Identifying Elder Abuse in the Home Care Setting

Q: A 78-year-old woman is brought to your office by her son. She has moderate Alzheimer’s disease and has had a previous stroke, which impairs her ability to communicate. She has episodes of agitation several times weekly, which eventually respond to behavioral modification. She lives in her own home, but requires care by home health aides 18 hours daily. Thus far, she has been able to stay alone at night. She seems depressed and fearful, and does not attempt to answer your questions. She has lost 15 pounds since her last visit 3 months ago. Several skin tears are noted, along with bruises on her arms. The son says these skin changes were not present when he last saw his mother 4 days previously.

What types of findings should make you suspicious for elder abuse? What are some of the characteristics of abusers? What are risk factors for abuse? What are the different types of elder abuse?

A: With the increase in the elderly population, all health care workers involved with the elderly must be able to recognize, evaluate, and treat elder abuse. Despite mandatory reporting laws and recent publicity, both in the lay press and medical literature, elder abuse remains significantly underreported.¹ Far more attention has been given to abuse in the nursing home setting than to abuse perpetuated by caregivers in the home care setting.

Obvious physical abuse is but one of the forms of elder abuse.² Psychological abuse may take the form of persistent belittling, ridicule, or an environment that creates chronic anxiety. Financial abuse results in monetary loss without benefit to the elderly individual. Elderly persons who live alone are most in danger of this, not just from direct caregivers, but also from unscrupulous neighbors or from Internet scams. Neglect or abandonment occurs when a caregiver refuses or fails to follow through on a commitment to care for an elder. Self-neglect may also be considered a form of abuse.³

Abuse should be suspected when encountering a withdrawn, depressed, or fearful patient. Repetitive or neurotic behaviors may also be seen. Malnutrition, dehydration, poor hygiene, or poor dress may also be warning signs. Scratches, extensive skin tears, or pressure ulcers often suggest abuse. Bruises of various ages are characteristic of abuse in the pediatric population, but may be less so in the elderly.⁴ Long-bone fractures in the frail elderly may be indicative of abuse, but may also occur with a minimal amount of trauma.⁵

Risk factors for abuse in the elderly include low income, minority status, advanced age, substance abuse by the patient or caregiver, prior history of abuse, and cognitive impairment.⁶ The amount of physical impairment in the patient is not necessarily associated with an increased risk for abuse. Females are more commonly abused and are the victims in nearly all cases of sexual abuse.

In most studies, the elderly person with dementia is more likely to be abused. This is especially true for those elderly individuals who have difficulty with communication or those with behavior problems. The diagnosis of elder abuse in patients with dementia can be difficult, especially if the person is unable to give a reliable history. Clues may include a rapid worsening of dementia, behavioral changes, signs suggestive of depression, and changes in appetite or sleep. The abused patient may also seem fearful or anxious.

Understanding the characteristics of the abusers may help raise suspicion in certain abuse cases. The abuser is commonly financially dependent upon the elder. In cases of family abuse, adult children abuse more frequently than spouses.The abuser is often male and the primary caregiver.⁷ It would seem intuitive that the amount of caregiver stress would correlate with the potential for abuse, but data do not necessarily support that supposition.⁸

Once abuse is suspected, it is imperative that a report be made to the appropriate authorities. The regulations and the responsible authorities will vary from state to state. Using other health care workers, such as nurses and social workers, will be helpful.