As hidden as the other forms of family violence may be, domestic elder abuse is even more concealed within our society. Elder abuse was first described in the literature in 1975, when the first reports of “granny battering” appeared. Vastly underreported, only one in four domestic elder abuse incidents (excluding the incidents of self-neglect) come to the attention of authorities.

The most common reporters of abuse are family members (17%) and social services agency staff (11%). Physicians reported only 1.4% of the cases. Although physicians are mandatory reporters in all states, many physicians feel ill-equipped to address this important social and medical problem. Health care professionals consistently underestimate the prevalence of elder abuse. Concerns for patient safety and retaliation by the caregiver, violation of the physician-patient relationship, patient autonomy, confidentiality, and trust issues are quoted as reasons for low reporting. A recent survey indicates that more than one-third of health care professionals had detected cases of elder abuse in the past year.

Family physicians are particularly well positioned to assist in identifying and managing elder abuse. Family medicine residencies focus on training residents regarding elder abuse more comprehensively than other primary care programs. Except for the primary caregivers, they may be the only ones to see an abused elderly patient. Older victims who suffer from neglect, self-neglect, or physical abuse are likely to seek care from their primary care physician or gain entry into the medical care system through an emergency department.

In the 2000 census, 35 million people in the United States were 65 years of age and older. Adults 85 years and older showed the highest percentage increase of any age group (38%), from 3.1 million to 4.2 million. As the baby boomers age, the number of elders in the United States will continue to increase. The societal cost for the identification and treatment of elder abuse is also projected to rise as the baby boomers enter the elder years.

Definition and Types of Abuse

Elder abuse is an all-inclusive term that describes all types of mistreatment and abusive behaviors toward older adults. The mistreatment can be either acts of commission (abuse) or acts of omission (neglect). Labeling a behavior as abusive, neglectful, or exploitative can depend on the frequency, duration, intensity, severity, consequences, and cultural context. Currently, state laws define elder abuse, and definitions vary considerably from one jurisdiction to another. Research definitions also vary, making it difficult to review comparative data.

There are three basic categories of elder abuse: (1) domestic elder abuse, (2) institutional elder abuse, and (3) self-neglect or self-abuse. The National Center on Elder Abuse (NCEA) describes seven different types of elder abuse: physical abuse, sexual abuse, emotional abuse, financial exploitation, neglect, abandonment, and self-neglect (Table 42-1).

Prevalence

According to the 2003 National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect, it is estimated that approximately one to two million elders were victims of various types of domestic elder abuse, excluding abuse due to self-neglect. More than 2%-10% of the nation’s elderly may be victims of moderate to severe abuse, but because of underreporting, poor detection, and differing definitions, the true estimate of elder abuse may be far greater. It is estimated that for every one case of elder abuse, neglect, exploitation, or self-neglect reported to authorities, about five more go unreported. Current estimates put the overall reporting of financial exploitation at only 1 in 25 cases, suggesting that there may be at least five million financial abuse victims each year. In a recent survey of almost 6000, there was a 1-year prevalence of 4.6% of emotional abuse, 1.6% of physical abuse, 0.6% of sexual abuse, 5.1% of potential neglect, and 5.2% of financial abuse by a family member.

In reported cases of domestic elder abuse, 77% of the victims were white and 22% were African American. The proportions of Native Americans and Asian Americans/Pacific Islanders were each less than 1%. Neglect—the failure of a designated caregiver to meet the needs of a dependent elderly person—is the most common form of elder maltreatment in domestic settings. In almost 90% of cases the perpetrator of the abuse is known, and in two-thirds of cases the perpetrators are spouses or adult children.

Risk Factors

Several explanations have been proposed to explain the origins of elder mistreatment. These explanations have focused on overburdened caregivers, dependent elders, mentally disturbed caregivers, a history of childhood abuse and neglect, and the marginalization of elders in society. Care setting also seems to influence risk of elder abuse. Paid home care has a relatively high rate of verbal abuse and assisted living settings have an unexpectedly high rate of neglect. Moving from paid home care to nursing homes has been shown to more than triple the odds of the elder experiencing neglect. Risk factors commonly cited for elder mistreatment are listed in Table 42-2.

From the Indicators of Abuse (IOA) screen, a profile of the abuser has been developed that can identify abuse cases 78%-85% of the time. The salient features of the profile are detailed in Table 42-3.