Committee Opinion
Number 568, July 2013


Committee on Health Care for Underserved Women
This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
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Elder Abuse and Women's Health

ABSTRACT: Elder abuse, a violation of human rights, is defined as a single or repeated act, or lack of appropriate actions, which causes harm, risk of harm, or distress to an individual 60 years or older. As many as 1 in 10 older adults have been victims of elder abuse. Most cases of abuse occur in women. The U.S. Census predicts that by 2030, the segment of the population that is older than 65 years will reach an estimated 72 million. Categories of elder abuse include physical, psychological, emotional, or sexual abuse; neglect; abandonment; and financial exploitation. Screening, education, and policy change are the best interventions for the prevention of elder abuse. Early identification and prompt referral should be part of the preventive health care visit for women aged 60 years and older.


Elder abuse is a prevalent issue that results in poor health outcomes and increases mortality (1). As many as 1 in 10 older adults have been victims of elder abuse (2). According to a national survey, more than 65% of elder abuse victims are women (3, 4). Elder abuse is defined as a “single or repeated act, or lack of appropriate actions, which causes harm, risk of harm, or distress to an individual 60 years or older and occurs:

a) within a relationship where there is an expectation of trust; or

b) when the targeted act is directed towards an elder person by virtue of age or disabilities.

Elder abuse can be intentional or unintentional, can take various forms, and includes but is not limited to physical, psychological, emotional, or sexual abuse, neglect, abandonment, and financial exploitation” (5) (see Box 1).

The U.S. Census data demonstrate significant growth of the segment of the population that is older than 65 years. An estimated 72 million individuals will be older than 65 years by 2030, 55% of whom will be female (6). It is estimated that for every case of elder abuse reported to a responsible agency, 23 cases were undetected (7). Screening for elder abuse is a crucial first step for obstetrician–gynecologists, particularly for older women who are more vulnerable, less inclined to discuss abuse without direct questioning, more likely to accept or minimize the degree of their situations, and to remain silent as abuse continues (8). Because obstetrician–gynecologists are often women’s sole health care contacts, they must understand how to screen for and manage this critical women’s health issue.

Box 1. Types of Elder Abuse With Historical and Examination Clues

Neglect

Refusal or failure to fulfill any part of an individual’s obligations or duties to an elder. Neglect also may include failure of an individual who has fiduciary responsibilities to provide care for an elderly individual (eg, pay for necessary home care services)

 

History

  • Missed appointments
  • Nonadherence to referrals or medications
  • Lack of health maintenance
  • Reports of depression, sadness, anxiety, or boredom

Examination

  • Poor hygiene
  • Lack of assistive devices
  • Inappropriate clothing
  • Malnutrition
  • Dehydration
  • Pressure ulcers
  • Uncontrolled diseases (eg, diabetes, hypertension, or congestive heart failure)
Emotional or psychological abuse Infliction of anguish, pain, or distress through verbal or nonverbal acts. Emotional and psychological psychological abuse includes but is not limited to verbal assaults, insults, threats, intimidation, humiliation, and abuse harassment. In addition, treating an elderly individual like an infant; isolating an elderly individual from his or her family, friends, or regular activities; giving an elderly individual the “silent treatment;” and enforced social isolation are examples of emotional and psychological abuse.
 

History

  • Social withdrawal
  • Depression or anxiety
  • Insomnia
  • Anorexia
  • Vague reports of health problems

Examination

  • Passivity
  • Poor engagement
  • Flat affect
  • Weight loss
Physical abuse Use of physical force that may result in bodily injury, physical pain, or impairment. Physical abuse may include, but is not limited to, such acts of violence as striking (with or without an object), beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. In addition, inappropriate use of drugs and physical restraints, force-feeding, and physical punishment are examples of physical abuse.
 

History

  • Frequent falls
  • Many emergency department visits
  • Lack of explanation of trauma
  • Delay in seeking care for trauma
  • Vague reports of health problems

Examination:

  • Patient declines full examination
  • Physical injuries, such as bruises on neck or upper back, extensive burns, multiple pressure ulcers, scratches, fractures, belt marks
  • Cowers when approached
Sexual abuse Nonconsensual sexual contact of any kind with an elderly individual. Sexual contact with any individual incapable of giving consent also is considered sexual abuse. It includes, but is not limited to, unwanted touching, all types of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photographing.
 

History:

  • Pelvic pain
  • Urinary burning
  • Behavioral changes when receiving personal care

Examination

  • Vaginal bleeding or discharge or genital lesions
  • Rectal trauma
  • Bruised inner thighs, buttocks, or breasts
  • Stained undergarments
Financial or material abuse and exploitation The illegal or improper use of an elderly individual’s funds, property, or assets. Examples include, but are not limited to, cashing an elderly or vulnerable individual’s checks without authorization or permission; forging an elderly individual’s signature; misusing or stealing an older individual’s money or possessions; coercing or deceiving an elderly individual into signing any document (eg, contracts or will); and the improper use of conservatorship, guardianship, or power of attorney.
 

History

  • Recent or sudden changes in health proxy, power of attorney, wills or deeds
  • Possessions taken
  • Inability to pay for basic needs
  • Eviction
  • Unexplained bank withdrawals or credit card charges

Examination

  • Poor control of medical problems
  • Poor hygiene
  • Lack of assistive devices
  • Inappropriate clothing
  • Malnutrition
  • Dehydration
  • Pressure ulcers
Data from Lachs MS, Pillemer K. Elder abuse. Lancet 2004;364:1263–72 and Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W, 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;100:292–7.

Population at Risk

Although all older adults are potential targets of abuse, elderly individuals are often the most physically or psychologically vulnerable. Individuals who have disabilities or are homebound may be so desperate for help that they exercise poor judgment in choosing whom to trust. A major risk factor for elder abuse is cognitive impairment; approximately 50% of adults older than 85 years are cognitively impaired (9). Depression and anxiety are highly prevalent among older adults and are risk factors for abuse. Social isolation adds risk of a variety of poor health outcomes, decreased lifespan, and increased morbidity (10).

Screening for Elder Abuse and Neglect

In 2013, the U.S. Preventive Services Task Force concluded that although there is sufficient evidence to recommend the universal screening of women of reproductive age for intimate partner violence, the evidence on the benefits and risks of screening for elder abuse is insufficient to make a recommendation. The task force, however, does indicate that a benefit may exist given the significant underreporting of this condition. Further research with standardized tools for screening and intervention, which currently are not available, would be necessary to fully understand the issue (11). Despite this conclusion, the American College of Obstetricians and Gynecologists supports screening of patients older than 60 years to help identify victims of abuse and provide them with appropriate medical and psychosocial care and referrals. The challenge in preventing and resolving elder abuse is to educate and motivate health care providers to screen routinely for abuse. Evaluation should include a thorough social history to assess family structure, the stability of social supports, financial stressors, and substance abuse or mental health history. Health care providers should directly question their patients about present and past abuse (see Box 2). Patients who report insomnia, high stress levels, depression, anxiety, or anorexia may experience or have experienced abuse. Multiple falls or fractures, multiple emergency department visits or hospitalizations, or chronic poorly controlled medical problems should prompt clinicians to consider an unstable social situation and abuse (12).

Box 2. Performing an Elder Mistreatment Assessment

  • Interview the patient separately and be aware that family members and caregivers may be abusers
  • Start with general, open-ended questions and progress to more specific questions
  • Note inconsistent or frequently changing stories
  • Observe patient’s reactions to accompanying family members or caregivers
  • Remain empathic

Sample Screening Questions for Patients

  • Do you feel safe in your home?
  • Are you afraid of anyone in your home?
  • Has anyone threatened you or verbally assaulted you?
  • Has anyone touched you without your permission?
  • Does anyone ever ask you to sign documents that you do not understand?
  • Has anyone ever taken your things without your permission?
  • Are you alone a lot?
  • Has anyone ever failed to help you when you were unable to help yourself?
  • Do you have anyone to share your worries with?

Modified from Stanford School of Medicine. Elder abuse: how to screen. Available at: http://elderabuse.stanford.edu/screening/how_screen.html. Retrieved April 4, 2013.

Signs of neglect can be subtle, including poor hygiene and nail care, weight loss, unkempt appearance, missing assistive devices (eg, hearing aids, glasses, or dentures), and inappropriate attire. Poor medication adherence or laboratory values reflecting dehydration, malnutrition, or abnormal medication levels also may suggest neglect (13).

Education, Intervention, and Reporting

Elder abuse education should begin with the entire population. Culturally sensitive educational materials should be available in health care facilities and community agencies. Such materials should describe the signs of abuse and the options for intervention and safety planning. All health care professionals should be trained in the detection of abuse and the first steps in responding to abuse. When cases of abuse are confirmed, most states mandate that health care providers report the case to Adult Protective Services. Health care providers should become familiar with their individual state mandates regarding the reporting of abuse because it varies from state to state. A list of the most up-to-date reporting requirements can be found at www.ncea.aoa.gov/stop_abuse/get_help/state/index.aspx. Partnering or having a referral relationship with social workers, nurses, and psychiatrists for outpatient referrals is an important step for health care providers. A team approach to the problem is the best way to ensure that the multiple psychosocial, medical, and legal aspects of a case are addressed.

Recommendations

The American College of Obstetricians and Gynecologists recommends the following:

  • Screen all patients older than 60 years for signs and symptoms of elder abuse using questions, such as those included in this document.
  • Advocate for a safe environment for all aging women to receive comprehensive high-quality and compassionate care from health care providers, caregivers, and agencies that care for the elderly.
  • Follow individual state guidelines for reporting elder abuse to Adult Protection Services.
  • Provide education regarding elder abuse to patients, family, caregivers, and health care providers.
  • Encourage research in the area of elder mistreatment and abuse.

Resources

The following resources are for information purposes only. Referral to these sources and web sites does not imply the endorsement of ACOG. These resources are not meant to be comprehensive. The exclusion of a source or web site does not reflect the quality of that source or web site. Please note that web sites are subject to change without notice.

Center of Excellence on Elder Abuse and Neglect
http://www.centeronelderabuse.org

Centers for Disease Control and Prevention: Elder Maltreatment
http://www.cdc.gov/ViolencePrevention/eldermaltreatment/index.html

Eldercare Locator
http://www.eldercare.gov/Eldercare.NET/Public/Index.aspx

National Adult Protective Services Association
http://www.napsa-now.org

National Center on Elder Abuse
http://www.ncea.aoa.gov

National Committee for the Prevention of Elder Abuse
http://www.preventelderabuse.org

National Domestic Violence Hotline
http://www.thehotline.org

NYC Department for the Aging
http://www.nyc.gov/html/dfta/html/home/home.shtml

NYC Elder Abuse Center
http://nyceac.com

References

  1. Lachs MS, Williams CS, O’Brien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. JAMA 1998;280: 428–32. [PubMed] [Full Text]
  2. Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W, 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;100:292–7. [PubMed] [Full Text]
  3. New York State Coalition on Elder Abuse. Under the radar: New York State elder abuse prevention study. Rochester (NY): NYSCEA; 2011. Available at: http://www.nyselderabuse.org/documents/ElderAbusePrevalenceStudy2011.pdf. Retrieved March 29, 2013.
  4. National Center on Elder Abuse. The 2004 survey of state adult protective services: abuse of adults 60 years of age and older. Washington, DC: NCEA; 2006. Available at: http://www.napsa-now.org/wp-content/uploads/2012/09/2-14-06- FINAL-60+REPORT.pdf. Retrieved May 15, 2013.
  5. NYC Elder Abuse Center. Definition of elder abuse. Available at: http://nyceac.com/about/definition. Retrieved March 29, 2013.
  6. Administration on Aging. A profile of older Americans: 2011. Washington, DC: AOA; 2011. Available at: http://www.aoa.gov/AoARoot/Aging_Statistics/Profile/2011/docs/2011profile.pdf. Retrieved March 29, 2013.
  7. American Psychological Association. Elder abuse and neglect: in search of solutions. Washington, DC: APA; 2012. Available at: http://www.apa.org/pi/aging/resources/guides/elder-abuse.pdf. Retrieved April 5, 2013.
  8. Adelman RD, Greene MG, Ory MG. Communication between older patients and their physicians. Clin Geriatr Med 2000;16:1–24, vii. [PubMed]
  9. Levine JM. Elder neglect and abuse. A primer for primary care physicians. Geriatrics 2003;58(10):37–40, 42–4. [PubMed]
  10. Berkman LF, Syme SL. Social networks, host resistance, and mortality: a nine-year follow-up study of Alameda County residents. Am J Epidemiol 1979;109:186–204. [PubMed]
  11. Moyer VA. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. Preventive services task force recommendation statement. U.S. Preventive Services Task Force. Ann Intern Med 2013;158:478–86. [PubMed] [Full Text]
  12. Perrone J. “Red flags” offer clues in spotting domestic abuse. In: American Medical Association. Violence: a compendium from JAMA, American Medical News, and the specialty journals of the American Medical Association. Chicago (IL): AMA; 1992. p. 160.
  13. Bond MC, Butler KH. Elder abuse and neglect: definitions, epidemiology, and approaches to emergency department screening. Clin Geriatr Med 2013;29:257–73. [PubMed]

Copyright July 2013 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.

ISSN 1074-861X

Elder abuse and women’s health. Committee Opinion No. 568. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:187–91.