Introduction

Mistreatment of the elderly, or "granny bashing" as the British called it, has been recognized as a medical and social problem for at least 20 years. However, because of differing definitions, poor detection and under-reporting, its extent is unknown. Some studies estimate that the prevalence of elder mistreatment ranges from 1 to 5% in the USA. Apart from the distress caused the subject while alive, it is alarming to read in a recent article that elder mistreatment is associated with shorter survival, even after adjusting for other factors associated with increased mortality in older adults.¹

Abuse of the elderly may be expressed as physical abuse, physical neglect, psychological abuse, financial exploitation, or violation of the victim's rights. The American Medical Association has proposed a standard definition of abuse: an act or omission that results in harm or threatened harm to the health or welfare of the subject. Abuse can include the intentional infliction of physical or mental injury, sexual abuse, or withholding necessary food, clothing and medical care. Unfortunately, elder mistreatment is under-reported, often because it is missed, or deliberately overlooked by physicians and professional caregivers. Reasons include infrequent physician attendance, poor training in recognizing the condition, the subtle presentation of symptoms and signs, inherent unfavorable attitudes toward the elderly (ageism), reluctance to recognize that a problem exists, and fear of confronting or reporting the offender.

Risk factors for elder mistreatment

An impaired patient - mentally or physically - is at greatest risk of mistreatment - particularly someone in need of assistance with feeding.² Caregivers experience "burnout" and frustration, which can lead to abuse of their charge. Alcohol abuse (by the patient or the caregiver) increases the risk of physical abuse and neglect. Finally, the personality and psychological character of the caregiver, as well as that of the patient, can play a causative role in situations involving mistreatment.

Obviously knowledge of the risk factors can assist in preventing elder mistreatment, if the persons involved are prepared to address them. Screening patients and caregivers before placement, if feasible, can be helpful. Adequate frequency of physician visits and availability of social community support will help avoid the circumstances leading to mistreatment.

Diagnosing mistreatment

A careful history should be taken, if possible, although older adults may have difficulty in giving accurate information because of cognitive impairment. Sometimes they are reticent, being afraid of retaliation by the offender - either in the form of physical abuse or threats of abandonment. Sometimes the fear of being moved to a nursing home may repress reports of mistreatment.

Somatic symptoms may be the dominant presenting complaints. The physician must ask directly about rough treatment, confinement or verbal abuse. Sometimes the information from the patient may be disguised or confused, or only given when the patient is away from the home i.e. at the doctor's office or the nursing home. Usually, the patient should be interviewed alone. Questions should be directed towards the patient's view of daily life, covering such topics as meals, medication, and trips to the shops or park. There should be some questions about the relationship with the caregiver, e.g. "how do you and Ms X get along?" and "does Ms X take good care of you?" Likely signs of depression or alcohol abuse should be sought, and it may be appropriate to discuss finances.

If any issues of mistreatment are raised, the caregiver should be interviewed as well. Great care must be taken not to over-interpret the patient's complaints, especially if there is cognitive impairment.

Results of the physical examination must be carefully and accurately recorded, as they may be needed as legal evidence of mistreatment. Signs of injury should be noted (traumatic alopecia, hematomas, burns, fractures or signs of previous fractures). Evidence of neglect may include unkempt appearance, weight loss, dehydration, poor oral hygiene, decubitus ulcers, inguinal rash, and fecal impaction. Any suspicions findings in the history or physical exam should be confirmed with laboratory and radiological exams, if this would be valuable. Thus dehydration and malnutrition can be established with simple lab tests such as a complete blood count, blood urea nitrogen, creatinine, total protein and albumin, and cholesterol levels. Results of all such tests should accompany the documentation of mistreatment.

Management

If patients are competent, the situation should be discussed with them initially, as they should play a role in the ultimate resolution. The physician should involve local social services and legal, financial and police services, to the full extent that the situation demands. (In the USA, all health care providers are mandated by law to report suspected mistreatment of the elderly.) Sometimes multidisciplinary teams can be effective - a group made up of a geriatrician, social worker, case management nurse, and ad hoc representatives from legal, financial and adult protective services. Senior advocacy volunteer groups are also helpful, if they are available in the local community. Solutions to the problem may involve replacement of a caregiver, relocation of the patient, or appointment of a legal guardian. If there is the slightest likelihood of elder abuse being proliferated by the caregiver or the institution involved, legal charges must be brought.

Comment

As with many common but under-diagnosed conditions, much can be improved if the level of awareness by physicians or other professional caregivers is raised. It is encouraging to learn, from a Dutch study, that 70% of victims are able to stop mistreatment, either by themselves or with the help of others.³ While elder abuse is unlikely to disappear, more widespread knowledge of the potential for mistreatment and the steps to take to eliminate it will do much to lessen its impact on society.