Stephen L. Read, MD
September 1, 2008
Psychiatric Times. Vol. 25 No. 10
Dr Read is clinical professor in the department of psychiatry and bio behavioral sciences at UCLA and the West Los Angeles Veterans Administration and maintains a private practice in geriatric and forensic psychiatry. He can be contacted via www.geriatricpsychiatrist.com. The author reports no conflicts of interest concerning the subject matter of this article. Personal facts and identities have been disguised in the Case Vignettes. In addition, the views expressed are those of Dr Read and are not the official position of the Veterans Administration or the University of California.
Elder abuse—behaviors toward the elderly that are malignant and damaging—has become a major public health issue. In Boston, more than 3 of 100 persons aged 65 years and older have been victims of elder abuse, and tens of thousands of cases are reported to Adult Protective Services Agencies annually in the United States.1 These numbers, which do not include financial elder abuse, can be expected to increase as the population of older persons increases.[1,2] Between 2000 and 2030 the population aged 65 years and older in the United States is projected to increase from 12.4% to 19.6%. Even more dramatically, the number of persons aged 80 years or older is anticipated to more than double from 9.3 million to 19.3 million.
Elder abuse is a concern for all practitioners who care for elderly patients or their family members. An elderly person’s fears of aging and dependence may be heightened by stories and news accounts of abuse. Medical and psychiatric care is fundamental in the identification, treatment, and mitigation of clinical effects of elder abuse, and physician documentation often provides evidence crucial for investigations of elder abuse. All practitioners need to be aware of the ethical and statutory requirements for reporting abuse or suspected abuse. In addition, elder abuse has broader effects that radiate through society—to family members, caregivers, institutions, and courts (issues beyond the scope of this article).
Here I review aspects and concepts of elder abuse and the implications for clinical and forensic practice. I will begin with an illustrative case vignette.
Mrs A was a long-widowed 86-year-old woman whose favorite nephew was unable to reach her by phone. He had been turned away at her door by Mr X, who said he was her conservator and thus responsible for Mrs A.
A social worker from Adult Protective Services was also rebuffed. Mrs A’s nephew sought the assistance of an elder law attorney, who obtained a court order for a medical and psychiatric evaluation of Mrs A.
Mrs A proved to be a sweet but frightened woman who clearly had lost a lot of weight. She was very weak and had been functionally confined by Mr X, with no access to a telephone. She appeared desperate for contact and conversation. Her short-term memory was impaired, and she did poorly on tests of mental control; she scored 21 on the Mini Mental State Examination (MMSE). Medical examination confirmed multiple bruises, malnutrition, and other untreated medical conditions.
Based on her impaired capacity and physical deterioration, with obvious evidence of injury, neglect, and abuse, and her overt fear of Mr X, a petition to the court finally removed Mr X as conservator. The lengthy process eventually consumed nearly two-thirds of Mrs A’s estate. (As conservator, Mr X was able to use her funds to oppose the actions against him.) Mrs A was finally able to live out her life in comfort and safety and with the attention of family and friends.
Definitions and typology
The American Medical Association defines elder abuse and/or neglect as “an act of commission or omission that results in harm or threatened harm to the health or welfare of an older adult,” whether intentional or unintentional. Several subtypes are recognized.
Physical abuse refers to the use of force that can result in injury, pain, or impairment. In addition, inappropriate use of drugs, restraints, or punishment, or the imposition of medical procedures without informed consent can be considered physical abuse.
Because physical abuse may result in injuries, prompt and careful physical examination is required. However, because the elderly are prone to falls and can easily fracture bones or tear skin, establishing abuse can be a clinical challenge. The problem is compounded in the case of lesions such as ulcers that can be either signs of serious neglect or difficult-to-avoid complications of wasting illnesses.
Sexual abuse includes rape and any other nonconsensual sexual contact, as well as other types of assault, exposure, nudity, etc. Sexual abuse of elders is an especially grave concern when unrelated caregivers attend patients with minimal or no supervision.
Emotional or psychological abuse refers to any verbal or nonverbal acts that result in anguish, pain, or other distress (eg, insults, threats, humiliation, harassment). Isolation from friends, family, and/or community can be considered psychological abuse and also potentially facilitates an abuser’s other goals, including secrecy. Adverse influence specifically related to psychological elder abuse may manifest in multiple ways. It can be verbal. Statements such as “no one else cares about you,” are often accompanied by efforts to isolate the victim by controlling access to mail, phone, or transportation. Such verbal abuse also creates “evidence” that family, friends, or neighbors do not, in fact, care. By creating doubt and fear through withholding or providing of basic needs (eg, food, hygiene, medications) and brow-beating the elderly person, the abuser can extract favors or concessions.
Manipulation of prescription medications, especially for pain, or controlling access to alcohol or cigarettes can also be a very effective means of control. Medically knowledgable abusers can control mental states by having their victim be relatively alert for a doctor’s visit but obtunded at other times.
In addition, romance can be used as a tool to manipulate the elderly person. Because elderly persons may frequently experience isolation or loneliness, they may be more prone to accept professions of love and desirability at face value. The pleasure of being considered attractive does not disappear with age nor does sexual responsiveness. Even further damage can be done. When the abuser is able to “prove” his or her dedication with marriage, he then gains legal rights and privileges.
Psychological manipulation is not necessarily associated with distress on the victim’s part— instead, an elderly person may experience comfort and caring. The victim will not give credence to the abuser’s ulterior motives. The victim may therefore collaborate in concealing the abuser’s role. Alternatively, the abuser may convince the victim that he or she is “bad,” that the abuser “really cares,” and is the only one preventing the elderly person from “going to a home.” This has been likened to the Stockholm syndrome (a psychological response in which a hostage shows signs of loyalty to his abductor). Paradoxically, lurid publicity about elder abuse can facilitate the effectiveness of the abuser’s strategy of persuading the victim that the abuser is the only bulwark against abandonment.
Financial elder abuse and exploitation are common. Financial gain serves as motivation for abuse, which can influence and/or control the victim. Financial abuse and exploitation are more likely to be identified by friends and neighbors, family members, financial professionals, or attorneys, than by physicians. The financial abuser can:
• Obtain power of attorney and then divert funds.
• Cheat on expenses and/or wages as the dependent elder becomes more impaired.
• Manipulate the elderly person into accepting unneeded or misjudged financial “services.”
• Transfer property into his name.
• Be named as beneficiary in testamentary documents—wills or trusts.
Elder abuse issues for the practicing clinician
A clinician may learn of suspected elder abuse directly from a patient. Alternatively, the clinician may become concerned after observing an elderly patient or after a family member, concerned party, or outside agency refers an elderly person. The victim may be unaware of exploitation or be intimidated or insulted at the implication that he is “crazy” or “becoming senile” and cannot take care of himself or his affairs. Appropriate response requires sensitivity and careful attention to issues of responsibility, trust, and confidentiality. The clinician should maintain an attitude of “healthy suspicion,” even with familiar patients and caregiving situations, as the following cautionary case vignette illustrates.
Dr X had cared for Mrs Y for many years, including the last decade of her life, as she slowly descended into dementia. Hired as a caregiver, Ms Z became a constant presence in Mrs Y’s life and Dr X relied on her for essentially all communication about Mrs Y. Although Dr X had recorded Mrs Y’s severe dementia, he did not question Ms Z’s salary increase and her subsequent purchase of a house with Mrs Y’s funds. Furthermore, having documented her strong desire to live out her life in her home, he did not protest when Ms Z moved Mrs Y into the new house.
After Mrs Y died, it was found that her will had been amended in the previous year and that her entire estate had been left to Ms Z. At trial, Dr X testified that although he did not believe Mrs Y was competent, he believed Ms Z “deserved” the benefits that had come her way. He was rebuked by the court for having ignored his own findings. In an attempt to safeguard decisions from the “undue” influence of caregivers such as Ms Z, special protections have been established by law.[6,7]
Identifying suspected elder abuse
Although it may lay the groundwork for a patient (or a family member) to begin to recognize an ongoing problem, simply asking an elderly person about abuse will not always identify a situation of abuse. Many cases will be overlooked. While various screening procedures have been suggested for the identification of elder abuse, none has gained general acceptance, and different approaches result in substantially different rates of identification.8 A better-accepted and more-effective method is the concept of identifying risk factors (Table).
In any case of suspected elder abuse, the clinician is advised to undertake a comprehensive examination. While the psychiatrist should describe obvious relevant physical findings, a physical examination should be undertaken by an appropriate specialist.
Documentation of a careful mental status examination is invaluable, both for clinical and evidentiary purposes. Mood and affective reactions may reveal difficulties even in the face of verbal denial. Careful evaluation of cognitive functions is especially essential. Vulnerability to financial abuse is elevated during the early and mild stages of dementia, when a person’s memory and cognition are declining, but when he can still sign a deed or contract, or execute a trust or will, albeit without clear understanding and appreciation.
Tests commonly used to screen for dementia, such as the MMSE, are useful but are not sensitive to the earliest manifestations of cognitive loss. In particular, diminished executive functioning—a set of capacities generally dependent on frontal lobe function—is more directly related to impaired decision making and vulnerability to abuse and specifically financial abuse but is not identified by the MMSE. It may be appropriate to refer the patient to a geriatric forensic mental health specialist for further evaluation.
Combating elder abuse
Requirements to report elder abuse are essentially universal in the United States, although definitions and specifics vary. Clinicians are advised to learn the requirements applicable in their jurisdiction. Specific definitions and obligations may also change from time to time. The physician can learn details from appropriate governmental bodies, professional societies, and/or malpractice carriers, as well as from institutions where one practices. Reporting can usually be done confidentially, although the source can often be surmised, with consequences for ongoing relationships.
Different practice settings may bring different resources or specific responsibilities. For example, abuse in nursing home settings has been extensively documented and more carefully studied than in other residential settings for vulnerable elders (including assisted living, smaller board and care homes, and, increasingly, home care settings). Physicians, and especially medical directors, need to be aware of the potential vulnerability for elder abuse in each setting, and the variable reporting, documentation, and administration
Office staff should be trained to be aware of elder abuse. They need be sensitive to clues that suggest abuse during their interactions with elderly patients or their caregivers (eg, when scheduling or cancelling appointments, during office visits, or from phone contacts and messages). An odd request for medication is one such clue: an elderly parent may be coerced into asking for pain medications to support his child’s or caregiver’s drug habit. Clinicians (and office staff) should be alert to signals that indicate vulnerability, and procedures should be in place whereby staff can share their concerns with the physician.
As in other areas, the quality, clarity, and completeness of the medical record is paramount. Certainly this is true if any issue were to be made about neglect or poor quality of care in the practice. Any clinician who must testify based on his own record will come to value the effort required to record observations carefully and thoroughly. Documenting the serial use of standard mental function tests can be very valuable as well (eg, in a postmortem challenge to a will).
The physician’s responsibility
Care and attention are advised before responding to a request for a statement about the mental capacity (or lack thereof) of a patient. Note the legal implications. A request from someone other than the patient should be scrutinized especially closely, both because of confidentiality concerns and because of the possibility that the request does not actually come from the patient or reflect the patient’s wishes and interests. Careful attention is advised if the requested statement has been written out for the doctor’s attestation (eg, by an attorney who wishes to “make it easy”). Remember that signing such a document is “under penalty of
perjury” and any inaccuracy or overstatement that may seem minor at the time may have uncomfortable implications in the glare of deposition, and errors may result in serious consequences.
Some actions, such as a declaration supporting a petition for conservatorship, are legally considered as being against the patient’s interests (and also may be regarded as such by the patient). The physician should therefore consider such requests carefully and review his own knowledge of the legal requirements of testamentary capacity or capacity for the action in question. An alternative course is to refer the patient for a forensic opinion rather than confound the responsibilities of clinical and forensic roles.
Payment for legal assessments is not considered “patient care” and therefore is not covered by Medicare or by most other policies. Because a conscientious approach to any legal matter requires time and may prudently involve a targeted interaction and assessment with the patient, consider scheduling such visits separately and establishing appropriate and separate billing procedures. Such actions will also reinforce to the patient that the physician does not regard such requests as routine or perfunctory.
A psychiatrist’s record may be subpoenaed relevant to a lawsuit or, less commonly, a criminal matter. In the great majority of cases, the records are sought not because of concerns about the physician’s care but to seek evidence about the patient’s condition as may be relevant to an allegation. Because a treating doctor’s observations are generally accorded great weight in court, testimony may be requested. Response to a subpoena requires proper observance of the rules of confidentiality; advice from counsel or malpractice carrier may be prudent. Be aware that professional fees are expected for reviewing medicolegal documents
Elder abuse can only be expected to increase in the coming years because of demographic trends and other social changes. Potential financial gains from vulnerable elders are attractive opportunities for unscrupulous persons or may serve as venues for continuing long-standing family conflicts. Physicians, whose practices may already be under duress because of multiple demands and constraints, must nonetheless recognize their important role in the identification of and protection against elder abuse.
As in other matters, there are complex ethical and legal issues that must be considered, including confidentiality and the implications for the patient’s autonomy. Psychiatrists and other mental health professionals have particularly crucial roles in the assessment of the mental functioning that forms the basis for determining capacity, and for evaluating the consequences of abuse. Finally, psychiatrists must also be particularly attentive to issues of confidentiality and conflict of interest in the assessment and treatment of elderly patients who may have been abused.
Personal facts and identities have been disguised in the Case Vignettes. In addition, the views expressed are those of Dr Read and are not the official position of the Veterans Administration or the University of California.
1. Pillemer K, Finkelhor D. The prevalence of elder abuse: a random sample survey. Gerontologist. 1988;28:51-57.
2. National Center on Elder Abuse. National Elder Abuse Incidence Study. Washington DC: American Public Human Services Association; 1998.
3. US Census Bureau. International database, 2001. Table 094. Midyear population, by age and sex.
http://www.census.gov/population/ www/projections/natdet-D1A.html. Accessed August 7, 2008.
4. Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. Chicago: American Medical Association; 1994:4-24.
5. Weinberg AD. Issues involving sexual abuse of nursing facility residents. J Am Med Dir Assoc. 2002;3:395-396.
6. Cal Probate Code, Section 21350.
7. Cal Probate Code, Section 21351.
8. Cohen M, Levin SH, Gagin R, Friedman G. Elder abuse: disparities between older people’s disclosure of abuse, evident signs of abuse, and a high risk of abuse. J Am Geriatr Soc. 2007;55:1224-1230.
9. Shugarman LR, Fries BE, Wolf RS, Morris JN. Identifying older people at risk of abuse during routine screening practices. J Am Geriatr Soc. 2003;51:24-31.
10. Martin R, Griffith R, Belue K, et al. Declining financial capacity in patients with mild Alzheimer disease: a one-year longitudinal study. Am J Geriatr Psychiatry. 2008;16:209-219.
11. Folstein M, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.
12. Royall DR. Mild cognitive impairment and functional status. J Am Geriatr Soc. 2006;54:163-165.
13. Lindbloom EJ, Brandt J, Hough LD, Meadows SE. Elder mistreatment in the nursing home: a systematic review. J Am Med Dir Assoc. 2007;8:610-616.
14. MacLean DS. Preventing abuse and neglect in long-term care, part II: clinical and administrative aspects. Ann Long-Term Care. 2000;8:65-70.
15. MacLean DS. Preventing abuse and neglect in long-term care, part I: legal and political aspects. Ann Long-Term Care. 1999;7:452-458.
16. Coyne AC, Reichman WE, Berbig LJ. The relationship between dementia and elder abuse. Am J Psychiatry. 1993;150:643-646.