The hidden health menace of elder abuse

Joslyn Weiner Fisher, MD; Carmel Bitondo Dyer, MD

VOL 113 / NO 4 / APRIL 2003 / POSTGRADUATE MEDICINE

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As many as 2 million elderly persons in the United States experience physical, psychologic, or sexual abuse each year. Nationally, spouses or intimate partners commit between 13% and 50% of elder abuse (1). Physicians can be instrumental in preventing and intervening in intimate partner violence in their elderly patients.

Although intimate partner violence is more prevalent among younger women, violence may exist in relationships between elderly persons and can lead to substantial health and socioeconomic consequences. A study by McCauley and associates (2) found that women who have experienced physical abuse have more somatic complaints (eg, chronic pelvic pain, headaches), higher levels of anxiety, and increased symptoms of depression compared with women who have not been abused. When compared with the general US population, victims of violence have twice as many physician visits, 2.5 times the outpatient costs, and a diminished sense of well-being (3). Annually, family violence accounts for up to $5 billion spent on medical, police, and court costs--as well as on shelters, unemployment, and reduced productivity (4). The consequences may be particularly dire for elderly persons because of the high number of comorbid illnesses and the frailty in this age-group. Lachs and colleagues (5) cited a threefold increased risk of death for community-dwelling elders with a reported history of abuse. In another study, Lachs and coworkers (6) found that two thirds of elderly victims of abuse had been seen in an emergency department at least once within a 5-year time frame surrounding the initial identification of abuse.

Although elderly abuse victims frequently present to the healthcare system, physicians often miss opportunities to recognize and address the underlying issue that precipitated the visit: intimate partner violence. The American Medical Association and other national medical organizations have established guidelines for identifying and intervening in cases of intimate partner violence and elder abuse. The Joint Commission on Accreditation of Healthcare Organizations requires a protocol for identification of and intervention in domestic violence cases to be implemented in all ambulatory care settings. Despite these efforts, fewer than 10% of primary care physicians routinely screen for domestic violence during regular office visits (7).

Clinical approach

Physicians can improve the healthcare system's response to elderly patients experiencing abuse. Steps include identification of and response to victims, establishment of a management plan, appropriate documentation and reporting of abuse, and provision of resources and referrals.

Since the consequences of intimate partner violence can be profound in an elderly person, why aren't these cases identified more routinely?

Patient, physician, and structural barriers to the identification of elder abuse must be recognized. Patients may remain silent for fear of retaliation by the batterer (eg, further violence, placement in a nursing home). Elderly victims may feel ashamed, sense their economic vulnerability, or face cultural or language barriers (8). Physicians may not be aware of the prevalence of intimate partner violence and elder abuse nor of the guidelines for handling such cases. A lack of time and privacy during office visits has been cited as another obstacle to intervention (9).

Perhaps the most interesting and challenging barrier to addressing intimate partner violence in elderly persons is distinguishing between the causes of abuse. Is the abuse secondary to caregiver stress, or is it persistent violence perpetrated by a chronic batterer? Should the thrust of the intervention rest on alleviating caregiver burden, or should it focus on maximizing patient safety? Because of these diverging concepts of causation, it may be appropriate to offer different sets of services to elderly patients who experience abuse by a spouse or intimate partner versus abuse by another caregiver.

Once recognized, these barriers to screening can be overcome. Risk factors for victimization include female sex, physical or cognitive impairment, social isolation, dependency, and possibly lower socioeconomic status (10). However, there is no classic profile of a victim. Identification begins with active listening, asking screening questions, and monitoring patients for physical and psychologic findings characteristic of abuse. Sample questions to ask patients and findings potentially suggestive of abuse are described in table 1.

Physician response

It is important for physicians to validate a patient's experience while supporting his or her autonomy. Physicians should remind the patient that he or she does not deserve to be abused, that help is available, and that he or she is not alone. Domestic violence involves complex relationships, and the distinction needs to be recognized between an independent patient involved in a long-term relationship in which the perpetrator maintains a violent cycle of power and control and a vulnerable patient who is physically or mentally unable to access resources because of abuse at the hands of an overburdened caregiver. Although no single solution exists, basic steps can be taken to empower the patient to prevent or alleviate the abusive situation.

Management plan

An elderly victim's decision-making capacity and current safety should guide the healthcare team's management strategy. If the patient is unable to make decisions or is in imminent danger, the appropriate agency, such as law enforcement or adult protective services, should be notified immediately. The patient may need to be hospitalized. Does the patient need immediate assistance, or is the development of a safety plan adequate? If the situation is less urgent, there is time to discuss safety planning with the patient.

Patients should be encouraged to call 911 if they find themselves in danger at home. If a patient must leave home quickly because of escalating abuse, he or she needs to have a safe place to go (eg, a friend's home, a shelter, a hospital). Patients should be told to take important papers with them. Some elderly patients may not be able to flee as readily as younger patients because of physical disability or financial constraints, and many shelters may not accept elderly women. Special plans should be devised for these patients. On the positive side, elderly patients who receive Social Security income may be able to afford alternate housing. Helping patients obtain county or state assistance also may help mitigate some high-risk situations.

Interdisciplinary efforts addressing the consequences of domestic violence have proved effective among victims by decreasing rates of depression, improving self-esteem, and increasing safety. Dyer and colleagues (11) demonstrated the feasibility of collaboration between a local adult protective service agency and a geriatric assessment team. An interdisciplinary team member can facilitate an elderly victim's access to such local resources as counseling, legal assistance, law enforcement, advocacy, and social services. Substance abuse treatment should be offered to perpetrators or victims if a need is indicated.

Documentation of abuse

Physicians can further assist a patient who experiences elder abuse by making accurate documentation (table 2). Many states require healthcare professionals to maintain records of reported or suspected abuse. The American Medical Association recommends that certain items be included in the patient chart for complete documentation of abuse or neglect, including the following (12):

• Chief complaint, history (in patient's words), and information about the perpetrator
• Physical examination with information about injuries--number, size, and location and their consistency with patient's explanation of injury
• Photographs and body charts may be used to enhance written information
• Name of caller if appointments are repeatedly canceled
• If police are contacted, name of person taking the report and any actions taken

Reporting requirements

Most physical, sexual, and financial abuses against elderly persons, whether committed by a spouse or another caregiver, are considered crimes in all states. A variety of mandatory reporting laws, including penalties for not reporting elder abuse, exist in 45 states. Most state statutes guarantee anonymity and immunity from liability for reporting elder abuse to adult protective service, social service, or law enforcement agencies. Physicians can contact their Area Agency on Aging or the National Center on Elder Abuse for information specific to their state.

Conclusion

Intimate partner violence is a well-recognized public health issue. As US demographics shift toward an older population, the health and socioeconomic consequences of elder abuse--especially abuse committed by an intimate partner--also will increase. Physicians can improve the well-being of their elderly patients by uncovering and intervening in cases of intimate partner violence.

References

1. National Center on Elder Abuse. The national elder abuse incidence study: final report, September 1998. Available at: http://www.aoa.gov/abuse/report/Acover.pdf. Accessed Feb 14, 2003
2. McCauley J, Kern DE, Kolodner K, et al. The "battering syndrome": prevalence and clinical characteristics of domestic violence in primary care internal medicine practices. Ann Intern Med 1995;123(10):737-46
3. Berrios D, Grady D. Domestic violence--risk factors and outcomes. West J Med 1991;155:133-5
4. National Institute of Justice, Centers for Disease Control and Prevention. Prevalence, incidence, and consequences of violence against women: findings from the National Violence Against Women Survey. Available at: http://www.ncjrs.org/pdffiles/172837.pdf. Accessed Feb 14, 2003
5. Lachs MS, Williams CS, O'Brien S, et al. The mortality of elder mistreatment. JAMA 1998;280(5):428-32
6. Lachs MS, Williams CS, O'Brien S, et al. ED use by older victims of family violence. Ann Emerg Med 1997;30(4):448-54
7. Rodriguez MA, Bauer HM, McLoughlin E, et al. Screening and intervention for intimate partner abuse: practices and attitudes of primary care physicians. JAMA 1999;282(5):468-74
8. Eisenstat SA, Bancroft L. Domestic violence. N Engl J Med 1999;341(12):886-92
9. Tilden VP, Schmidt TA, Limandri BJ, et al. Factors that influence clinicians' assessment and management of family violence. Am J Public Health 1994;84:628-33
10. Lachs MS, Williams C, O'Brien S, et al. Risk factors for reported elder abuse and neglect: a nine-year observational cohort study. Gerontologist 1997;37(4):469-74
11. Dyer CB, Gleason MS, Murphy KP, et al. Treating elder neglect: collaboration between a geriatrics assessment team and adult protective services. South Med J 1999;92(2):242-4
12. Diagnostic and treatment guidelines on elder abuse and neglect. Chicago: American Medical Assn, 1994:4-24

The authors acknowledge Sam Riley, Cecilia Dykes, and Maria F. Delgado for their technical assistance.

Dr Fisher is assistant professor, department of internal medicine, Baylor College of Medicine, Houston, and director, VIVA Clinic, Ben Taub General Hospital, Houston. Dr Dyer is associate professor, department of internal medicine, Baylor College of Medicine. Correspondence: Joslyn Weiner Fisher, MD, Ben Taub General Hospital, Section of General Medicine, 1504 Taub Loop, 2RM 81-001A-F, Houston, TX 77030. E-mail: jweiner@bcm.tmc.edu.

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