Elder Abuse: A Well-Kept Secret

Elder mistreatment is a common yet frequently under-recognized problem in our society. Family members often want to help care for their elders at home but may not be aware of the work and sacrifice involved, particularly as the older person becomes more dependent. As a result, the stress of the situation may lead to neglect or abuse. This article focuses on defining the scope of the problem, addressing the related issue of self-neglect, and outlining community resources for caregivers of the elderly.

Definitions

Elder mistreatment is defined as any intentional action or nonaction that causes harm to an elderly person. This includes willful infliction of physical pain or injury, debilitating mental anguish, or financial exploitation as well as active and passive neglect.

More than one type of abuse can be inflicted simultaneously. Neglect comprises 80 percent of abuse claims. Active neglect is the failure of a caregiver to intervene or resolve a significant need despite the awareness of available resources. Passive neglect is unintentional and stems from lack of knowledge or a genuine inability to provide care. The primary goal of elder abuse intervention is to link the elder to appropriate community resources rather than to penalize the caregiver.

Physical abuse: non-accidental use of physical force that results in bodily injury, pain, or impairment.
Sexual abuse: non-consensual sexual contact of any kind with an older person.
Emotional abuse: infliction of mental or emotional anguish by threat, humiliation, or other verbal or non-verbal abusive conduct.
Exploitation: unauthorized use of funds, property, or resources of an older person.

Identification

Approximately four percent of elders experience moderate to severe abuse each year, with women at greater risk. Clinicians can overlook elder mistreatment because there are no brief, easy-to-use, and well-validated screening tools. The elderly voluntarily disclose abuse at home only about a third of the time. More often this comes to light through inspection of the patient's physical appearance, the social service evaluation of the patient's living conditions, or reports of neighbors and non-abusive relatives. It is important for medical professionals to interview older adults and their caregivers separately to obtain honest information about the clinical presentation and home environment. All elderly patients should be asked if they feel safe where they live and with those who render assistance to them.

Elderly patients hesitate to disclose mistreatment because they are frequently dependent on the abuser for basic needs such as food, shelter, medical care, and social stimulation. They may feel embarrassed or ashamed if the perpetrator is a family member. Elders may fear not being believed. They may also fear reprisal, abandonment, or institutionalization. Denial of abuse by the patient or caregiver does not preclude the diagnosis.

Risk factors

Research has demonstrated that in 86 percent of cases of elder mistreatment the abuser is a relative, and in 75 percent of the cases the abuser lives with the elderly person. Fifty percent of the abusers are children or grandchildren and 40 percent are spouses. Risk factors for abuse include being frail, suffering poor health, and experiencing cognitive impairment such as dementia or confusion.

Additional risks include dependence of the elderly upon the caregiver, social isolation, and a history of violence, particularly among spouses. The major risk factors of potential abusers include substance abuse or mental illness in the caregiver, external factors causing stress in the caregiver's life, and dependence of the abuser on the victim for housing and other forms of material support.

Self-neglect

We are all familiar with the elderly person who lives alone and appears to be slipping in their ability to care for their personal appearance and living quarters, yet adamantly refuses offers of assistance. Examples of self-neglect include not obtaining adequate nourishment, not taking medication, and not seeking medical care for acute problems.

A recent study showed a significantly higher prevalence of depression and dementia in seniors exhibiting self-neglect compared to other seniors. In situations of self-neglect, the health care provider assesses the individual's mental competency, roughly defined as the ability to understand the consequences of one's actions. If someone is legally competent, they are free to live as they choose, and others cannot impose restrictions upon them, such as placement in a nursing home. If the senior is incompetent, more protective measures can be taken to assist them.

Community resources

Caring for an elderly parent at home is inherently stressful and abusive situations can be prevented by providing caregivers with support. Caregivers need information about the many services designed to help the elderly.

In 1999 Nancy Archibald of the Special Needs Support Center (formerly the Upper Valley Support Group) led a community effort to develop "An Upper Valley Resource Directory for the Caregiver of an Aging Parent." This 200-page comprehensive manual focuses on local services that can make a difference in the life of the elderly person and her caregivers, and would also assist those providing care long-distance. The directory includes information on local support groups, an invaluable resource for caregivers. The guide is available for $8.50 by calling (603) 448-6310.

State programs

New Hampshire

Those suspecting elder mistreatment or abuse may call the District Office of the New Hampshire Bureau of Elderly and Adult Services. The closest office to the Upper Valley is in Claremont. Call (800) 982-1001 for more information.

Vermont

There are two programs to address the different levels of abuse and neglect. In situations where the senior appears to be in immediate danger, it is appropriate to call Adult Protective Services at (802) 241-2345. This is a state office; cases are distributed to the regional office that serves the area where the client lives.
In cases of suspected self-neglect or less severe abuse, the appropriate agency is the Council on Aging of Southeastern Vermont, which can be reached at (800) 642-5119. The calls are referred to a social worker who visits the seniors at home and links them to appropriate community services such as meals-on-wheels, in-home personal care, and transportation. The social worker can also help seniors complete the paperwork for government assistance programs when applicable.

Resources at DHMC

For patients at Dartmouth-Hitchcock Medical Center, the Office of Care Management at (603) 650-5789 provides assistance with coordination of services for community-dwelling seniors who require help maintaining independent living at home. These care managers can meet with seniors and their families to explore options to prevent abusive situations from arising.