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October 2008

Clinical Update: Comprehensive
When the Diagnosis Is Elder Abuse
By Miriam Karmel, Contributing Writer

The older patient who presents with a pair of broken spectacles may need your help, though not the kind that took years of training to deliver. Damaged eyeglasses could be a warning sign of abuse, which is a growing public health problem among the elderly. An estimated 1 to 2 million Americans age 65 and older have been injured, exploited or mistreated by someone on whom they depend for care. And ophthalmologists may be on the front lines for recognizing when an elderly patient is suffering from maltreatment.

A Spectrum Both Broad and Sad

Since the term “elder abuse” first appeared in a 1975 British Medical Journal article,1 the problem, or at least its recognition, has grown exponentially. Between 1986 and 1996 the number of reported cases in the United States jumped from 117,000 to 293,000—an increase of 150.4 percent.2

Elder abuse goes beyond battering or physical harm to include sexual and emotional abuse, financial or material exploitation, and abandonment or neglect. The last two types of abuse, according to the National Center on Elder Abuse, account for more than half of all cases. “The most common thing we see is neglect, more than actual physical or sexual abuse. People just aren’t being cared for,” said Kumar Rao, MD, a member of the Academy’s Committee on Aging and an assistant professor of ophthalmology at Washington University in St. Louis. There are also cases of self-neglect, in which the patients can’t care for themselves or they refuse care.

Clinging, dangerously, to independence. Most of the neglect that Dr. Rao sees is self-imposed. “Sometimes the elderly don’t want the help,” he said, explaining that they fear being institutionalized, or they feel able to care for themselves and don’t want someone else involved in their care. Consequently, neglect can set in despite the good intentions of family and friends. The signs are often nuanced. “What we may see is a disheveled appearance or difficulty with hygiene,” Dr. Rao said. “Then we see they’re not responding to therapies we’re prescribing because they’re not able to give themselves the medications. So the disease progresses, despite our best efforts.”

Daniel J. Briceland, MD, also a member of the Committee on Aging, agreed. “I see a moderate to significant amount of neglect,” he said. But Dr. Briceland, who tends primarily to a geriatric population in Sun City West, Ariz., can’t recall encountering a single case of physical abuse in over 17 years of practice. Such cases, he said, are more likely to surface in the emergency room or orthopedic office.

Medical care suffers. Dr. Briceland recalled a case in which he treated the elderly father of one of his regular patients. The father lived in a nursing home and had only count fingers vision because of a cataract. “No one had taken him to a doctor,” said Dr. Briceland, adding that the man’s son, who was in his 70s, couldn’t believe that the nursing home hadn’t attended to his father’s needs. Such neglect is not uncommon, said Dr. Briceland, adding that glaucoma and macular degeneration can also go untreated. Patients are often just unable to adhere to a medication regimen, or caretakers are not giving the medications at appropriate intervals.

Skipped appointments may signal another form of neglect. “There are a lot of folks who just aren’t coming in for follow-up treatments, despite repeated office reminders, including letters and phone calls,” Dr. Briceland said. Someone with glaucoma, who should be seen every four months, may show up one year later, he said.

These are all red flags for possible abuse, and doctors need to be aware of them, Dr. Briceland said. “It’s their responsibility. Physicians need to pause and step back from just looking at the eye. Ask questions. And even better—listen. Then you’re better able to assess what the individual’s needs are.”


The Responsibility to Report

Though statutes and definitions vary from state to state, the law generally requires reporting of even suspected abuse. All 50 states have laws governing elder abuse reporting. In 42 states reporting is mandatory, and all the laws provide immunity from liability for those who report in good faith.

In its Basic and Clinical Science Course (Update on General Medicine, Section 1), the Academy advises doctors to write a complete written report of any suspected case of elder neglect or abuse. The policy states: “Documentation of any suspicious injuries is mandatory, including type, size, location, and characteristics of injury and stage of healing.”

Preventing more harm. “Elder abuse is more and more recognized as the old-age equivalent of child abuse. More harm could come to the patient if you don’t report,” said Anne M. Menke, RN, PhD, a risk manager with Ophthalmic Mutual Insurance Company. “But as with child abuse, you want to have a good- faith reason to believe that there’s a problem. That might be harder to tell with older folks.” If a physician feels a patient has been harmed by someone, whether actively or by neglect, they should do something about it, Ms. Menke said.

It has been argued that failure to report obvious cases of abuse may qualify as negligence or malpractice,3 but Ms. Menke can’t recall a single malpractice case arising from elder abuse. “Failure to report is a medical board action,” she said. “But it’s not a malpractice case. That has to be filed by the patient.”

Caring for the whole patient. But first, before taking any action, the physician must be prepared to consider abuse or neglect. “You have to have it on your radar,” Dr. Rao said. “If you’re not thinking about it, you’re not going to recognize it. If you suspect abuse, and don’t know how to report it, call your local emergency room. That’s what I do. They’re more likely to handle situations like this than we are.”

And recognition, as Dr. Briceland noted, requires looking beyond the eye. “We’re physicians first. We’re not just ophthalmologists,” he said. “Part of being physicians is taking care of the whole patient. It is your responsibility as a physician to be aware of the individual’s total health care needs. You can’t just look at their eye and send them out the door.”

1 Burston, G. R. Br Med J 1975;3:592.
2 “Reporting of Elder Abuse in Domestic Settings,” National Center on Elder Abuse, updated November 2007.
3 Gibbs, L. M. and L. Mosqueda. Am Fam Physician 2007;75(5):628.


Eight Signs of Trouble, Nine Questions to Ask

The signs of elder abuse may be as subtle as failure to appear for a scheduled appointment or as blatant as broken spectacles or vitreous hemorrhage. Geriatrician Myron Miller, MD, identified the clinical signs of abuse that ophthalmologists are likely to recognize. These may include signs of dehydration; sunken eyes; scalp, facial or neck ecchymoses; abrasions; burns or lacerations; recent trauma to the eyes reflected in subconjunctival or vitreous hemorrhages; and traumatic cataract, retinal detachment or orbital fractures.

But Dr. Miller, who is professor of medicine at Johns Hopkins University and director of geriatric medicine at Sinai Hospital in Baltimore, acknowledged that abuse is also manifested in less clinical ways. “More commonly, individuals may have broken their glasses and do not have a full explanation of why it happened,” he said. “In addition, there may be an inadequate response to what should be a straightforward medical treatment for a problem or noncompliance to a prescribed treatment regimen.”

Academy advice. The Academy, in its Basic and Clinical Science Course (Update on General Medicine, Section 1), advises ophthalmologists to suspect elder abuse in the following circumstances:

  • Repeated visits to the ER or office.
  • Conflicting or noncredible history from caregiver or patient.
  • Unexplained delay in seeking treatment.
  • Unexplained, inconsistent, vague or poor explanations for injuries.
  • History of being “accident-prone.”
  • Expressions of ambivalence, anger or fear by the patient toward the caregiver.
  • Poor compliance with follow-up or care instructions.
  • Evidence of physical abuse (skin bruises, lacerations, wounds in various stages of healing, unusually shaped bruises, burns, welts, patches of hair loss, or unexplained subconjunctival, retinal or vitreous hemorrhage).

AMA advice. Most episodes of elder abuse are perpetrated by a family member or other caregiver, so it may be necessary to obtain a history without the caregiver. When directing questions to the patient, the AMA recommends asking:1

  • Has anyone at home ever hurt you?
  • Has anyone ever touched you without your consent?
  • Has anyone ever made you do things you didn’t want to do?
  • Has anyone taken anything that was yours without asking?
  • Has anyone ever scolded or threatened you?
  • Have you ever signed any document that you didn’t understand?
  • Are you afraid of anyone at home?
  • Are you alone a lot?
  • Has anyone ever failed to help you take care of yourself when you needed help?

1 Aravanis, S. C. et al. Arch Fam Med 1993;2(4):371-388.