Elder Abuse and Neglect: Help Starts With Recognizing the Problem
Ms. C, the Director of Volunteer Services at a community hospital, receives a call from a nurse about one of her volunteers, Mrs. S. The nurse explains that the staff is concerned about Mrs. S, who is a 72-year-old widowed retired nurse. Mrs. S has been a volunteer at the hospital for many years, and following the death of her husband the previous year, she has been coming in almost every day. The nurse explains that Mrs. S often stays quite late into the evening, and has started asking if she can sleep there at night. Mrs. S is performing her volunteer services quite well, and is frequently requested by staff and patients. The nurse feels that Mrs. S is often afraid to leave the hospital, and appears to have lost weight. The staff gives her food and snacks, but she puts them away in her bag to take home. They have asked her if she needs any help, but she denies that anything is wrong. Ms. C wonders if Mrs. S is simply pushing herself too hard.
When Ms. C goes to the Pediatric Oncology unit, she finds Mrs. S reading stories to the children. Ms. C is surprised to see how thin and tired Mrs. S appears. She remembers how meticulous Mrs. S had always been about her appearance, and sees that her clothing looks wrinkled, and her hair is tied up with an old scarf. Ms. C insists that Mrs. S have lunch with her that day, and finds that she is reluctant to leave the unit. Mrs. S appears hungry and eats a full lunch and two desserts. Ms. C asks her if she would like a less demanding assignment, such as answering the telephone or working at the hospital reception desk. Mrs. S becomes extremely anxious, and tells Ms. C that she needs a place to stay because there was a flood in her house. Despite many attempts at offering to help with arrangements to repair her home, all Mrs. S asks for is to stay in the hospital. Ms. C coordinates a program for respite care and has some available rooms, but must consult with Mrs. I, the hospital administrator, before allowing Mrs. S to stay there.
Ms. C also convinces Mrs. S to see her primary care doctor, Dr. R, who has an office in the hospital. Dr. R has known Mrs. S for many years, and took over her husband’s internal medicine practice when he retired. He looks at Mrs. S and immediately asks about her son, Frank. Mrs. S starts crying and tells him that her son, who has a history of schizophrenia and alcohol abuse, left the adult home where he was living and came to her asking for help. She has always felt guilty about Frank, feeling she should have done more for him. Over the years, the couple sent Frank to many long-term treatment facilities, residential care centers, and private psychiatric hospitals. He recently moved into Mrs. S’s house. He has been poorly compliant with his medications, is chronically delusional, and frequently spends his Supplemental Security Income check on alcohol. Following the death of his father, he started demanding that his mother give him money. He often returns home intoxicated, sleeps all day, and yells at Mrs. S at night when he wakes up wanting food. Dr. R offers to call the police and have Frank brought to the hospital, but Mrs. S tells him she does not want to do that to her son.
Dr. R finds that Mrs. S is underweight, but otherwise medically stable. He calls Mrs. I, who is also a former social worker who had assisted Mrs. S and her husband with Frank’s care over the years. Dr. R feels that Frank has probably taken over the home now that his father is not there to set limits, but Mrs. S continues to deny that he is a problem. Mrs. I arrives and escorts Mrs. S to a respite room, offering many options to help with Frank. Mrs. S reports that she is tired and asks to go to sleep. The administrator tells her to get some sleep and promises to return in the morning. Mrs. I leaves for the evening, knowing how difficult it has been for Mrs. S to cope with her son and realizing that the situation appears quite serious, since Mrs. S would rather sleep at the hospital than return to her home to deal with the problem.
Elder abuse and neglect is one of the most underrecognized, underreported, and poorly funded problems in modern society.1 The term elder mistreatment refers to the physical abuse, emotional abuse, neglect, abandonment, or financial exploitation of an older adult inflicted by others.2 Elder mistreatment may be intentional or unintentional. Older adults are very reluctant to report incidents of abuse out of fear, shame, embarrassment, and feelings of hopelessness that nothing can be done to help them.3 The prevalence of elder abuse and neglect is difficult to determine because reporting mechanisms vary widely and screening for mistreatment is inconsistent. Estimates suggest that approximately 4% of those over age 65 years are victims of abuse or neglect.4 Others place the prevalence as high as 2 million cases per year.1 More than 80% of incidents of mistreatment go unreported, leading to an increase in hospitalizations, use of emergency services, and a high rate of excess morbidity and mortality among the victims.5
As the case of Mrs. S illustrates, financial exploitation is one of the most common types of elder abuse, with emotional abuse, threats, and coercion frequently occurring as a means of gaining control and access to property and funds.6 In almost 90% of cases in the community, the abuser is a family member. In two-thirds of cases, it is a spouse or adult child. The abuser frequently depends on the older adult for housing, financial support, or assistance. Often, the abuser may have substance dependence and other mental health problems, or suffer from the stress of caregiving in a severe manner. Typically, the abuser does not recognize that the behavior is neglectful, exploitive, or harmful. An abuser may act under the belief than any attention provided to an older adult is a “favor” that is justified.1,6 At greatest risk for elder abuse are women over the age of 75 years, those who live alone, and elderly persons who suffer from frailty, confusion, or depression.2 Physical abuse, neglect, and preventing access to care are forms of abuse that the clinician may encounter in an office setting. Unfortunately, signs of abuse are often attributed to ongoing chronic medical problems, frailty, or dementia.3 Frequent visits to the physician or emergency room for lacerations, bruises, fractures, burns, dehydration, or signs of any sexual trauma should cause the clinician to investigate further to ensure the patient’s safety.7 Signs of bruising around the wrists or ankles is highly suspicious of the use of physical restraints, and must alert the clinician to look for additional symptoms of abuse and neglect1,3-6 (Table).
It is important to recognize that overburdened caregivers may become neglectful without intending any harm. Interviewing the older adult and the caregiver individually, and screening for caregiver stress and burden, may help to prevent potentially destructive situations by offering referrals to social services and community agencies to assist with care planning needs.2,3 Involvement of family members to reduce caregiver stress or assist with some aspects of caregiving may also be of benefit. Abuse and neglect may also occur in institutions, including nursing homes, assisted living facilities, and adult board-and-care homes. Risk factors for abuse by staff members include lack of training, high levels of behavioral disturbances in patients, and significant caregiver burden. Long-term care facilities are highly regulated, and suspected abuse or neglect of nursing home residents should be reported through the state Department of Health or the long-term care Ombudsman Program.1,5 Information and location of state and local ombudsman offices may be found at: www.ltcombudsman.org.
An older adult may neglect personal care, begin hoarding, and become noncompliant with medical care. This self-neglect is one of the most common referrals made to Adult Protective Services agencies.4 Often, the neglect is the result of cognitive loss, but it is important to consider the autonomy and rights of the older adult. While concerned professionals often feel frustrated and helpless, an older adult may choose not to seek help, refuse to press charges against a family member, or decide to live in suboptimal conditions. Ethical, legal, and psychiatric consultations are helpful in these cases, but the rights and decision-making capacity of the older adult must be respected. In cases where an older adult is found to be significantly impaired and lack the ability to make decisions, legal guardianship or conservatorship may be necessary.6
All 50 states, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands have laws that establish services for the protection of adults. Healthcare professionals should always document and report cases of suspected elder abuse and neglect. Reports are confidential, and the clinician cannot be held liable for making a report based on professional judgment. The National Center on Elder Abuse (NCEA) provides links and information regarding the contact numbers to report suspected elder abuse in both the community and institutional settings.6 This information and links to other resources on elder mistreatment can be accessed through its website: www. elderabusecenter.org. The Eldercare Locator (1-800-677-1116 or www.eldercare.gov) provides referrals to local agencies and services for elder abuse and neglect.
OUTCOME OF THE CASE PATIENT
Mrs. S spent the night in a hospital respite room. In the morning, Mrs. I and Ms. C brought her fresh clothing and makeup, and took her out for breakfast. Mrs. I was sympathetic but firm in her approach. She informed Mrs. S that she could not stay in the hospital and needed to take care of herself. She offered to drive Mrs. S to her home and talk with Frank. Ms. C agreed to accompany them. Mrs. S’s home is in an affluent section of the city. When they arrived, they noticed that beer bottles were thrown across the lawn, and the front door was open. It appeared that several men were wandering in and around the house. Mrs. I drove around the block, telling Mrs. S that the situation appeared unsafe and that she needed to call the police. They waited nearby until the police arrived. Frank and several men who had lived with him in the adult residence were found intoxicated. They were brought to the emergency room. A search of the house found equipment used to make methamphetamine, as well as a large quantity of the drug in bags. All of the men, including Frank, were later arrested and charged with felony drug possession. Frank was placed in the hospital unit of the county jail, where he underwent detoxification from alcohol and was placed back on his antipsychotic medication. Mrs. I helped Mrs. S arrange for her house to be cleaned and the locks changed. Despite advice from Mrs. I that Frank should remain in jail, Mrs. S hired an attorney and posted bail for Frank. He was eventually allowed to plead guilty to a lesser charge and serve probation. Mrs. S moved into a senior housing building, and, with the help of Mrs. I, hired a case manager for Frank. He now lives in a supervised residence and has limited contact with his mother. Mrs. S continues to feel guilty about her son, but is safe in her apartment and continues her volunteer work at the hospital.