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.
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:
within a relationship where there is an expectation of trust; or
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 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.
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 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.
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)|
|• Missed appointments||• Poor hygiene|
|• Nonadherence to referrals or medications||• Lack of assistive devices|
|• Lack of health maintenance||• Inappropriate clothing|
|• Reports of depression, sadness, anxiety, or boredom||• Malnutrition|
|• 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 abuse includes but is not limited to verbal assaults, insults, threats, intimidation, humiliation, and 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.|
|• Social withdrawal||• Passivity|
|• Depression or anxiety||• Poor engagement|
|• Insomnia||• Flat affect|
|• Anorexia||• Weight loss|
|• Vague reports of health problems|
|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.|
|• Frequent falls||• Patient declines full examination|
|• Many emergency department visits||• Physical injuries, such as bruises on neck or upper back, extensive burns, multiple pressure ulcers, scratches, fractures, belt marks|
|• Delay in seeking care for trauma||• Cowers when approached|
|• Vague reports of health problems|
|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.|
|• Pelvic pain||• Vaginal bleeding or discharge or genital lesions|
|• Urinary burning||• Rectal trauma|
|• Behavioral changes when receiving personal care||• Bruised inner thighs, buttocks, or breasts|
|• Stained undergarments|
|Financial or material abuse and exploitation||The illegal or improper use of an elderly individualÃ¢â‚¬â„¢s funds, property, or assets. Examples include, but are not limited to, cashing an elderly or vulnerable individualÃ¢â‚¬â„¢s checks without authorization or permission; forging an elderly individualÃ¢â‚¬â„¢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.|
|• Recent or sudden changes in health proxy, power of attorney, wills, or deeds||• Poor control of medical problems|
|• Possessions taken||• Poor hygiene|
|• Inability to pay for basic needs||• Lack of assistive devices|
|• Eviction||• Inappropriate clothing|
|• Unexplained bank withdrawals or credit card charges||• Malnutrition|
|• Pressure ulcers|
Data from Lachs MS, Pillemer K. Elder abuse. Lancet 2004;364:1263–72and 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.
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.
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
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.
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.
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/eldermal treatment/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