Elder Abuse
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Over the past 35 years, tremendous strides have been made in identifying and increasing awareness about patterns of abusive relationships. Child abuse and intimate partner violence have received significantly more recognition than elder abuse and continue to receive more attention in both public and medical domains.
With current medical advances and the adoption of healthier lifestyles, people are living longer. Older Americans now comprise the fastest growing segment of the United States population. The 2010 US Census recorded 40.3 million people aged 65 years or older as comprising 13% of the population. [1] By the year 2020, this group will increase by 5.5%, and by 2050, older Americans are projected to account for 25% of the population. [2]
As a result of the number of older Americans, the number of elder abuse cases will increase, and the impact of elder abuse as a public health issue will grow. [3] Victims of violence have twice as many physician visits compared with the general US population, allowing opportunities for discovery and intervention. Due to the relative isolation of many elders who are mistreated, an unexpected visit to the emergency department may be the only opportunity for detection. Emergency physicians are in a unique position to identify, advocate for, and help manage this vulnerable population.
Elder mistreatment is a multidimensional phenomenon that encompasses a broad range of behaviors, events, and circumstances. Unlike random acts of violence or exploitation, elder abuse is often perpetrated by person(s) known to the victim, and usually consists of repetitive instances of misconduct. It encompasses any act of commission or omission that results in harm or threatened harm to the health and welfare of an older adult.
The US National Academy of Sciences defines elder abuse as follows:
Intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended), to a vulnerable elder by a caregiver or other person who stands in a trusted relationship to the elder
Failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.
From the legal system through the lay press to the medical literature, the terminology used to describe elder abuse is not consistent. Terms vary among researchers, and usage is not consistent in the laws of different states. Even the age at which a person is considered elderly, usually 60 or 65 years, is debated. Seven categories of elder abuse have been described by the National Center on Elder Abuse (NCEA). [4] Categories include the following:
Physical abuse – Any act of violence that causes pain, injury, impairment, or disease, including striking, pushing, force-feeding, and improper use of physical restraints or medication
Emotional or psychological abuse – Conduct that causes mental anguish including threats, verbal or nonverbal insults, isolation, and humiliation. Some legal definitions require identification of at least 10 episodes of this type of behavior within a single year to constitute abuse.
Financial or material exploitation – Misuse of an elderly person’s money or assets for personal gain. Acts such as stealing (money, social security checks, possessions) or coercion (changing a will, assuming power of attorney) constitute financial abuse.
Neglect – Failure of a caretaker to provide for the patient’s basic needs. As in the previous examples of abuse, neglect can be physical, emotional, or financial. Physical neglect is failure to provide eyeglasses or dentures, preventive health care, safety precautions, or hygiene. Emotional neglect includes failure to provide social stimulation (leaving an older person alone for extended periods). Financial neglect involves failure to use the resources available to restore or maintain the well-being of the aging adult.
Sexual abuse – Nonconsensual intimate contact or exposure or any similar activity when the patient is incapable of giving consent. Family members, friends, institutional employees, and fellow patients can commit sexual abuse. [5]
Self-neglect – Behavior in which seniors compromise their own health and safety, as when an aging adult refuses needed help with various daily activities. When the patient is deemed competent, many ethical questions arise regarding the patient’s right of autonomy and the physician’s oath of beneficence.
Abandonment – The desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.
Further training is needed for physicians regarding elder abuse. [6]
United States
Due to the inconsistencies in the working definitions of elder abuse, differences in sampling and survey methods, and underreporting of cases, obtaining accurate information on the incidence of elder abuse and neglect is difficult. Although it is difficult to estimate the incidence of elder abuse and neglect, a 2010 US study found an incidence of 7.6-10% among study participants. [7] Other studies suggest that 3-10% of elders are abused or neglected.
Many factors play a role in the underestimation of the number of abused elders. Patient factors include fear, shame, guilt, or ignorance. Healthcare providers underestimate and underreport elder abuse due to decreased recognition of the problem, lack of awareness of reporting requirements, including who to report to, and concerns about physician-patient confidentiality.
In addition, many studies routinely exclude certain populations such as persons unable to respond to a survey, speakers of languages other than English, and persons with mental illness, further complicating accurate tallies of the number of older persons who are abused. Despite difficulty in identifying the exact frequency of elder abuse, the occurrence is common enough to be encountered regularly in daily clinical practice. As a result, healthcare providers must maintain a high index of suspicion.
Elders who are victim to physical abuse, caregiver neglect, or self-neglect have triple the mortality of those never reported as abused. Early detection and intervention by healthcare professionals in elder abuse cases may lead to decreased morbidity and mortality. Healthcare provider involvement is paramount, as studies have shown that only 1 in 6 victims are likely to self-report mistreatment to the appropriate legal authorities.
Elder abuse occurs among members of all racial, socioeconomic, and religious backgrounds. The NCEA found the following racial and ethnic distribution among older persons who had been abused: [8]
White, non-Hispanic – 66.4%
Black – 18.7%
Hispanic – 10%
Other – 4.9%
Women are believed to be the most common victims of abuse, perhaps because they report abuse at higher rates or because the severity of injury in women typically is greater than in men. Numerous studies, however, have found no differences based on sex.
By definition, elder abuse occurs in the elderly, although there is no universally accepted definition of when old age begins. Typically, 60 or 65 years is considered the threshold of old age.
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Tintinalli JE, Ruiz E, Krome RL. Emergency Medicine: A Comprehensive Study Guide. McGraw Hill Text; 1996. 1377-78.
Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine
Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Robert Harwood, MD, MPH, FACEP, FAAEM Senior Physcian, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine
Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Council of Emergency Medicine Residency Directors, American College of Emergency Physicians, American Medical Association, Phi Beta Kappa, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Barry E Brenner, MD, PhD, FACEP Professor of Emergency Medicine, Professor of Internal Medicine, Program Director for Emergency Medicine, Sanz Laniado Medical Center, Netanya, Israel
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Steven A Conrad, MD, PhD Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, Society of Critical Care Medicine
Disclosure: Nothing to disclose.
Laurel H Krouse, MD Staff Physician, Department of Emergency Medicine, Paoli Hospital
Disclosure: Nothing to disclose.
Monique I Sellas, MD Staff Physician, Department of Emergency Medicine, Massachusetts General Hospital; Clinical Instructor, Harvard Medical School
Monique I Sellas, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Forensic Examiners, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Elder Abuse
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