(February 1999)
Retirement. Independence. Friends. Family. The finale of the American Dream.
Unfortunately, this was not so for more than one half million seniors who, in 1996 experienced a very dark side of aging: Abuse.
These 551,000 elderly non-institutionalized individuals have been described as the "tip of the iceberg" of unreported elder abuse nationwide. The National Center on Elder Abuse (NCEA) estimates that for every reported case, another five incidences are not.
What is elder abuse? It is the willful infliction of physical or psychological pain or injury to an adult 60 years of age and older; it is the misuse of a senior's financial assets without their knowledge or consent; and it is the consequence of inadequate caregiving knowledge or the refusal to provide necessary aid or assistive devices.
Four categories of abuse are generally accepted: physical, emotional, financial, and neglect. The following indicators are not exhaustive but are intended to give the clinician a framework for identification.
Physical abuse is suspected in cases of contradictory or implausible explanations of an injury, misaligned fractures, bruises in various stages of healing, or signs of sexual coercion. Emotional, or psychological abuse threatens, isolates, humiliates, or intimidates the elder. Financial exploitation depletes the seniors' funds or assets through uncharacteristic bank withdrawals, transfers, or closing of bank accounts.
A dehydrated, malnourished presentation, or abnormal lab values suggesting medication noncompliance indicate neglect. Self neglect will additionally result in poor hygiene, weight loss, or a disheveled appearance. According to the literature, neglect cases are the most widely reported, followed by incidences of psychological, financial, and physical abuse.
Elder abuse, as with other areas of domestic violence, requires that professionals in all fields of practice be aware of risk factors suggesting an abusive situation. Studies have shown a high correlation between elder abuse and dependency, substance abuse, caregiver stress, abuser pathology and a cycle of family violence. According to the NCEA's Incidence Study released in September of 1998, women in 1996 were disproportionately victimized, particularly those 80 years of age and older. Almost sixty percent of the abused exhibited some degree of cognitive impairment and almost one half of the substantiated cases involved individuals who were unable to care for themselves. Two thirds were clinically depressed. In nearly 90% of the substantiated cases, family members perpetrated the abuse. Adult male children, aged 41-59 were more likely to abuse, followed by spouses, other relatives and grandchildren. Approximately one third of the abusers were themselves more than 60 years of age.
How can the clinician intervene in suspected abuse? First, discuss the situation with a supervisor or a case management agency familiar with elder abuse. Involve the local adult protective services if dementia is present and no family members are willing or able to help. Should the victim be cognitively intact, interview them privately, apart from the alleged abuser. Normalize the situation, offering reassurance that other seniors have had similar experiences. Roadblocks such as the senior's sense of embarrassment and shame that a family member "could do such a thing", fosters denial and excuses for the abuser's behavior. Conduct a comprehensive assessment of the client's needs, linking them with appropriate social services. Medical and mental health referrals, and family education on the aging process and caregiving are cornerstones of preventive care for the older person.
Recommend participation in appropriate activities and the maintenance of social contacts. Elder abuse support groups are available citywide and are a valuable resource in restoring the senior's self esteem. Use the legal system. Call 911 or the local police precinct in cases of assault or other criminal activity, and involve the court system for Orders of Protection. Encourage the senior to follow through on violations of the Order with immediate phone calls to the police. Advocate with seniors, urging legislators to develop a public policy that will provide adequate legal protections while preserving the autonomy and dignity of the older individual.
To date, New York State is one of the few states that does not have a mandatory reporting law for non-institutional elder abuse. Controversy swirls around mandated reporting, with public hearings held last spring in New York City to provide a forum for providers, advocates, and lawmakers to address this issue. It is evident that as our older population grows, so does recognition of the problem of elder mistreatment. Central to exposing abuse is the empowerment of the abused, and the reframing of what abusive behavior is in the public mind. Acting on this new-found awareness and taken to the floor of the legislature, we can guide the debate for the safety and well-being of everyone's mom and dad.