Domestic Violence in an Older Couple
Mr. and Mrs. C are brought to the local hospital Emergency Department in an ambulance accompanied by the police. This older couple is well known to the Emergency Department staff due to their frequent visits for injuries. Mr. C is a 68-year-old retired construction worker who has been admitted several times to the hospital’s Chemical Dependency unit for alcohol withdrawal. Mrs. C is 64 years old and still works part-time as a bartender in a local pub. The couple has been married for 44 years and has three adult sons. Their youngest son, Mr. DC, frequently moves back home, as he has difficulty keeping a steady job, and sometimes works with his mother at the pub.
Mr. C is found to have alcohol on his breath and multiple lacerations on his face and hands. Mrs. C has a bruise over her left cheek and complains of pain over the area of her right ribs. When interviewed, the couple describes “getting into it again.” Mrs. C reports that she had returned home from her job at the pub at 3:00 am after waiting nearly one hour for her husband to pick her up. She had finally gotten a ride home from one of the patrons at the bar and became angry upon finding her husband sleeping on the couch surrounded by beer cans. She admits to screaming at him to wake him up. Mr. C reports that he had “had a few beers” to relax and woke up to a threatening, screaming wife who started hitting him with a glass vase. He admits to pushing her back and hitting her in the face. The police were called by Mr. DC, who heard them fighting. The police officers know the couple well. They make frequent visits to their home for complaints of domestic disturbances and sometimes are able to stop the confrontations before they become violent.
Mr. and Mrs. C have attended court-ordered anger management counseling and marital counseling after being issued citations by the police. They have returned to their pattern of episodic verbal and physical abuse after completing each program. The couple’s frequent visits to the Emergency Department of hospitals usually results in offers of counseling referrals, which they refuse. They often become remorseful and leave the hospital holding hands while promising to “treat each other better.” Usually their injuries are limited to superficial lacerations and bruises.
Mr. C is evaluated by the physician, who finds him to be tremulous, diaphoretic, and tachycardic. He complains of abdominal pain and vomits bright red blood. He is admitted to the Telemetry unit with a diagnosis of an acute gastrointestinal hemorrhage and alcohol withdrawal. Mrs. C is found to have three fractured ribs and a fracture of her left orbit. She frequently asks for pain medication by name and states that she prefers oxycodone. Mrs. C is admitted to the Surgery service for evaluation of her orbital fracture and need for surgery. Mrs. C is given morphine sulfate 8 mg subcutaneously every 3 hours for pain and lorazepam 2 mg intramuscularly every 4 hours for agitation. Several hours after admission, she demands more pain medication one hour after receiving morphine sulfate 8 mg and threatens to leave the hospital. She is given an additional dose of morphine sulfate 8 mg and is asked about her use of medications at home. She admits to taking multiple opioid medications daily, including up to 6 tablets of hydrocodone 5 mg with 6-8 tablets of oxycodone 5 mg. Mrs. C reports that she doesn’t drink alcohol but finds that pills help her “get through the day.” Her orbital swelling is prominent, and the surgeons are concerned that she may lose vision in her eye. A request is made for a social worker, caseworker from Adult Protective Services (APS), and psychiatrist to see both Mr. and Mrs. C.
Domestic violence, often referred to as intimate partner violence, is not limited to young adults. As this case illustrates, domestic violence may involve the abuse of older adults by partners who are both perpetrators and victims.1 Elder abuse within families often involves older adults with a history of destructive and violent relationships with family histories involving abuse and neglect.1,2 Often, the spouses share a similar background of family conflict, childhood abuse, parental neglect, and substance abuse.3 The pattern of abusive behavior may escalate from verbal and emotional abuse to physical violence under times of stress or change within the family.4 While women are far more likely to be the victims of intimate partner violence, men represent at least 20% of victims. Male victims are less likely to be identified or offered assistance.2
Elder abuse is a significant problem that includes the physical abuse, psychological abuse, financial exploitation, sexual abuse, and neglect of older persons.5 The prevalence of elder abuse and neglect is difficult to identify, as it is believed that only 20% of cases of suspected abuse are reported to local agencies.6,7 It is estimated that 500,000 older adults are the victims of at least one type of abuse or neglect.6,7
Family members, including spouses, adult children, and other relatives, are by far the most common perpetrators of elder abuse.7 Often, these family members are living with the older adult and are acting in a caregiver role for their relative who has become increasingly dependent. It is estimated that more than 50% of elder abuse and neglect is committed by family members.6,7 Abuse also occurs when nonfamily caregivers are involved, and in institutional settings, such as nursing homes and adult homes. (See additional information about nursing home abuse below.) Identifying risk factors for elder abuse, such as frailty, substance abuse, cognitive loss, and dependence, will help the clinician remain vigilant in screening for mistreatment4-7 (Table I).
It is important to recognize the types of elder abuse as well as the signs and symptoms of potential abuse and neglect. Physical abuse involves the use of force to inflict pain, injury, and harm to the older adult. Signs of physical abuse include unexplained bruises, broken bones, frequent injuries, and marks on the wrists, arms, and legs that may indicate the use of physical restraints. Psychological abuse refers to the verbal and emotional acts of humiliation, intimidation, and threatening behavior that provoke distress and fear. Financial abuse involves the theft, exploitation, and diversion of an older adult’s funds or property for use by the abuser. Sexual abuse is the unwanted, nonconsensual, or forcible sexual contact with an older adult. Sexual abuse may also involve sexual contact with an older adult who is too cognitively impaired to understand such activity. Neglect is the intentional refusal to allow or assist the older adult in obtaining needed food, medical care, medications, treatment, and access to services. Self-neglect is an increasing problem in which the older person refuses to accept needed services, assistance, medical care, or medications.5-7 Self-neglect in an older person who may be impaired or incapacitated may be ignored by those who are in contact with the patient.6
Help for an older adult who is in an abusive situation involves ensuring the safety of the individual, removing the abuser, or placing the older person in a residential or institutional setting.1,6 Legal interventions, including orders of protection or criminal charges in order to recover stolen money, are available but often are underutilized.6-8 Victims of elder abuse may benefit from counseling to help reduce the trauma and the demoralization that may result from maltreatment.4,5 Abusers of the elderly may benefit from educational programs and drug treatment if appropriate, but counseling with the victim is not recommended and usually results in more trauma. Couples who engage in domestic violence should receive individual treatment, and the outcome should be evaluated before any joint or marital therapy is considered.1,2 In some cases, victims and abusers will return to their previous pattern of behavior despite interventions. It is important to remember that adults with capacity may refuse assistance for elder abuse situations. Help should be offered and made available, along with offers of a safety plan for the older adult3,4,8 (Table II).
Elder abuse occurs most often in the community setting, particularly as older adults become dependent on family and caregivers for assistance.5 Elder abuse also occurs in the institutional setting if caregivers fail to provide necessary care and treatment or are abusive.5,6 Each state has a hotline number to call in order to report nursing home abuse. The National Citizens’ Coalition for Nursing Home Reform has information on its website (www.nccnhr.org) regarding the identification and reporting of nursing home abuse.
First responders, such as police, emergency medical services, and firefighters, are often in the unique position of identifying elder abuse in the home, community, or institutional setting.8 Healthcare professionals should be vigilant about screening for elder abuse and neglect.9 This may require making attempts to contact older adults who miss appointments and directly questioning an older patient without family members or caregivers present.7,9 In 45 states, the reporting of suspected elder abuse and neglect is mandated.3 In all 50 states, it is encouraged. The local APS agency is empowered with the mission to investigate reports of elder abuse and neglect. The filing of a report with this agency is the means of evaluating the problem and obtaining assistance and services for the older adult.3
Information for healthcare professionals and patients can be accessed at the National Center on Elder Abuse website (www.ncea.aoa.gov). The Eldercare Locator provides a national hotline to report suspected elder abuse or neglect (1-800-677-1116), in addition to the website (www.eldercare.gov), which offers information about many programs and services for the elderly in each state and local region.
Outcome of the Case Patients
While Mr. and Mrs. C received treatment for their acute medical needs, the social worker, psychiatrist, and APS caseworker met with Mr. DC. He reported that both parents are alcoholics, but his mother had stopped drinking several years ago after being arrested for driving under the influence of alcohol. He has seen multiple prescription medication bottles around the house and stated that his mother is never without her pills. Mr. DC described a troubled home life growing up, where he and his brothers were often left on their own. He explained that his family life consisted of daily fights about “almost everything.” His parents yelled at each other, screamed at him and his brothers, and typically argued late into the night while drinking. His brothers currently have no contact with their parents. Mr. DC has had difficulties with alcohol and drugs himself and had moved back home after losing his job. He found that his parents’ violent behavior toward each other had increased, in addition to verbal abuse and threats. He had called the police several times in the past month, hoping that they could receive some type of help. Mr. DC felt helpless and planned to move in with his girlfriend.
Mr. C underwent treatment for his gastrointestinal bleeding, which was found to be the result of a gastric ulcer. He was given multiple blood transfusions in addition to undergoing endoscopy. He also required aggressive treatment for acute alcohol withdrawal and remained in a state of delirium for 7 days. After Mr. C was medically stable, a meeting was held with the social worker, the couple’s caseworker from APS, the psychiatrist, and Mr. DC. Mr. C was informed that he needed to attend a residential treatment facility for alcohol and chemical dependency. He initially refused, stating that he needed to take care of his wife. The APS caseworker firmly informed Mr. C that if he refused residential treatment she would have to report this to his probation officer, and he would face the possibility of jail time. The team made it clear that Mr. and Mrs. C each needed to get help individually and at separate facilities. Mr. C agreed to go to the program and was discharged on the tenth hospital day.
Mrs. C spent 15 days in the hospital undergoing several procedures to repair her orbital fracture. She complained often of severe pain and asked for medication frequently. She was given sustained-release oxycodone 80 mg every 12 hours and still required oxycodone 10 mg with acetominophen 650 mg 2-3 times daily for breakthrough pain. She asked about her husband often. Mrs. C told the staff that she loved her husband and needed to be with him. The social worker, psychiatrist, APS worker, and Mr. DC met with her to discuss her options for treatment. The hospital’s Chemical Dependency unit provides treatment for opioid and prescription drug abuse and would allow Mrs. C to receive follow-up care with her surgeon. Mrs. C adamantly denied having any problem with drugs and was angry and hostile at the team and her son. She refused any type of treatment and stated that she was shocked her husband was “sent away” without her consent. The team worked with Mrs. C over the next several days and sent chemical dependency counselors to see her. They also provided a letter from her husband, encouraging her to get help. She remained angry and denied needing any help except “a ride home.” As Mrs. C had no pending legal problems and had a house to return to, she was discharged with many referrals for outpatient treatment and follow-up visits with the APS caseworker.
After successfully completing 90 days of treatment at the residential facility, Mr. C moved into an apartment with his son and his son’s girlfriend. He remains sober after 6 months and attends 12-step meetings. He has written letters to his two older sons and would like to establish some contact with them. Mrs. C has had a difficult course. She continues to take multiple prescription opioid medications and visits many doctors with complaints of chronic pain. Mr. C has offered to meet her at a 12-step meeting, but she refuses and becomes verbally abusive. Her APS caseworker continues to visit her to check on her safety and offer assistance.
The author reports no relevant financial relationships.
Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Ave @ 16th Street #6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659; e-mail: firstname.lastname@example.org.