An under-recognized epidemic of elder abuse needs your awareness and action
Your preventive and protective efforts to combat this public health concern should be refined and redoubled
No federal standard exists for states to follow when defining and addressing elder abuse, which can complicate identification and reporting of abuse. Laws governing elder abuse do not allow states to determine the fate of the older adult, who can decide for himself (herself) whether to use or waive protective services.42 Older adults might choose not to report abuse because of shame, intimidation, or fear,43 or to protect a caregiver, who often is a family member.
Elder abuse reports can come from a variety of sources; convincing evidence is, as noted, unnecessary to report it. Health care providers are mandated reporters, but
it is believed that the number of clinicians who report elder abuse based on suspicion is far below what it should be. One study found that 94% of physicians said that they either were unable to prove that the abuse had occurred or decided not to report it.11 Another study found that only 1.4% of elder abuse cases reported to APS come from physicians.44
There are several possible reasons for underreporting elder abuse, including (1) the difficulty of distinguishing elder abuse and neglect from sequelae of normal aging and (2) the fact that cognitive and functional impairment of the abused person makes it difficult, even impossible, to establish the narrative of how the abuse happened. Nursing homes in particular provide a high level of oversight because residents have an average of ≥3 functional deficits.4 Other reasons for underreporting—some of which are difficult to understand, and excuse, in a clinician—are:
• subtlety of signs
• victim denial
• ignorance of reporting procedures
• inadequate training
• lack of information about resources
• concern about losing physician–patient rapport
• concern about involvement in the legal system
• time limitations
• doubt about the effectiveness of APS.16
Assessing capacityThe older adult’s wishes must be respected unless a health care provider or the legal system determines that he lacks functional capacity to make decisions.16
How is capacity evaluated? A capacity evaluation has 3 components:
• Comprehension is a person’s factual understanding of the situation, including
consequences and alternatives
• Free choice is a person’s voluntary decision to accept or reject a proposed treatment, free of coercion (in this setting, free choice is the older adult’s decision whether to report the abuse)
• Reliability is a person’s ability to provide a consistent choice over time.45
Most capacity evaluations are conducted by clinical interview. No single, brief test is used universally, and there is the possibility of inter-rater variability.45 Examples of tests used to assess capacity are the Folstein Mini-Mental Status Examination and the MacArthur Competence Assessment Tool-Treatment45; the latter is a structured interview that incorporates information specific to the individual patient’s decision-making situation.46 Regardless of the approach, the psychiatrist-evaluator ensures that the older adult has been given the appropriate information
to provide informed consent about the situation.47
If the evaluator determines that a person lacks capacity to make decisions, efforts should be made to determine if the cause of that impairment is reversible.47 Older adults who have dementia or other underlying psychiatric condition that impairs cognition might benefit from more education on their situation; ones who appear fearful of consequences should be introduced to a trusted advisor to assist in making competent judgments.47
If the older adult is found to lack capacity, a substitute decision-maker must be sought.47 Many states have statutes specifying the order in which family members are contacted.48 The need to appoint an advisor can become knotty because the suspected abuser often is a family member; clinicians and others involved in identifying a decision-maker to speak on behalf of an older adult should choose carefully.
Prevention and screeningKey to reducing the prevalence of elder abuse in the community is formulating
strategies for prevention and screening. The American Medical Association recommends that clinicians “incorporate routine questions related to elder abuse and neglect into daily practice.”49 Older adults might not admit to abuse or neglect unless they are asked; speak to patients at eye level, keep questions simple, direct, and nonjudgmental, and assure them (1) that discussions are confidential and (2) that their safety is your primary goal.50,51
Comprehensive approaches to questioning patients are available and often recommended for screening for elder abuse.4 However, screening in the office setting often involves short, directly administered questionnaires.49 For example, the Health and Safety Screen developed at the University of Maine comprises 6 questions52:
• Has anyone close to you called you names or insulted you recently?
• Are you afraid of anyone in your life?
• Are you able to use the telephone anytime you want to?
• Has anyone forced you to do things you didn’t want to do?
• Has anyone taken things or money that belong to you without your OK?
• Has anyone close to you tried to hurt you or harm you recently?
