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'Elder abuse': the case for greater involvement of geriatricians.

It is ironic that the phenomenon of 'elder abuse' in the United Kingdom has only recently begun to achieve widespread credibility. The first English language report of 'granny battering' was British [1] but it has been in the United States that much of the formative work has been carried out. There is a familiar ring to the emergence in the US of a problem requiring a multidisciplinary approach to which the clinician has a central role. Following an initial period of interest however [2], clinicians in the UK have been conspicuous by their absence from the central debate, despite their potential role in the detection, management and possible prevention of abuse of older people. The reasons for this are not readily apparent but may include a degree of clinical and academic discomfort surrounding the topic. Debate rages as to the most appropriate definition of the term elder abuse [3] and the complex nature of the problem may prohibit a single unifying clinical definition. Research is still in its infancy and there are few accurate data quantifying the extent of the problem. Meanwhile intervention strategies are fragmentary and uncoordinated [4]. Nevertheless there can be no room for complacency. The field of child abuse has taught us that the process of raising awareness amongst professional groups is an essential overture to the advancement of knowledge and development of sound clinical practice. It is now inconceivable that a clinician would neglect the issue of child abuse but this current knowledge base conceals a tortuous journey along a steep learning curve. The role of the paediatrician in this process has been salutary and those specializing in the care of elderly people now have much to contribute to the rapidly growing study of eider abuse. Workers in the US have proposed the metaphor of a chronic disease, viewing abuse and neglect as a 'geriatric syndrome': a collection of symptoms and signs indicating a range of social and medical pathology [5]. Bridging the gap to awareness of the issue, the geriatrician is therefore admirably equipped to play a central role in the diagnosis and management of the problem.

Setting aside academic discussion centring on the most appropriate definitions, it is of more clinical relevance to deconstruct the problem into its principal constituents. Physical abuse encompasses a variety of activities such as pushing, striking, incorrect positioning, forced feeding and improper restraint. Such actions most frequently lead to injuries such as bruising or abrasions, and less frequently to more serious wounds or fractures. Sexual coercion and assault also form part of the spectrum. Psychological abuse implies the infliction of mental anguish and often accompanies physical abuse. It may take a variety of forms including verbal berating, harassment, intimidation, threats of punishment or deprivation, infantilization, social isolation and threats of institutionalization. Financial abuse reflects the improper use of finances or resources for the gain of the abuser. This may include stealing of money or possessions and coercion into signing contracts. Perhaps peripheral to the clinician's usual agenda, such issues may be intrinsic to a particular presentation. Finally it is essential to consider neglect, the failure of a cater to respond adequately to care needs such as food, shelter, clothing, supportive relationships, freedom from harassment or violent threats and the requirements of activities of daily living. Neglect may be either wilful or non-wilful and further debate surrounds the identity, roles and responsibilities of the carer. Pragmatically the issues for the clinician centre on a vulnerable elderly person and hence the terms eider mistreatment [6] or inadequate care [7] may be more tangible.

There remains a paucity of epidemiological data but British and American studies show a degree of consistency. A study of 2020 elderly persons in Boston established an overall prevalence of 3.2% which subdivided into physical abuse 2.2%, verbal abuse 1.1% and neglect 0.4% [8]. From more recent British work emerged a prevalence of physical abuse of 2.0%, verbal abuse 5.0% and financial abuse 2.0% [9]. Although the potential for further work remains, it is questionable how much additional epidemiological data will advance the debate.

Anecdotal evidence has been powerful in establishing the frail, functionally impaired elderly woman as being at high risk of abuse by a carer who finally cracks under immense strain [2]. Although objective evidence is less persuasive, frailty is likely to be contributory by means of increased vulnerability in the presence of additional risk factors such as cohabitation and cognitive impairment. In reality however any elderly person, irrespective of illness, disability or mental impairment [10] and regardless of sex, racial, ethnic or socioeconomic group [11] may be at risk of abuse. The pathogenesis of an abusive situation may be found more frequently in the characteristics of the abuser [12]. Of particular importance are the presence of physical, functional or cognitive impairment, alcohol or substance abuse and dependence on the elderly person for financial support or housing. The clinician should be alerted to a carer history of violent or abusive interpersonal relationships and should maintain a high index of suspicion for the presence of 'care-giver stress'.

The geriatrician is well accustomed to compiling a differential diagnosis from non-specific and puzzling presentations. Delay in seeking medical help, inconsistent or implausible history, examination and laboratory findings, absence of a designated care-giver at presentation and chronic disease disequilibrium in the presence of an adequate care plan all raise the possibility of abuse or neglect. Armed with a greater awareness of abuse and in the familiar setting of a multidisciplinary team, the geriatrician can therefore proceed to evaluate a given presentation for its abusive or neglectful content. Furthermore the alert clinician can readily screen for such issues by routinely asking elderly patients about their perception of personal safety and experience of physical, verbal or psychological abuse or neglect [5]. Such questions logically form part of an expanded social history. Routine clinical practice calls for full physical, neurological and cognitive assessment of a patient. The clinician must in addition assess the behaviour of the patient in relation to the carer looking for evidence of fear and withdrawal or infantilization. Although the geriatrician is skilled in gleaning corroborative information from a variety of sources, a heightened awareness of abuse will ensure thorough acquisition and informed appraisal of the data thus derived. This is particularly true for interviews with the caret, which must occur in isolation from the patient. Such a process will present many new challenges to clinicians.

The nature of abuse, its chronicity and the ability of the patient to accept or refuse intervention will determine management. This must be based upon the principles of individual choice, autonomy and empowerment wherever possible. When a cognitively competent individual elects to remain in an abusive situation the clinician's role becomes that of counsellor rather than intervenor. Elderly people may value autonomy above personal safety [13]. There are significant resource implications for the successful management of a case once identified. In the US an infrastructure of management resources is available to the clinician. Most States have instituted 24-hour telephone hotlines linking the clinician to Adult Protective Services. These are the primary agencies with legal responsibility and authority to investigate reports of abuse and neglect and to provide services to elderly victims. In all States the clinician is supported by a legislative framework and in the majority reporting is mandatory. The provision of a long-term care ombudsman programme and nurse aide registry in each State provide additional safeguards against abuse in institutional care. Nevertheless, the American model has not been entirely successful. Only one in 14 cases of abuse are currently reported [14] and many physicians may not be aware of the mandatory reporting laws enacted in their State [15]. Indeed the appropriateness of the legislation itself is under scrutiny [16]. The UK model is considerably more rudimentary, reflecting a low level of awareness amongst health-care professionals. Management guidelines have been developed in a haphazard fashion [17] and fail to embody all aspects of the diagnosis [18]. Existing legislation does not lend itself to management of abusive situations although some consideration has been given to the construction of a new framework [19]. We have a long way to go. In 1993 however an organization Action on Elder Abuse was formed. Consultant geriatricians are numbered amongst its multidisciplinary membership, some on Council helping to form policy. The aims of the organization include policy change and practice modification through raised awareness, education, research promotion and the collection and dissemination of information.

The practising geriatrician, working within a multi-disciplinary environment, already has available many of the skills and resources required to confront abuse of elderly people. Adjustments to current history-taking and examination techniques may unveil previously occult social and medical pathology. By equipping themselves, their colleagues and their students with a working knowledge of the issues surrounding abuse and neglect of older people, geriatricians will occupy a key role in the diagnosis of the syndrome and will be well placed to fuel the debate on a cogent strategy for management and prevention. We can learn from the American experience by lobbying for further resources in order to avoid the emergence of unsupported legislative frameworks. It is tempting to view elder abuse purely in statistical terms as a minority problem but the true scale of neglect is largely unknown. It is clear that the issues raised by the diagnosis exhibit many themes common to modern geriatric practice and geriatricians must not omit an opportunity to improve the quality of their patients' lives.

MARTIN VERNON GERRY BENNETT Department of Health Care of the Elderly, London Hospital Medical College, The Royal London Hospital, London E1 1BB


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12. Bennett GCJ. Elder abuse: shifting emphasis from abused to abuser. Geriatr Med 1990;20(5):45-9.

13. Pillemer KA. Ten tentative truths about elder abuse. J Health Home Rehabil Adult 1990; Spring: 465-83.

14. Tatara T. Summaries of national elder abuse data: an exploratory study of state statistics. National Aging Resource Center on EIder Abuse, Washington DC, 1990.

15. Brewer RA, Jones JS. Reporting elder abuse: limitations of statutes. Ann Emerg Med 1989;18:1217-21.

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19. The Law Commission. Consultation Paper 130: Mentally incapacitated and other vulnerable adults. London: H.M.S.O. 1993.
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Author:Vernon, Martin; Bennett, Gerry
Publication:Age and Ageing
Date:May 1, 1995
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