Elder abuse is a growing public health problem in the United States, with research suggesting that women may be at higher risk of abuse than men are. Laws on elder abuse have emerged over the recent decades, with nearly all states requiring mandatory reporting of suspected elder abuse cases. Physicians play key roles in helping their elder patients; they are often the only accessible individuals outside a frail elderly patient’s family circle and are therefore in an ideal position to detect, manage, and prevent elder abuse. Unfortunately, they are not living up to their potential for reporting elder abuse. Physicians must confront and overcome barriers to detecting and reporting in order to provide appropriate care to elderly patients. This article defines elder abuse, outlines barriers to detecting and reporting elder abuse, provides an overview of the existing elder abuse laws, discusses the dilemmas surrounding mandatory reporting, and offers suggestions on how to manage cases of suspected abuse. (JAMWA. 2004;59:248-254)
Reporting Elder Abuse: A Medical, Legal, and Ethical Overview
Gina S. Wei, MD, MPH; Jerome E. Herbers, Jr., MD
The term “elder abuse” (synonymous with “elder maltreatment”) encompasses physical, sexual, and psychological abuse; financial or material exploitation; neglect; self-neglect; and abandonment (Table 1). It first appeared in the medical literature in a 1975 British Medical Journal article entitled “Granny-battering” and gained public attention a few years later with the release of a US Congressional report. 1,2 In the decades since then, all states and the District of Columbia (DC) have passed laws covering elder abuse3 and researchers have begun investigating it. Nevertheless, elder abuse remains a US public health problem. Community surveys from the late 1980s to mid-1990s found that 1% to 12% of elderly respondents reported some form of maltreatment.4-6 The 1006 National Elder Abuse Incidence Study7 found that 555 011 people older than 60 experienced abuse, neglect, and/or self-neglect in a 1-year period. From January 1, 1999, through January 1, 2001, 5238 nursing homes (~ one-third of all US nursing homes) were cited for abuse violations.8
Several cross-sectional studies have found elder abuse to be more prevalent in those with short-term memory problems, psychiatric diagnoses, and alcohol abuse, as well as among the widowed, divorced, or separated.9,10 Recent research has also found that with the exception of abandonment, elderly women are more likely than elderly men to be victims of all categories of abuse (women made up about 58% of the US elderly population in 1996, but were the victims in 76% of psychological abuse cases, 71% of physical abuse, 63% of financial or material exploitation, and 60% of neglect).7 A recent descriptive study of more than 62 000 reportedly mistreated or neglected elderly people in Texas also confirmed that elderly women may be at higher risk of abuse than men are.11 Dr. Wei is in the Division of Epidemiology and Clinical Applications at the National Heart, Lung, and Blood Institute in Bethesda, Maryland, and Dr. Herbers is with the Medical Service of the Washington VA Medical Center in Washington, DC.
Table 1. Types of Elder Abuse3,7
| Type | Definition |
| Physical abuse | An act carried out with the intention of causing physical pain or injury |
| Sexual abuse | The infliction of nonconsensual sexual contact of any kind |
| Psychological abuse | An act carried out with the intention of causing emotional pain or injury |
| Financial or material exploitation | The improper use of an elderly person’s resources |
| Neglect | The failure of a designated caregiver to provide goods or services necessary for a dependent person |
| Self-neglect | Behavior that threatens one's own health or safety |
| * | |
| Abandonment | The desertion of an elderly person by an individual who had physical custody or otherwise had assumed |
| | responsibility for providing care for that person |
*Abandonment has sometimes been considered a subcategory of neglect.
Only a few prospective studies have examined how various factors actually predict abuse. A 1982 community-based study of more than 28 000 men and women older than 65 found during its initial 2 years of follow-up that use of adult protective services (APS) was associated with functional disability such as requiring assistance with feeding, minority status, older age, and poor social network.12 After 11 years of follow up, bivariate analyses identified several factors associated with APS use (including baseline sociodemographic status, functional impairments, medical conditions, and social networks), but multivariate analyses found that sociodemographic variables only (low income, nonwhite race, and age older than 75 years) were independent predictors of APS use.13
According to the American Medical Association, physicians are often the only accessible individuals outside a frail elderly patient’s family circle and are therefore in an ideal position to detect, manage, and prevent elder abuse.14 During an ideal clinical encounter, an astute and knowledgeable physician would uncover signs and symptoms consistent with abuse (see Table 2). Once recognized, the physician would report the case to a state agency, usually APS. A study of more than 17 000 cases of possible elder abuse reported in Michigan found that only 2% of these cases were reported by physicians and that the reporting rates did not increase over the study’s 5-year period.15 Clearly, physicians are not living up to their potential to detect and report elder abuse. This paper outlines barriers to detecting and reporting elder abuse, reviews the existing legislation addressing elder abuse, and provides suggestions on how to manage cases of suspected abuse.
Volume 59, No 4
Barriers to Detecting and Reporting Elder Abuse
Several barriers prevent physicians from detecting elder abuse. First, they often lack the expertise needed to recognize signs of abuse (Table 2). Few medical schools provide formal training on elder abuse screening or interviewing techniques.16 Older people tend to have multiple medical problems, and it can be very challenging to sort through long lists of physical complaints and correctly decipher which are due to normal aging, chronic illnesses, or mistreatment. Even with trained expertise, a short clinic visit often does not allow adequate time for a physician to thoroughly uncover subtle findings suggestive of abuse. Moreover, victims may suffer such shame, denial, or fear that they opt to keep the secrets well hidden.17 Shame and denial can easily result from wounded pride, particularly since abusers are frequently members of the victims’ families.4 Fear can become a major stumbling block to open discussion, because patients may believe that disclosure will only aggravate the abuse.
Physicians who suspect elder abuse are required by law in most states to report it to a state agency. It is unclear why so many physicians fail to do so. There is some evidence that physicians are unfamiliar with elder abuse legislation,18 and they may falsely believe that only substantiated cases can be reported. Some doctors may also have the misconception that the law requires them to obtain the patient’s approval before reporting. Other possible explanations include physicians’ fear of retaliatory litigation from patients or their families, lack of self-confidence in identifying abuse, desire to avoid court involvement or interfere with patients’ personal affairs, and skepticism in the state’s ability to intervene adequately to ensure better outcomes.19 These barriers must be confronted and overcome in order to provide appropriate care to elderly patients.
Table 2. Common Signs and Symptoms of Elder Abuse/Maltreatment*
Type of Abuse Signs and Symptoms
| Physical Abuse | • bruises, lacerations, open wounds, cuts, burns, bone or skull fractures, sprains, dislocations, internal injuries, untreated injuries, & ropemarks (especially in hard-to-reach locations) | | | • patchy hair loss | | | • broken eyeglasses/frames and signs of being restrained | | | • findings ofmedication overdose or underuse of prescribed drugs | | | • sudden change in behavior (including being withdrawn and flinching) | | | • caregiver’s refusal to allow visitors to see an elder alone | | Sexual Abuse | • bruises around the breasts or genital area | | | • unexplained sexually transmitted disease | | | • unexplained vaginal or anal bleeding | | | • torn, stained, or bloody underclothing | | | • oral trauma (eg, ecchymoses, fractured teeth) | | Psychological abuse | • emotionally agitated or withdrawn/noncommunicative | | | • unusual behavior usually attributed to dementia (eg, sucking, biting, rocking) | | | • ambivalence toward caregiver | | Financial or Material | • sudden changes in bank account or banking practice | | | exploitation • inclusion of additional names on an elder’s bank signature card | | | • abrupt changes in a will or other financial documents | | | • unexplained disappearance of funds or valuable possessions | | | • bills unpaid despite the availability of adequate financial resources | | | • sudden appearance of previously uninvolved relatives claiming their rights to an elder’s affairs and possessions | | | • unexplained sudden transfer of assets to a family member or someone outside the family | | | • provision of unnecessary services | | Neglect or Self-Neglect | • dehydration, malnutrition, untreated bed sores, and poor personal hygiene | | | • unattended or untreated health problems | | | • hazardous or unsafe living condition/arrangements | | | • unsanitary and unclean living conditions, inappropriate dress | | | • medication overdose or underuse | | Abandonment | • desertion of an elder at a hospital, a nursing facility, or other institution | | | • desertion of an elder at a shopping center or other public location |
|
*This list of signs and symptoms is not meant to be comprehensive. Adopted from www.elderabusecenter.org/default.cfm?p=basics.cfm. Retrieved February 19, 2004.
Elder Abuse Laws
It is important that all physicians know and understand their states’ laws governing elder abuse. Currently, all 50 states and DC have laws that authorize the provision of APS in elder abuse cases.20,21 These APS laws generally establish a system for the reporting and investigating suspected elder abuse and often provide for social services to protect the victims. As of 2002, 44 states plus DC had mandatory reporting provisions in their APS laws; one should not assume, however, that reporting is entirely voluntary in the other 6 states (Colorado, New Jersey, New York, North Dakota, South Dakota, and Wisconsin), as there are mandatory reporting provisions in non-APS laws that may relate to elder abuse cases (e-mail communication from Lori A. Stiegel, JD, associate staff director, American Bar Association Commission on Law and Aging, August 26, 2004). Thirty-eight states plus DC had laws specifying penalties for failing to report as of 2000.22 Penalties vary from fines to jail sentences; physicians may also be reported to the state’s medical licensing authority.22,23
Statutes, definitions, and reporting requirements for elder abuse vary considerably from state to state, even among those that mandate reporting.22 First, although all state APS laws that mandate reporting include health care professionals as mandatory reporters, the definition of professionals varies from state to state.24 Second, some state APS laws cover community-dwelling elderly only, but others include those in long-term care facilities (note: states whose APS
250 Wei et al Reporting Elder Abuse: A Medical, Legal, and Ethical Overview JOURNAL OF THE AMERICAN MEDICAL WOMEN’S ASSOCIATION
laws cover community residents only have separate laws addressing institutional abuse). States can also differ in their definitions of long-term care facilities – some include mental health, and others do not.21 Third, several states limit reporting requirements to those who are “vulnerable,” and others include everyone over the specified age, regardless of their vulnerability. Definitions of vulnerability also can vary considerably, though they generally refer to the presence of debilitating illness that limits independence, judgment, or both.22 For example, in Florida, elder abuse reporting laws apply only to those 60 years or older who are also vulnerable or dependent on the suspected abuser. But in Rhode Island, mandatory reporting applies to all who are older than 60 regardless of vulnerability.22 Finally, state laws also differ in: 1) the age at which a victim is covered; 2)the circumstances under which a victim is covered; 3) the types of abuse, exploitation, and neglect that are covered; 4) the situations that require mandatory reporting; 5) the classification of the abuse as criminal or civil; 6) the investigation procedures; and 7) the resolutions for abuse.21
Despite differences in state elder abuse laws, some common themes exist. First, all APS laws (whether they have mandatory or voluntary reporting) provide immunity from liability for those who report in good faith. Although every state offers protection from civil liability, most also offer protection from criminal liability.24 To be found liable for reporting, one typically would had to have made the report in an intentionally false and malicious manner.14 Second, mandatory reporting laws generally require the reporting of suspected abuse. Physicians should report whenever there is reasonable cause to suspect abuse, keeping in mind that substantiation is the state agency’s job. Third, a mandatory reporting law typically does not exempt a physician from reporting simply because a competent elderly patient insists that the physician not do so. That said, competency can nevertheless influence the outcome of an investigation, as laws are usually written to allow the elderly to refuse services.22 Vulnerability should not be confused with competency – a patient may be competent but vulnerable. For example, an elderly woman with severe mobility restriction due to a hip fracture may be alert and competent but vulnerable. After suspecting neglect by an overburdened caretaker, the physician immediately reports the case to state APS. An investigation by APS leads to recommendations that include referral for respite care, which, as a competent individual, the elderly woman has the right to accept or refuse.
In contrast to state statutes, federal laws do not play a direct role in reporting abuse or protecting the abused. The federal government chiefly provides additional funding for
Elder Abuse Internet Sites
Administration on Aging (www.aoa.gov)
Has information for physicians and patients on a wide
spectrum of issues related to the elder population, with
elder abuse as one of its many topics.
Long-Term Care Ombudsman Resource Center
(www.ltcombudsman.org)
Provides background information on support, technical
assistance, and training to the LTC Ombudsman
Programs.
American Bar Association Commission on Law and
Aging (www.abanet.org/aging)
Provides information on laws pertinent to elders; has
contact information by state (direct link is
www.abanet.org/aging/statemap.html) and other law-
related services for legal assistance providers.
National Center on Elder Abuse
(www.elderabusecenter.org)
Serves as an information clearinghouse on elder abuse
laws; lists phone numbers (direct link is
www.elderabusecenter.org/default.cfm?p=
statehotlines.cfm) to report suspected abuse cases by
state.
elder abuse awareness, training, and coordination activities in local and state communities.21 It authorizes the Administration on Aging (AoA) to fund the National Center on Elder Abuse (NCEA) as a resource for public awareness. It also established the Long-Term Care (LTC) Ombudsman Program, under which thousands of paid and volunteer ombudsmen work on behalf of residents in hundreds of communities to advocate, provide information, and work to effect structural changes at the local, state, and national level.25 The Elder Justice Act of 200326 proposes requiring criminal background checks of long-term care nursing aides, better training for workers in detecting elder abuse, establishing a federal Office of Adult Protective Services within the US Department of Health and Human Services, and enhancing law enforcement response.
For a general overview of elder abuse laws and other resources for the elderly, check the Web sites of the AoA, LTC Ombudsman Programs, the American Bar Association Commission on Law and Aging, and NCEA (see sidebar). There is no single Web site that lists and describes in detail the elder abuse provisions in each state. To learn more about the elder
Volume 59, No 4 Wei et al Reporting Elder Abuse: A Medical, Legal, and Ethical Overview 251
abuse laws in your state, consult your institution’s attorney, the local AoA, APS, or Ombudsman Program. You may be able to obtain copies of state laws from your local public li
brary or a nearby publicly accessible law library.27
Mandatory Reporting Laws
Although elder abuse laws are generally thought of as positive efforts for the protection of the elderly, mandatory reporting has generated controversy. A survey of physicians19 found that many are concerned about their ability to detect abuse, are unsure how the law operates, and have reservations about reporting abuse. They are skeptical of the states’ ability to investigate or adequately serve the abused. Some are hesitant to report because they fear exacerbating the abusive situation. Others are concerned that requiring physicians to report will interfere with patients’ rights to autonomy and privacy, thereby breaking doctor-patient confidentiality and destroying relationships.28,29 They argue that this could lead to litigation from patients or their families (who are often the suspect abusers). Some fear that mandatory reporting will turn patients away from seeking much-needed medical care. Provisions mandating reporting of elder abuse are modeled after child abuse statutes; both are based on the state’s power to protect individuals who cannot or will not protect themselves.14 Some contend that mandatory reporting of elder abuse perpetuates society’s patronizing view of older people and that older victims should have the same opportunity to refuse reporting as adult domestic violence victims do (only few states specifically require reporting of domestic abuse).30
Others argue that these laws fail to consider unintentional abuse by caregivers. A conscientious but overburdened caregiver can inadvertently cause significant harm, by forgetting to give a brittle diabetic patient her one dose of insulin, for example. Similarly, neglect could result from a well-meaning but uninformed caretaker who does not know that a bedridden patient should be turned routinely. A caretaker who has undetected medical conditions herself, such as mild dementia, could also easily and unknowingly cause harm. These scenarios provoke different feelings of blame compared with situations of intentional abuse. Critics of mandatory reporting worry that these caregivers could be unfairly punished.
252 Wei et al Reporting Elder Abuse: A Medical, Legal, and Ethical Overview
Proponents of mandatory reporting believe that it may encourage physicians who are initially hesitant to report to be more forthcoming. They point out that mandatory reporting supports physicians’ ethical obligation to beneficence – that the intent is not to patronize the elderly, but to protect them from potentially life-threatening harm. They argue that physicians are obligated to act in the best interest of their elderly patients as they are of minor patients, because inaction can lead to immediate devastating consequences, including death. Moreover, they point out that the law does not ignore a patient’s rights to autonomy; elderly patients typically maintain the right to refuse services offered by APS (unless they are incapacitated as declared by the court and a guardian has been appointed).22
Supporters of mandatory reporting point out that all states provide immunity from liability for those who report in good faith.24 To those who say the law unfairly punishes physicians who are unfamiliar with its requirements, proponents argue that the problem does not stem from the law but from the physician’s lack of education and training. They believe that it is the duty of every physician to know and under
stand the law in his/her state, to demand quality training from medical schools, residencies, hospitals, APS agencies, and medical professional societies and to strive to develop a system for reporting suspected abuse. To those who argue the law does not account for unintentional abuse, proponents respond that reporting does not automatically lead to prosecution or punishment, but only to investigations by state authorities, who have expertise in considering all factors before taking further actions.
Clinical Management
Because elder abuse is an independent risk factor for death, correct management is critical.31 Victims are found in various clinical settings, including the emergency department, dentist or physician’s office, or at home during a physician’s or nurse’s visit. Physicians should learn to recognize the common signs and symptoms of elder abuse, many of which can be subtle (Table 2). When the physician suspects a problem, he/she should conduct a thorough history and physical exam, and the caretaker should be asked to leave the examining room during the interview. Victims may not be ready to expose the truth immediately; so rather than asking directly if abuse has occurred, the physician should begin
JOURNAL OF THE AMERICAN MEDICAL WOMEN’S ASSOCIATION
Effective management of
elder abuse requires a
multidisciplinary approach
that covers broad areas of
medical treatment, mental health
care , social services,
and legal assistance.
with questions about the nature of the relationship with the caregiver, conditions of the home, and circumstances surrounding her physical signs and symptoms. A cognitive assessment is also recommended. If the patient has significant dementia, the physician should seek out someone other than the suspected perpetrator who could provide additional medical or social history. Careful history taking should be followed by a complete physical examination, including overall skin check (for bruises) and genital exam. Appropriate blood tests and imaging studies should be ordered as guided by history and physical exam findings. Detailed documentation, including verbatim descriptions of events, relevant medical and social history, drawings or photographs of injuries, pertinent laboratory and imaging results, and physician’s assessment and decision to report, is crucial since the medical record may become part of a legal record.
When abuse is suspected, a physician’s highest priority is to ensure the safety of the patient. The physician should ascertain the degree of danger, and if it is immediate and life threatening, should separate the abused from the abuser and call 911. Reporting procedures should be followed; the NCEA Web site (see sidebar on page 251) provides toll-free
phone numbers to call for instructions.32 After reporting, the state agencies will proceed with their own evaluation accordingly.14 Meanwhile, the physician should strive to maintain a positive doctor-patient relationship by having open discussion with the patient. The physician should explain that he/she is obligated to report suspected abuse. Some patients may be upset to learn that a report has been made. If so, the physician should explore the patient’s rationale for choosing to remain in the abusive situation. If it is to protect the abuser, the doctor should reassure the patient that the intent is not to punish but to stop the mistreatment and to get help. The physician should emphasize the seriousness of the problem, including the potential for the mistreatment to escalate if no intervention is performed.
A multidisciplinary approach using a team comprised of a primary care physician, geriatrician, psychiatrist or psychologist, nurses, and social worker is recommended for managing abuse, as it often affects the victim physically, emotionally, socially, and financially. The advantages of a team are many, including varieties of expertise and lessening the demands on the primary care provider by sharing the burden among the team members. Individual team members can also provide specialized referrals to support groups, home care, respite, and community services such as legal and/or financial planning.
Summary
Elder abuse is a public health concern in the United States, particularly among women. As the US population continues to age, the number of victimized patients will likely increase. Physicians play key roles in identifying elder abuse. They are often the only contacts for frail elderly patients besides their family members, who frequently are the abusers. Unfortunately, physicians are not living up to their potential of identifying and reporting elder abuse, as they often lack the knowledge, time, and skills to detect or handle these cases. They must strive to work through these barriers, familiarize themselves with their state laws, and be more diligent in reporting suspected cases. Effective management of elder abuse requires a multidisciplinary approach that covers broad areas of medical treatment, mental health care, social services, and legal assistance. Researchers should test strategies to improve management of abuse victims. Effective techniques and programs are also needed to adequately train health care professionals in detecting and managing suspected cases of elder maltreatment.
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254 Wei et al Reporting Elder Abuse: A Medical, Legal, and Ethical Overview JOURNAL OF THE AMERICAN MEDICAL WOMEN’S ASSOCIATION
Toronto journalist Judy Steed has been writing about social issues for 30 years. Last fall, she embarked on a one-year project to document the most pressing policy implications of our aging society as part of the 2008 Atkinson Fellowship in Public Policy.
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