Elder Abuse: Making a Difference
CASE PRESENTATION
Dr. K received a call from one of the residents at the hospital emergency department. His patient, Mrs. B, was going to be admitted due to chest pain, shortness of breath, and poorly controlled blood pressure. Dr. K had been concerned about Mrs. B for several months. She is a 76-year-old widowed woman who suffers from congestive heart failure, hypertension, type II diabetes mellitus, osteoarthritis, and mild renal insufficiency. She was always a very compliant patient who was stable on a regime of atenolol 25 mg once daily, furosemide 40 mg once daily, potassium chloride 20 mEq once daily, ramipril 5 mg once daily, metformin 850 mg once daily, and acetaminophen 650 mg 4 times per day. She has been a widow for five years, but remains active in a senior citizen center and volunteers at the local public library. Six months ago, Mrs. B’s daughter, a divorced mother with three children, moved back into her mother’s home. Initially, her daughter appeared very involved, accompanying Mrs. B to her appointments with Dr. K. The daughter visited Dr. K for her own medical needs, and asked if the doctor could bill her mother’s Medicare account for the visits. She also complained about the high cost of prescription medications and talked about ordering medications more cheaply over the Internet. Dr. K counseled the daughter about the need to fill the prescription from reputable pharmacies, and was willing to extend professional courtesy for the office visits.
He became concerned when Mrs. B returned several times complaining of dizziness and weakness, and was found to have elevated blood sugars in the 300 mg/dL range. In addition, her blood pressure was 180/100 mm Hg on one visit. He asked Mrs. B if she was taking her medications, and she rather quickly said yes. She also denied any problems and accepted new prescriptions for higher doses of medications. Dr. K offered to call her pharmacy, but Mrs. B said that her daughter now filled the prescriptions. Dr. K asked Mrs. B to return in one week and bring all of her medications. She missed that visit, and several weeks later she was admitted to the hospital. Mrs. B’s blood pressure and diabetes were brought under control quickly in the hospital when she was placed back on the regime she took in the past.
Dr. K asked Mrs. B about her medications, and she reluctantly told him that her daughter was buying medications over the Internet with Mrs. B’s credit cards. Her daughter became angry when Mrs. B complained that the pills looked different than usual. A social service consult was requested by Dr. K due to suspected financial abuse. In addition, the nursing staff reported that Mrs. B’s daughter and her three teenage sons visited regularly, but were observed eating her food. Mrs. B’s daughter asked the hospital social worker for her mother’s wallet, which had been locked in the hospital safe. She stated that she needed her mother’s ATM card to buy food and medication. When the social worker pointed out that her mother was receiving food and medication in the hospital, the daughter became threatening and was ultimately asked to leave by security staff.
The social worker directly asked Mrs. B if her daughter had been threatening her. Initially, Mrs. B was reluctant to say anything, but became tearful when the social worker asked about the condition of her house, revealing that her daughter and grandsons are very sloppy and messy. They had been borrowing money from her on a daily basis, and her daughter had been wearing her jewelry. Mrs. B was worried that her youngest grandson, who is 16 years old, was not attending school. Her daughter asked to return home after she became divorced, and then lost her job within a short period of time. Mrs. B described her daughter as a “difficult child” who was always rebellious, but she seemed to settle down after she got married more than 20 years ago. Mrs. B has an older son who lives in another state. He manages most of her finances since the death of her husband. Mrs. B tearfully told the social worker that three days ago, her daughter became enraged when she found a document giving her older brother power of attorney for her mother. She demanded that Mrs. B sign a new power of attorney. She did this and then developed chest pain, leading to her hospitalization. The social worker explained that what her daughter did is wrong and offered to contact her son. She also offered to have Mrs. B complete a new power of attorney, again designating her son. Mrs. B did this, but stated that she is afraid of what will happen when her daughter finds out.
DISCUSSION
Abuse of the elderly ranges from financial exploitation to neglect and refusal to provide needed care, to overt physical harm.1 Older adults are vulnerable to abuse of all kinds. The increasing needs for assistance and dependence on caregivers, social isolation, and frailty, combined with the reluctance to complain about their abusers, make elder abuse an extremely underreported crime.2-5 Mistreatment of the older adult includes physical, emotional, or psychological harm, sexual abuse, financial exploitation, and neglect by caregivers.1,6 Elder abuse occurs among all racial, ethnic, and socioeconomic groups. It involves the rich, the poor, and the middle class, and requires that heath care providers be vigilant in identifying warning signs that may indicate elder abuse.2,7 Warning signs and symptoms of elder abuse and neglect are listed in the Table.1-6
As the case of Mrs. B illustrates, family members are the most common persons involved in elder abuse, and financial exploitation is typical. In almost 90% of cases in the community setting, the abuser is a family member. In two-thirds of cases, it is a spouse or an adult child.8 The abuser frequently depends on the older adult for housing, financial support, or assistance. Often, the abuser may have substance abuse or mental health problems, or suffer from the stress of caregiving in a severe manner. Typically, they do not feel that their behavior is abusive. The most common types of elder abuse in order of prevalence are: neglect, emotional abuse, financial exploitation, physical abuse, and sexual assault.5 In 1988, the Administration on Aging identified more than 551,011 elderly persons who experienced abuse or neglect.8 The current number of elderly who suffer from abuse and neglect is significant—more than 2 million incidents per year. Given that abuse of the elderly is often chronic and may contribute to the death of the older adult, intervention has great potential to reduce not only suffering but also mortality.2,3
At greatest risk for elder abuse are women over age 80, those who live alone, and elderly who suffer from frailty, confusion, or depression.3 Older adults who are victims of abuse and neglect often visit emergency rooms and present with a variety of physical and emotional complaints.5 Denial of the abuse is common, as many elderly live in fear of their abusers and suffer from shame and embarrassment. Assessment of the older adult should include careful physical evaluation of injuries and bruises, as well as gentle questions regarding living arrangements, financial and social supports, and emotional stressors.2-6 Interactions between the patient and family members or caregivers may offer important information. As this case illustrates, the behavior of Mrs. B’s daughter led the physician to suspect exploitation and potential mistreatment. Missed appointments in patients who are frail and vulnerable warrant further inquiry or contact of a relative or friend, if possible.
Abuse of the elderly also occurs in institutional settings including hospitals, nursing homes, assisted living facilities, and board-and-care homes. Nursing homes have ombudsman programs with representatives who are able to take confidential reports of abuse of residents. In addition, each state facility is required to post a toll-free number to report suspected abuse to the state Department of Health.1,3 The most valuable intervention that a physician can provide in cases of suspected abuse or neglect is making an initial report to the appropriate agency.1-7 Currently, 47 states have laws requiring health care professionals to report abuse of an older person who is incapacitated or unable to report for themselves. All 50 states encourage the voluntary reporting of elder abuse.4,5 Every state has an agency designated to receive and investigate allegations of elder abuse and neglect. In most regions, this is an Adult Protective Services agency.1,2 The Eldercare Locator (800-677-1116), a nationwide assistance directory provided by the National Association of Area Agencies on Aging (N4A), will provide referral to the local agency that will investigate a report of elder abuse or neglect.3-5
The outcome of each case will depend on the results of an investigation, the nature of the abuse, and the possible social and legal options available. If an older adult has the capacity to make decisions, his or her wishes must be respected, even when a choice is made to return to an abusive relationship. It is frustrating when an older adult refuses to press charges if a crime has been committed or refuses to leave an abusive relationship. Offers of assistance should always be made and should continue. When an elderly person is cognitively impaired, legal options of guardianship or conservatorship may be needed.1-3 The National Center on Elder Abuse (NCEA) is an organization that provides information and training on the abuse of older persons for professionals and the public.8 Information may be accessed at their website: www.elderabusecenter.org.
OUTCOME OF THE CASE PATIENT
The social worker called Mrs. B’s son, who immediately arranged to come to see his mother. Mr. B stated that his sister had relied on money from their mother her entire life, but he never believed that things would get this bad. He asked if Mrs. B could remain in the hospital until he could check on his mother’s finances and remove his sister from the house. Arrangements were made for Mrs. B to be transferred to a local nursing facility for short-term rehabilitation. Mrs. B’s son arrived within a few days, and found that his sister had applied for and received multiple credit cards in his mother’s name. He was able to cancel the cards and contact credit bureaus and the bank to have any further activity on Mrs. B’s account cancelled. He found that his sister had ordered a new set of ATM cards and contacted a realtor about selling their mother’s house. He filed charges against her and her sons, although these were later dropped when Mrs. B refused to give a statement to the police and district attorney.
Mr. B arranged for the police to be present when his sister packed her things and left the house, checking jewelry and other valuables before they left. Overall, his sister had spent more than $10,000 over a 6-month period. In addition, she bought a variety of drugs over the Internet, including stimulants, sedatives, and muscle relaxants. She had not filled any of her mother’s prescriptions. Fortunately, Mrs. B had enough money in savings to pay her debts. Despite her son’s many attempts to have her file charges against her daughter, she refused. She was willing to accept help to prevent further problems. Her son arranged with Dr. K, her local bank, and the senior center to be informed of any changes in her living situation or general condition. The hospital social worker referred her to a community program that provided weekend visitation on days that the senior center was closed. Mrs. B was discharged home and returned to the senior center and her volunteer job. She enjoys the weekend visits. She is medically stable and compliant with her medications.