Author Contributions: Dr. Dong was responsible for the conception and drafting of the manuscript.
Address correspondence to XinQi Dong, Rush Institute for Healthy Aging, Rush University Medical Center, 1645 West Jackson Blvd, Suite 675, Chicago, IL 60612. ude.hsur@gnod_iqnix
The publisher's final edited version of this article is available at J Am Geriatr SocElder abuse, also called elder mistreatment or elder maltreatment, includes psychological, physical, and sexual abuse; neglect (caregiver and self-neglect); and financial exploitation. Although elder abuse is a newer field of violence research than domestic violence and child abuse, it is a common, fatal, costly, yet understudied condition. 1 An estimated 10% of U.S. older adults have experienced some form of elder abuse, yet only a fraction is reported to Adult Protective Services (APS). 2 Healthcare professionals account for one of the smallest proportions of reporters. Even though understanding of the economic effect of elder abuse is incomplete, financial exploitation itself was estimated to cost $2.9 billion in 2009. 2
For decades, professionals and the public have viewed elder abuse and broader violence as predominately social or family problems. Since the first citation of elder abuse in a letter to the editor in the British Medical Journal in 1975, 3 there has been inadequate attention to elder abuse from public health, social services, health, legal, and criminal justice professionals. The situation appears to be changing. In the last decade, there have been major national initiatives to promote awareness of elder abuse, including work by the National Research Council, Centers for Disease Control and Prevention, Senate Special Committee on Aging, Government Accountability Office, White House, Centers for Medicare and Medicaid Services (CMS), Institute of Medicine, Department of Justice, and U.S. Preventive Services Task Force (USPSTF).
Screening for elder abuse is complex; the intended benefits should be balanced against potential harms. Despite the incompleteness of the evidence, the benefits outweigh the harms of inaction. Because of the scope and effect of the issue, screening for elder abuse in healthcare settings should be a priority. Practical suggestions are provided to healthcare professionals to detect and treat cases of elder abuse.
Elder abuse is associated with risk of morbidity and mortality especially in those with greater vulnerability: cognitive impairment, physical disability, psychological distress, and social isolation. 4,5 Elder abuse is associated with greater risk of mortality and cardiovascular-related mortality, even after adjusting for an extensive list of potential confounders. 4 Moreover, elder abuse predicts higher rates of emergency department use, hospitalization, readmission, skilled nursing placement, and hospice use. 2 Despite the frequency with which elder abuse victims interact with healthcare systems, most pass through these systems unrecognized; this is a missed opportunity to improve quality of care.
There are many screening tools to detect elder abuse through potential victims and perpetrators in various settings (e.g., community, clinical, institutional) and through various methods (e.g., telephone, in-person, computer assisted, self-administered). CMS suggested the two measures highlighted below based on available evidence. These measures provide a basis for heightening clinicians’ suspicion for elder abuse and asking additional questions to explore potential elder abuse 6 ( Table 1 ). The Hwalek-Sengstock Elder Abuse Screening Test measures violation of personal rights or direct abuse, characteristics of vulnerability, and potentially abusive situations. The Vulnerability to Abuse Screening Scale (VASS) measures vulnerability, dependence, dejection, and coercion. These measures have been tested in diverse populations and racial and ethnic groups; VASS has demonstrated predictive validity.
Brief Screening Measures for Elder Abuse.
| Hwalek-Sengstock Elder Abuse Screening Test | Vulnerability to Abuse Screening Scale |
|---|---|
| 1. Has anyone close to you tried to hurt or harm you recently? | 1. Are you afraid of anyone in your family? |
| 2. Do you feel uncomfortable with anyone in your family? | 2. Has anyone close to you tried to hurt or harm you recently? |
| 3. Does anyone tell you that you give them too much trouble? | 3. Has anyone close to you called you names or put you down or made you feel bad recently? |
| 4. Has anyone forced you to do things that you didn’t want to do? | 4. Does someone in your family make you stay in bed or tell you you’re sick when you know you aren’t? |
| 5. Do you feel that nobody wants you around? | 5. Has anyone forced you to do things you didn’t want to do? |
| 6. Who makes decisions about your life… like how you should live or where you should live? | 6. Has anyone taken things that belong to you without your OK? |
As with any screening measure, there is potential for unintended consequences. The two measures noted above may not capture specific subtypes of elder abuse or the social, family, or cultural context of potential abuse. These measures have not been validated in people with cognitive impairment, who are at particularly high risk. False-positive results could cause psychological distress to older adults and families and could jeopardize the physician–patient relationship. False-negative results may negate the abusive situations and provide false assurance, which may further increase older adults’ risk for adverse outcomes. There is also concern that screening might put older adults at greater risk and result in harm from the perpetrator(s). Moreover, because there may be limited evidence on effective intervention and prevention strategies to ameliorate elder abuse, there is insufficient guidance to assist healthcare professionals, many of whom may not have the knowledge, time, or skills to address complex cases. In 2013, the USPSTF report to the U.S. Congress suggested that elder abuse should be a priority research area, to better quantify these assumptions. 7
In 2013, CMS held a national symposium on the role of elder abuse screening as a Physician Quality Reporting System (PQRS) measure in Medicare beneficiaries. 6 Experts systematically examined the scope and effect of elder abuse, especially in healthcare settings. The VASS and Hwalek-Sengstock Elder Abuse Screening Test were recommended as suitable measures to detect elder abuse. CMS also recognized the limitations of existing knowledge and called for research and guidelines to support healthcare professionals. CMS has approved PQRS measure 181 to screen for elder abuse and follow-up, but clinician use has been low. This PQRS measure could be instrumental in improving reporting of elder abuse and quality measures in healthcare systems.
Healthcare professionals are well situated to screen for elder abuse and detect vulnerabilities. 8 Assessing functional, cognitive, and psychosocial well-being is important to understanding vulnerability associated with elder abuse. A risk prediction index was constructed that suggested that older adults with three or four vulnerability factors have a risk of elder abuse that is almost four times as great, and those with five or more vulnerability factors have a risk of elder abuse that is more than 26 times as great as those with two or fewer vulnerability factors. 9
Because elder abuse victims often interact with health systems, greater screening and treatment could improve quality of care. Primary care outpatient practices, inpatient hospitalization episodes, discharge planners, and home healthcare givers could play pivotal roles in identifying potentially unsafe situations that could jeopardize the safety and well-being of older adults. Because elder abuse victims disproportionally interact with the emergency department, hospital system, and nursing homes, the brief screening measures above should be incorporated as part of the psychosocial and home safety assessment by physicians, nurses, therapists, and discharge planners. Early detection and interventions, such as leveraging effective treatment of underlying problems, providing community-based and individuals-centered services, and appropriately involving family, may help ameliorate or stop elder abuse ( Figure 1 ).
Healthcare professional management strategies for elder abuse. APS = Adult Protective Services. (Adapted from JAGS: 2015: Pending Press by Dong XQ).
Although screening and risk prediction for elder abuse are important steps, it is just as critical to assist healthcare professionals in taking appropriate steps if an individual screens positive. 10 Elder abuse should be reported to APS whenever a reasonable suspicion of elder abuse arises. The goal is to make an informed referral to APS. When health professionals suspect elder abuse, detailed histories should be gathered, especially about psychosocial, family, and cultural factors. Specific findings from physical examination that may further indicate elder abuse should also be documented. Healthcare professionals should document observations of patient behavior, reactions to questions, and family dynamics and conflicts. Whenever indicated, healthcare professionals should order laboratory and imaging tests. These types of documentation are critical for supporting the interdisciplinary team and APS in ameliorating elder abuse and protecting vulnerable older adults. Healthcare professionals should also devise patient-centered plans to provide support, education, and follow-up; monitor ongoing abuse; and institute safety plans.
Almost all U.S. states have mandatory reporting legislation requiring healthcare professionals to report reasonable suspicions of elder abuse to APS. Despite these laws, many healthcare professionals are reluctant to report elder abuse because of concerns about lack of time, limited knowledge, fear of offending the individual and family, and sense of inability to make a difference. When a health professional suspects elder abuse, he or she should contact the local state number, the ElderCare Locator (800–677–1116), or the National Center on Elder Abuse.
Health professionals, especially geriatricians, promote an individual’s rights to autonomy and self-determination, maintain a family unit whenever possible, and provide recommendations for the least-restrictive services and safety plan. Occasionally, despite best attempts, people refuse services aimed to protect them. It must be presumed that an older adult has decision-making capacity (DMC), and the individual’s choices must be accepted until a healthcare provider or the legal system has determined that he or she lacks capacity, although capacity is not present or absent; rather it is a gradient relationship between the actions in question and an older adult’s ability to make these decisions.
Given the scope of elder abuse and the devastating effect on the individual, family, community, and healthcare system, health professionals should consider integrating routine screening of elder abuse to improve quality of care. Despite the incomplete evidence to screen for elder abuse, as the late astronomer Carl Sagan said, “Absence of evidence is not evidence of absence.” Although gaps remain in the field of elder abuse, unified and coordinated efforts at the national level must preserve and protect the rights of the vulnerable aging population.
The author would like to thank APS staff and other frontline aging professionals around the globe for their continued dedication and commitment to protect the vulnerable victims of elder abuse.
Conflict of Interest: Dr. Dong was supported by National Institute on Aging Grants R01 AG042318, R01 MD006173, R01 CA163830, R34MH100443, R34MH100393, R21AG038815, and RC4 AG039085), a Paul B. Beeson Award in Aging, the Starr Foundation, the American Federation for Aging Research, the John A. Hartford Foundation, and the Atlantic Philanthropies.
Sponsor’s Role: None.
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