Elder Abuse
The Underreported Tradegy
By Diane McGrogan, M.S.W., L.C.S.W.
The dilemma often facing elders in an abusive situation is whether fear of more abuse is stronger than fear of punishment for revealing information. Even though words may be unspoken, the media, in highly publicized reports of hideous living conditions, reinforces the fear of institutionalized life. So elder abuse, a tragedy that affects between four and ten percent of the senior population in the United States, goes largely unreported. Some experts estimate that only one of 14 domestic elder abuse incidents, only seven percent of the total, comes to the attention of authorities.1
According to government statistics cited by CBS News, there were 300,000 cases of elder abuse reported in the United States in 1996 — three times the number reported a decade ago. With actual incidents of elder abuse conservatively estimated at 1.3 million per year, this means more than one million cases go unreported.
The threat of an even worse situation, such as being institutionalized, as well as the need to protect the privacy of the family at all costs, keeps the victim silent, even unwilling, to seek necessary medical attention. Such reticence makes addressing this national tragedy, which leaves more than 1.3 million adults living in fear and shame, another complication.
The High Risk Factors
According to the National Center on Elder Abuse (NCEA), abuse of the elderly can take the forms of physical abuse, sexual abuse, emotional abuse, financial or material exploitation, neglect, abandonment or self-neglect. While not all cases of elder abuse involve family violence, 1994 NCEA data indicates that adult children are the most frequent abusers of the elderly, with family violence accounting for more than 65 percent of reported elder-abuse cases.
The perpetrators themselves are often the victims of previous abuse — perhaps by the elderly relative who is now in their charge.2 They're exhausted and frustrated, faced with a living situation not of their choosing. In high-risk situations, when there's drinking, drugs or mental illness present, the chances for abuse skyrocket.
Psychopathology of the individual was found to be one of the main causes of mistreatment in a national survey of elder mistreatment in Canada.3 In another study, more than one-half (56 percent) of the abusers had mental or emotional problems and almost three-quarters (70 percent) were dependent on their victims for financial support.4 The abusers may have profound disabling conditions: addiction to alcohol or drugs, a sociopathic personality, serious psychiatric disturbances, dementia, mental retardation or chronic inability to make appropriate judgments about the care of a dependent elder.5 So heading off elder abuse is a matter of managing a spectrum of social ills from child abuse, domestic violence and drug abuse to properly caring for the mentally ill. These conditions underscore the importance of diagnosing, documenting and treating the abused person.
Diagnosing and Documenting Elder Abuse
Elder abuse is often discovered in the emergency room, when a patient is being treated for an injury. But even when the cause for hospitalization appears to be unrelated, healthcare professionals must be on the lookout for indicators of abuse. For example, we admitted an elderly woman for injuries resulting from what her caretaker claimed was a fall. Soon after admission, she became unconscious, requiring life support, and the medical staff was pursuing a serious head injury. But a nurse, as a matter of course, was turning the patient and noticed multiple bruises on her back. The nurse immediately called for an instant camera to document the injuries. We then continued to photo document the healing process, using a professional instant camera from Polaroid's Spectra Injury Documention Kit.
Though cliché, a picture is literally "worth a thousand words" — especially when it comes to prosecuting an abuser. In this case, the photos spoke for the silent victim. Even if wounds heal by the time an abuser is brought to court, clear documentation of the injuries, from first discovery throughout the healing process, is an invaluable tool in securing a conviction.
When elder abuse takes the form of neglect or abandonment, there's no substitute for visual evidence. A social worker's images of filthy living conditions, rotting food in the refrigerator or a medicine cabinet in disarray can quickly and effectively tell the story: What might look like careless housekeeping could actually be a caregiver's neglect. But an observer won't necessarily know until later, so witnesses should take photos immediately, before anyone has a chance to clean up and destroy the evidence. Often the abuser, when faced with overwhelming evidence collected by the medical and law enforcement teams, pleads guilty instead of going to trial.
Treatment: A Safe Place
The prosecution stage, even when the evidence speaks for itself, is particularly troublesome in elder abuse. In cases of severe neglect, when patients may be dehydrated or deprived of medication, they can be incoherent and confused. The first priorities are treatment and stabilization. Second, it's crucial to gain the trust of the victim, possibly refraining from befriending the caretaker. Third, the victim must be safe, comfortable and in privacy to facilitate discussion of the abuse.
Once the victim is safely away from the abuser, there's still the question of day-to-day living. "Where will I go" Who will take care of me if my caregiver goes to jail? I'm away from my abuser, but do I have to go into a nursing home?" ask the fearful victims.
Education plays a major role in fighting elder abuse. Victims must know that there are alternatives to an abusive living situation. Most communities support their senior population with programs such as the following, aimed at helping people maintain independence while upgrading their quality of life:
A Call for Zero Tolerance
In 42 states, doctors, nurses, social workers, psychologists and pharmacists are designated as mandatory reporters of domestic elder abuse, required by law to report suspected cases of abuse, neglect and exploitation. Historically, domestic elder abuse reports come from physicians, healthcare professionals and law enforcement personnel, as well as from those who provide other services to the elderly. Family members of victims, friends and neighbors, clergy and acquaintances provide invaluable reporting information and support to the victims.
But community assistance is not enough. We must have zero tolerance for elder abuse. Every organization, corporation and individual must take a stand and say, "This is not acceptable." Encourage your place of business to include education and awareness training on the topic of elder abuse. Stay in contact with your elderly neighbors. If you suspect an abusive situation, call the police or your area agency on aging.
As healthcare professionals, we must make it our duty to recognize elder abuse, document and treat it, offering solutions, so that more victims come forth, thereby breaking the abuse cycle for the elderly and bringing their abusers to justice
References
1. Excluding the incidents of self-neglect.
2. Many researchers have concluded that domestic violence, such as child abuse and
neglect and spouse abuse is learned in the home and passed from one generation
to the next. Quinn, Mary Jo and Tomita, Susan K. "Elder Abuse and Neglect,
Causes, Diagnosis and Intervention Strategies," pg. 107, (1997).
3. Quinn and Tomita, pgs. 111-112, (1997).
4. Quinn and Tomita, pgs. 111-112, (1997).
Diane McGrogan is the manager of Social Service Programs for Scripps, a multi-hospital Healthcare System in San Diego, CA. She has over 20 years experience in social work and is a National Association of Social Workers diplomate in clinical social work. Diane has co-authored and contributed to a number of journal articles and recently assisted the San Diego City Attorney's Office in producing a training video, Mandated Medical Reporting of Domestic Violence Incidents.