Elder Abuse and Mistreatment
Between three to ten percent of older adults in the United States experience mistreatment and abuse. In a large scale study done by researchers, Pillemer and Finklehor, the number of estimated maltreated elderly is between 700,000 and 1,000,000. The risk of abuse for men was actually double that of women, The reason is that older adults who live with others are actually at a greater risk compared to those who live alone. However, when the type of abuse was compared, women victims appear to suffer more serious physical abuse than do men.
There are four types of a recognized elder mistreatment. Physical abuse is that of purposeful misuse of medications or bodily assault. Psychological abuse is characterized by humiliation, harassment, and/or manipulation. Isolation and misuse of living arrangements fall in the category of sociological abuse. Legal abuse means theft or the misuse of civil rights.
There are at least six identifiable risk factors of elder mistreatment. The first is psychopathology on the part of the abuser. The medical professional can question whether any of the relatives who are in frequent contact with the frail elder have a history of severe mental illness. Is there a history of aggressive or acting out behavior on the part of the care-giving family members? Are there any signs of alcohol and/or drug abuse?
Transgenerational violence, i.e. , past history of family violence, is another risk factor.
Dependency on the part of the adult child is a red flag for elder mistreatment. For example, is the adult child or other relative in the home dependent on the frail elder for income, shelter, or emotional support?
The fourth risk factor is that of psychological stress. Have any major stressful life events occurred recently on the part of the caregiver? Is there chronic financial stress in the family? Isolation is also a risk factor. Is the older person satisfied with the amount of contact he or she is having with other family members, friends and neighbors? Is the older person pursuing any interests outside of the home.
The last identified risk factor is the specific living arrangement. Most studies have found that elders are more likely to be abused by people with whom they are living.
Indicators of Mistreatment
In each case of mistreatment, several forms of abuse may be present. The presence of any one of the indicators does not automatically mean abuse. It is the clustering of the indicators that suggests the possibility of underlying abuse.
Regarding physical signs of abuse, the person being abused is often afraid of increased abuse and recriminations. He or she may not tell the primary care physician that abuse is occurring. The mistreated elder may worry that an outsider will judge the relative too harshly, and consequently will go to lengths to tell others that the abuser is a good but possibly troubled person. It frequently takes persistence on the part of the healthcare provider before a victim will talk about his or her problems
In one example of a patient in my practice, an 82 year old woman living with her daughter and son-in-law, was not “permitted” to watch television or eat with the family. Her son-in-law sequestered her into one small room of the house. Shortly after moving in, she developed signs of clinical depression. Her primary care doctor sent her for psychotherapy, and she eventually revealed her living situation and its impact on her. A successful intervention was to encourage her to move to an assisted living facility where she could live in what proved to be a less confining environment. This patient had a history of being a passive victim as a child, wife, and later at the hand of her son-in-law. Psychotherapy helped her to make the decision to live more independently, in an environment free of the criticism of her son -in-law.
Physicians can intervene and help to prevent elder mistreatment in the following ways:
1. Give permission for the caregiver to set boundaries and limits. For many families it is psychologically harmful to take frail elders into their home. Encourage the caregiver to investigate options.
2. Provide information about respite services, adult day care centers, and support groups. Geriatric Care Managers can make in-home visits and help families with their decisions about available community services and care options.
3. When mistreatment and suspected, refer to Adult Protective Services.
Dr Paula Hartman-Stein is a clinical psychologist and rounder o/the Center for healthy Aging, a multi-.disciplinary practice devoted to the care of older adults and their family members. She is the current president of the Akron Area Psychological Association.
22/Bulletin, October, 1998Summit County Medical Society, Vol. 72, #10