Elder abuse: Primary care strategies for screening
Elder abuse: Primary care strategies for screening
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At a glance
Elder abuse is a topic often avoided but important to consider. Frail, elderly individuals with increased vulnerability and limited reserves to rebound are most impacted. Primary-care providers (PCPs), who have access to these patients via office visits, are in a position to identify and intervene if necessary.
Recognizing patients who are at risk for elder abuse or those who have experienced elder abuse can guide plans to promote patient safety. This article identifies approaches for primary-care screening, including strategies to identify and minimize the risk of elder abuse for homebound patients.
Extent and impact of the problem
Elder abuse is considered a growing form of family violence. Each year, an estimated 1 to 2 million older adults are impacted and the number of abuse cases increases.1 Actual numbers of cases may be underestimated, since elder abuse is thought to be underreported. Because the most frail and vulnerable are impacted, including elders with dementia, patients' ability to report abuse may be limited.
PCPs may also miss reporting opportunities because presentations of abuse are subtle and many have limited familiarity with the provider's responsibilities. The impact of abuse on elders may be magnified related to physical aging changes, leading to increased illness, loss of independence or death.2 In addition to physical injury, psychological trauma and loss of self-esteem occur.Current societal trends support the need for increased attention to the problem of elder abuse. A growing older adult population is resulting in larger numbers of frail elders and their increasing needs for family caregiving. Spouses or adult children are the typical caregivers, providing an estimated 80% of all home-care services.3 Since elder abuse often occurs in the home setting among family members, the PCP may be the main person to see the patient and offer help.
Forms of elder abuse
Elder abuse is considered a form of violence against older adults and can occur in any setting. Abuse can take multiple forms, with overlap between the forms. Definitions for the various aspects of elder abuse from the National Center on Elder Abuse (NCEA) provide a starting point in understanding its breadth.4
Physical abuse. Elder abuse may involve the use of force that threatens or physically injures an elder who is vulnerable. This includes rough handling or actual violent behavior resulting in injuries. Sexual activity forced on a vulnerable elder who is unable to grant consent is also considered abuse.
Neglect. Failure or refusal on the part of the caregiver to provide necessities that impact an elder's safety or physical or emotional needs constitutes neglect. It is more subtle than elder abuse and the most commonly reported form of elder mistreatment. The caregiver is one who is considered to owe a duty of care to the patient, and the neglect can be considered active or passive depending on the intent. Self-neglect is a related concept focusing on a patient's lack of self-care, distinguished by the absence of a caregiver.5
Psychological/emotional abuse. Psychological abuse in the elderly can be subtle and challenging to pinpoint and describe. Verbal abuse or ignoring, rejecting, belittling, threatening, or isolating the elder are common indicators. Victims may exhibit distress, pain, and mental anguish.Financial exploitation. While PCPs focus primarily on a patient's physical and mental health, financial abuse also occurs and may come to the attention of providers or office staff. This form of abuse involves undue influence to gain control over an older person's money or property and includes theft, fraud, or misuse of authority.
Barriers to addressing abuse
Elder abuse becomes a hidden problem for several reasons: Victims often do not wish to report the abuse, abuse can be hard to detect, and providers may lack awareness of the abuse or knowledge on how to report. Most older adults want to stay in their homes as long as possible. The decision not to report abuse is often related to the victim's perceived comfort of home, family loyalty, fear of the unknown or even concerns of retaliation. In addition, the ability of elders to report may be limited because of frailties. In complex elder abuse situations, the abused patient may be ambivalent rather than angry toward the abusing caregiver.
Detection of physical abuse can be challenging. Some symptoms look like chronic illness or changes associated with advanced physical aging, including cognitive decline. Increased weakness, greater risk of falling or limited functional abilities also make abuse difficult to detect. Older patients who are frail and have physical and or mental deficits are most at risk.
Elder abuse is thought to be underreported by clinicians. PCPs note limited education and experience with elder abuse.6,7 Abuse codes in the International Classification of Diseases (ICD) system are rarely used, suggesting that providers tend to code an injury or condition as the primary diagnosis rather than the abuse. There may be a lack of awareness or reluctance to use abuse codes.8
Barriers to identifying and reporting abuse by PCPs focus on issues of time; lack of access to screening tools; limited knowledge of risk factors and symptoms; insufficient observation time with the older adult; and various issues relating to the act of reporting, including limited understanding of reporting mechanisms.2 A sense of discomfort with the problem and lack of clinician education are suggested as causes of underreporting, as is an absence of professional protocols guiding documentation and justification.9
Role of the provider
Providers have a key role in screening for elder abuse. This is especially important for their patients living at home; in some cases, the provider may be the only contact a patient has outside the abuse situation. Starting points for screening and assisting patients are highlighted in Table 1 and include knowing the risk factors, extending the history and physical examination to identify indicators, and understanding the provider's role in promoting patient care and safety.
Know the risk factors. Certain indicators suggest a higher risk of being abused. Risk factors for abuse of older adults center around patient frailty. Those at risk to carry out the abuse are most often caregivers of the frail; diverse psychosocial factors are also related to abuser roles.
Patient risk factors for abuse. Frail, elderly patients are most at risk for elder abuse. Common descriptors of patient frailty include multiple comorbidities, decreased strength, fall risks, polypharmacy, and functional deficits.10,11 Physical variables specific to increased risk for elder abuse include female gender, poor health, and cognitive impairment. Other issues include dependency on care and requiring assistance with activities of daily living. Social factors related to abuse risk include isolation and a history of family violence or of drug and/or alcohol abuse.Caregiver risk factors to abuse. Elder abuse involves at least one person besides the victim, with most abusers being family caregivers. Typically, family members are not paid for their care services, and they take on numerous supportive tasks for patients. Caregiving increases the stressors on complex family situations, with ongoing stressors building and new acute stressors adding their impact. In addition to providing care for frail patients, factors that lead to abuse include family and job stressors; limited finances; poor relationship quality; perceived caregiving burden; little social support; depression; and history of family violence, including child or spousal abuse. Additionally, abuse of substances and caregiver psychopathology are considered. The caregiver who is financially dependent on the elder, such as an adult child, is another person considered to be at high risk for abusing.12
Screening for abuse. All elders are considered at risk for abuse. Addressing questions to the elder in a manner that conveys respect and maintains patient dignity and self-esteem is indicated. This applies particularly to the elder who may already be suffering emotionally from the impact of abuse. Use of funnel-type questions that start broad and then become more detailed is recommended.14 Such an approach is only minimally obtrusive and helps guide a more focused examination with an awareness of the potential for elder abuse.2
PCPs build on all information available to them. In addition to observing and speaking with the older adult patient, providers have the opportunity to focus on those caregivers who present with the patient and to ask questions about the caregiving situation. This includes asking about and synthesizing the health problems, living arrangements, and support systems that comprise a patient's situation.
Gaining the history—what to listen for. Extending traditional history questions and observations provides an opportunity to consider potential abuse in all older adults. Listening for clues to problems provides a good starting point for all patients and allows opportunity for a further brief screen that most individuals would not find objectionable. In addition to traditional health history questions, PCPs can be specific and ask: Is someone hurting you? And if injury is present, Did someone do this to you?2Speaking with potential victims in a private, safe place allows them an opportunity to express any feelings or fears they might have about the caregiving situation. This means separating the patient and caregiver for portions of the interview or examination. The health history allows opportunity to complete the following:
- Assess the quality of interactions with patients and caregivers. A mismatch of verbal and nonverbal communication behaviors often provides clues to problems.
- Listen for meanings and inconsistencies. Descriptions from the patient and the caregiver of how an injury occurred should match.