NEJM study on Elder Abuse

[With an] estimated overall prevalence of elder abuse of approximately 10%… a busy physician caring for older adults will encounter a victim of such abuse on a frequent basis, regardless of whether the physician recognizes the abuse.

Link opens New England Journal of Medicine site in a new tab

REVIEW ARTICLE

ELDER ABUSE

Mark S. Lachs, M.D., M.P.H., and Karl A. Pillemer, Ph.D.

Although it has probably existed since antiquity, elder abuse was first described in the medical literature in the 1970s.1 Many initial attempts to define the clinical spectrum of the phenomenon and to formulate effective intervention strategies were limited by their anecdotal nature or were epidemiologically flawed. The past decade, however, has seen improvements in the quality of research on elder abuse that should be of interest to clinicians who care for older adults and their families. Financial exploitation of older adults, which was explored only minimally in the initial studies, has recently been identified as a virtual epidemic and as a problem that may be detected or suspected by an alert physician.

In the field of long-term care, studies have uncovered high rates of interpersonal violence and aggression toward older adults; in particular, abuse of older residents by other residents in long-term care facilities is now recognized as a problem that is more common than physical abuse by staff.2,3 The use of interdisciplinary or interprofessional teams, also referred to as multidisciplinary teams in the context of elder abuse, has emerged as one of the intervention strategies to address the complex and multidimensional needs and problems of victims of elder abuse, and such teams are an important resource for physicians.4,5 These new developments suggest an expanded role for physicians in assessing and treating victims of elder abuse and in referring them for further care.

In this review, we summarize research and clinical evidence on the extent, assessment, and management of elder abuse, derived from our analysis of high-quality studies and recent systematic studies and reviews of the literature on elder abuse.6-10

DEFINITIONS AND ESTIMATES OF PREVALENCE

Debates about how to define elder abuse and which types of behavior to include in the definition greatly inhibited progress during the early period of research on this topic. Initial formulations were overly broad and included types of behavior that are not typically part of definitions of domestic abuse, such as crime by strangers, age discrimination, and failure to care for oneself (referred to as “self-neglect”). Over the past decade, however, consensus has arisen about the inclusion of five major types of elder abuse11-13: physical abuse, or acts carried out with the intention to cause physical pain or injury; psychological or verbal abuse, defined as acts carried out with the aim of causing emotional pain or injury; sexual abuse, defined as nonconsensual sexual contact of any kind; financial exploitation, involving the misappropriation of an older person’s money or property; and neglect, or the failure of a designated caregiver to meet the needs of a dependent older person [emphasis added] (Table 1)   

(Forms of Elder Abuse and Clinical Procedures for Assessment by the Physician.).

When these types of abuse have been considered together, epidemiologic surveys have shown generally similar prevalences of elder abuse over a period of 12 months, as indicated by three high-quality epidemiologic studies of community-dwelling older people (60 years of age or older). In a survey of more than 4000 older people in New York State, the rate of elder abuse was found to be 7.6%16,17; in a national survey by Laumann et al., the rate was 9%,12 and in a national telephone survey by Acierno et al.,18 the rate was 10%. It is likely that these figures are underestimates; the reliance on self-reported information from persons who are able to participate in a survey excludes patients with dementia, and studies have shown that dementia places older persons at greater risk for mistreatment.19 When the available evidence is taken into consideration, an estimated overall prevalence of elder abuse of approximately 10% appears reasonable. Thus, a busy physician caring for older adults will encounter a victim of such abuse on a frequent basis, regardless of whether the physician recognizes the abuse.

More at NEJM site

CONCLUSIONS

Because victims of elder abuse tend to be isolated, their interactions with physicians, which may be intermittent or rare, present critically important opportunities to recognize elder abuse and to intervene or refer the victims to appropriate providers. Advances in our understanding of the many manifestations of elder abuse and the emergence of interprofessional-team approaches also point to an important role for physicians in addressing this major public health problem. Both research and clinical experience suggest that cases of elder abuse can rarely, if ever, be successfully treated by the physician alone. Therefore, the response of the medical professional must include connecting with specialists in other disciplines, including social work, law enforcement, and protective services, ideally in the context of an interprofessional-team approach.

Leave a Reply