Elder Abuse

Elder abuse is an important public health problem. It is a violation of human rights and is a significant cause of illness, injury, loss of productivity, isolation, and despair, according to the World Health Organization. The National Elder Abuse Incidence Study (1998) found that in 1996, nearly half a million persons aged 60 years or older had been physically abused, neglected, or in some way mistreated. This study, which was based on Adult Protective Service records and sentinel reports (eg, reports from community professionals), very likely greatly underestimated the true scope of the problem of abuse of older Americans, because the majority of elder abuse cases are unreported and are undetected by monitoring agents. A 2017 study that summarized 52 studies in 28 countries from diverse regions estimated that over the past year, 15.7% of people aged 60 and over were subjected to some form of abuse. In the United States, the prevalence of elder maltreatment was reported as 7.6%–10% of study participants and is estimated to affect 11.4% of adults aged 60 years and older. Worldwide, it is estimated that only 1 in 24 cases of elder abuse is reported, in part because elderly individuals are often afraid to report the abuse to family, friends, or the authorities. The EU Charter of Fundamental Rights, Article 25, states that “The Union recognizes and respects the rights of the elderly to lead a life of dignity and independence and to participate in social and cultural life,” yet 47% of European people believe that poor treatment, neglect, and abuse of older people are common in their countries.

Major risk factors for elder abuse include external stresses due to marital, financial, and legal difficulties; dependent relationships (eg, the abuser may be dependent on the older patient for finances or housing, or vice versa); mental illness and substance abuse; social isolation; and misinformation about normal aging or about the patient’s medical or nutritional needs. Maltreatment can occur at home, in assisted living facilities, or in nursing homes. It can take the form of physical or psychological abuse, material misappropriation, neglect and abandonment, or sexual abuse.

Physical abuse means inflicting physical pain or injury upon an older adult. Psychological abuse includes verbal assaults, threats of abuse, harassment, and intimidation. Material misappropriation or financial abuse of the elderly includes taking money or property or using/misusing money or property without the owner’s knowledge or permission; forging or forcing an elderly person’s signature; misusing ATM cards or credit cards; and persuading an elderly individual to change a will or an insurance policy. Passive neglect is a caregiver’s failure to provide an older adult with life’s necessities such as food, water, hygiene, clothing, shelter, medical care, or medication. Neglect may be intentional or unintentional and may be related to financial constraints or lack of other resources (eg, transportation, supervision). Elder abuse also includes deprivation of basic rights (eg, decision-making for care, privacy) and abandonment.

The ophthalmologist may be the first physician to see an older patient who is being abused or neglected. The signs may be subtle, and early recognition is key. The ophthalmologist should suspect elder abuse in the following circumstances:

• broken eyeglasses, with a report by the patient of being slapped or abused

• evidence of physical abuse (eg, bruises, black eyes, fractures, lacerations, wounds in various stages of healing, burns, welts, patches of hair loss, or unexplained subconjunctival, retinal, or vitreous hemorrhage)

• repeated visits to the emergency department or office

• conflicting or noncredible history from caregiver or patient

• unexplained delay in seeking treatment

• unexplained, inconsistent, vague, or poorly explained injuries

• history of being “accident prone”

• expressions of ambivalence, anger, hostility, or fear by the patient toward the caregiver

• poor adherence to follow-up or care instructions

Sometimes it is necessary to obtain the patient history with the caregiver out of the room. Directed questions for the patient include “Has anyone at home tried to harm you?”; “Has anyone tried to make you do things that you don’t wish to do?”; and “Has anyone taken anything from you without your consent?”

Any suspected case of elder neglect or abuse should prompt a complete written report. Documentation of any suspicious injuries is mandatory, including type, size, location, and characteristics of injury and stage of healing. Requirements for reporting elder abuse vary from state to state, and many areas have abuse hotlines for reporting maltreatment. The physician should be aware of local services for adult protection, community social services, and law enforcement agencies.

• Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health. 2010;100(2):292–297.

• National Council on Aging website: Elder Abuse Facts. www.ncoa.org/public-policy-action/elder-justice/elder-abuse-facts. Accessed February 21, 2019.

Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.