reluctant to admit they have been abused, while other abused elders may not conceive of themselves as victims, believing they are dependent and need the abuser to take care of their affairs.

Language and cultural barriers can be a major obstacle to identifying elder abuse, and elders from ethnic, sexual, or religious minorities may be particularly vulnerable. They may need to be interviewed using a translator or other mediator. Family members, especially the patient’s children, should not be used as translators, since these individuals may themselves be the perpetrators, and because using an elder’s children as translators can convey disrespect. Professional translators or a phone translation service should be used whenever possible.

Legal and ethical issues

In cases of elder abuse and suspected elder abuse, there are complex ethical and legal issues that must be considered:

• Avoid role conflicts and dual role relationships where possible. Consider referring the patient for an independent forensic opinion rather than mixing up the responsibilities of clinical and forensic roles.
• Be mindful of patient confidentiality if called to court in response to a subpoena.
• Have procedures in place that clarify the relationship, fees, and expectations for your forensic work.
• Obtain specific legal decision-making capacity for different tasks, including capacity to manage finances, sign a contract, marry, or make a will.
• Informed consent may be difficult to obtain from an older person in cases of diminished capacity.

Clinicians should consider seeking professional legal advice from attorneys or from their malpractice carrier if questions arise about how to manage legal and ethical aspects of elder abuse situations.

Documentation and reporting

Thorough documentation is very important in elder abuse situations. The medical record may later comprise critical evidence in legal proceedings about the documented abuse. Clinicians should record their observations carefully and thoroughly, including mental status examination findings, cognitive findings, quotations from the older victim, photographs (in the case of physical abuse findings), and clarifying sources of collateral information.

Global jurisdictions vary widely in their requirements to report elder abuse. Reporting is often done on a confidential basis. Clinicians should learn the requirements applicable where they work. Nursing homes and other institutions may have special reporting requirements and procedures.

Conclusion

The world’s rapidly growing elderly population comprises diverse racial, ethnic, gender, and sexual minority populations in each region and globally. Elder abuse can be expected to increase in the coming years due to demographic trends and other social changes. Despite the alarming prevalence of elder abuse and its serious health consequences, there is a current lack of scientifically rigorous

intervention research on elder abuse. Much remains to be learned about how to prevent elder abuse and how to intervene effectively.

As all of us age, we strive to maintain our dignity and independence. We seek a good, long life free from harm and abuse. Careful elder abuse evaluations are needed to help shine a light on the issues surrounding elder abuse and to serve our vulnerable elderly population. Geriatric psychiatrists play an important role in the identification of and protection against elder abuse.

For further reading:

• Acierno, R et al. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. American Journal of Public Health, 100(2), 292-7.
• Dong, X., Ed. (2017). "Elder abuse: Research, practice and policy."
• Kohn, R et al.  (2018). Elder Abuse. In: Geriatric forensic psychiatry: principles and practice. J. C. Holzer, R. Kohn, J. M. Ellison and P. R. Recupero. New York, NY, Oxford University Press.
• Pillemer, K., Burnes, D., Riffin, C., & Lachs, M. S. (2016). Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies. The Gerontologist, 56 Suppl 2(Suppl 2), S194-205.
• Read, SL. (2016). The Four Categories of Elder Abuse: Evaluation Approaches. Psychiatric Times. Vol. 33, Issue 1.

Karen Reimers, MD, FRCPC is an adult psychiatrist with special interests in geriatric psychiatry, addictions, and capacity assessment. She enjoys teaching Psychiatry residents about clinical topics.

Excerpted from the IPA Bulletin, Volume 35, Number 4: IPA Members can download the full PDF issue here.