Dr. Steve Tam of UC Irvine explains the growing issue of elder abuse and why it is likely to grow in the coming decades. Know the signs of different types of abuse and how to respond to suspected cases.

1. Steven Tam, MD
Assistant Clinical Professor
UCI Internal Medicine/Geriatrics

2. No disclosures

3. Objectives
 Describe the definitions, categories,
impact and prevalence of Elder Abuse
and Neglect
 Recognize historical and physical signs
of elder abuse and neglect, and review
other markers
 Discuss proper documentation of
findings in suspected elder abuse and
proper reporting procedures.

5. The Case of “Just a Hygiene
Problem”
 78 year old woman, who lives with her
son (primary caregiver), history of
diabetes, difficulty walking (spinal
stenosis?) – wheelchair bound, chronic
edema
 Brought in to the ER for altered mental
status, found to have a UTI

6. The Case of “Just a Hygiene
Problem”
 Skin not checked until the patient
transferred to the ward floor
 The RN notifies the Attending regarding
the skin
 The Attending says “just a hygiene
problem” to nurse, in front of all other
learners.
 Nurse calls APS.

7. What should’ve be done???

9. What does this population
longevity mean?
 As Age increases, so do the number of
health, social, and psychological isses that
make older people more dependent:
Chronic illness, More medications
Depression & Dementia
Quantity and Quality of social support/situation
 Decrease in Reserves
 Increase in vulnerability to Abuse
Difficulty defending self, more likely to get
injured

10. National Elder Abuse Incidence Study

13. Definitions
 From National Center on Elder Abuse:
 “Any knowing, intentional, or negligent act by a caregiver
or any other person (paid or unpaid) that causes harm or
a serious risk of harm to a vulnerable adult.”
 PC 368[b][1]:
Any person who knows or reasonably should know that a
person is an elder or DA and who, under circumstances
or conditions likely to cause GBH or death .....having the
care or custody of any elder or DA, willfully causes or
permits the person or health of the elder or DA to be
injured, or willfully causes or permits the elder or DA to
be placed in a situation in which his or her person or
health is endangered.....

14. In California: an “Elder is…”
 65 years and older
 ALSO don’t forget:
“Dependent adult” is 18-64 years AND
“who has physical or mental limitations that
restrict his or her ability to carry out normal
activities or to protect his or her rights,
including, but not limited to, persons who
have physical or developmental disabilities,
or whose physical or mental abilities have
diminished because of age.” (W&I Code
15610.23)

15. Types of Elder Abuse:
 Physical Abuse:
 use of physical force that may result in bodily injury, pain or
impairment
 Financial Abuse:
 Illegal or improper use of an adult’s resources through deceit,
theft, coercion, fraud, undue influence or other means
 Emotional Abuse:
 Infliction of anguish, distress or intimidation through verbal or
non-verbal acts or threats
 Sexual Abuse:
 Non-consensual sexual contact, harassment, inappropriate
comments or threats. Consider non-consensual if the person
does not make, or incapable of making an informed choice
 Neglect:
 Failure to provide basic neecessary care or services when such
failure may lead to harm or risk of serious harm

16. Sexual Abuse Case
• 81 year old gentleman cognitively impaired
is allegedly sexually abused by a hired
care giver at home (for respite) while wife
is attending to other matters. Abuser
admits to performing the acts, but says that
the gentleman consented to it.
• Our VAST team was asked by law enforcement
to assess the capacity of the gentleman
• He had a MOCA score of 6/30. Upon further
history with wife, she revealed, he was
diagnosed with dementia years prior.

17. Types of Abuse
 Self-Neglect: (often included within neglect)
 Abandonment:
 A Caregiver’s desertion places the adult in serious risk of
harm
 Involuntary Seclusion(Isolation):
 Confinement, restriction or isolation of an adult for the
convenience of a caregiver or to discipline the adult
 Wrongful restraint:
 The use of a physical or chemical restraint to limit the
movement of an adult for the convenience of the caregiver
or to discipline the adult.
 Abduction:
 Removal from this state and the restraint from returning to this
state, of an elder or dependent adult who does not have the
capacity to consent

19. Incidence and Prevalence:
 True Numbers not known:
○ Difficulties:
 Reluctance to admit
- Shame, fear of losing independence
- Fear of being moved
 Older adults may quietly disappear from society without much
inquiry
 Maybe too incapacitated to report
 Signs of abuse maybe missed or mistaken for “usual aging.”
 National Elder Abuse Incidence Study, 1998:
○ 236,000 reports of seniors abused at home in one
year
○ 50,000 reports of abuse in nursing homes in one
year

20. Elder Abuse
 Estimated that 4-10% of people 65 or older
are victimized by relatives, caretakers or
strangers.
Up to 4.3% of older adults physically abused
annually
It is not known how big the problem exactly is!
 Physicians are mandated to report
suspected abuse
 <2% of APS reports are filed by physicians.
Lack of understanding of reporting mechanisms
represented the most significant obstacle

21. Elder Abuse Incidence
 FOR EVERY REPORT OF
ABUSE….
 55 GO UNREPORTED
National Elder Abuse Incidence Study, 1998

22. Types of Elder Abuse
• Neglect 49%
• Emotional 35%
• Physical 30%
• Financial 26%
• Abandonment 4%
• Sexual 1%
National Elder Abuse Incidence Study, 1998National Elder Abuse Incidence Study, 1998

23. Elder Abuse – California
Incidence
• 47,000 reports of abuse
• “235,000” abused elders, when you
considered unreported cases
• CA APS Report 1997
• Approximately 110,000 reports of abuse
were received statewide during State
fiscal year 2006-07
• CA APS Report 2007

24. APS serves adults with physical or mental impairments, as well as the
elderly. Elder and Dependent Adult Victims – Orange County, APS 2010
report
YEAR REPORTS ELDERS DEPENDENT
ADULTS
2010 7422 72% 28%
2009 6870 71% 29%
2008 6567 70% 30%
2007 6355 70% 30%
2006 5650 71% 29%
2005 5418 70% 30%
2004 5219 69% 31%
2003 5049 69% 31%
2002 5273 71% 29%
2001 4973 72% 28%
2000 4503 77% 23%
Abuse by others Frequency
Physical 16%
Sexual 2%
Financial 29%
Neglect 27%
Abandonment 1%
Isolation 2%
Abduction 0.2%
Psychological 24%

25. Dependent Adult Abuse
 Little known about the abuse of
dependent adults
 1999 - the federal government convened
a group of experts to identify
○ 4 to 10 times higher risk of becoming victims of
abuse
○ 10 times higher risk of being sexually assaulted
○ Less likely to report abuse
○ Lower rates of police follow-up and successful
conviction of perpetrators
Victimization of Dependent AdultsVictimization of Dependent Adults
Conference, 1999Conference, 1999

27. Risk Factors – the abused
 Over 80 years are 2-3 times more likely
to be abused
 Female: in 2/3 of all reports, victim is a
woman
 Presence of cognitive impairment
 Dependent, Dementia, Physically
Aggressive, Verbally Abusive

28. Risk Factors – the abuser
 Depressive symptoms
 Financial ties
 Felt they had a poor emotional status and
had role limitations in activities and/or
work as a result of caregiving role
 People with inadequately treated mental
health and/or substance abuse problems
are more likely to be abusive
 People who feel
stressed/burdened/resentful are more
likely to be abusive

29. Risk Factors – the context!
 People with inadequately treated mental
health and/or substance abuse problems
are more likely to be abusive
 People who feel
stressed/burdened/resentful are more
likely to be abusive
 Providing care for an older adult who is
physically combative and/or verbally
abusive
 Financial, Marital, Employment, Change in
Elder/Caregiver Dependency Relationship

30. Risk Factors-Special Issues
 Adults with Disabilities
○ 44% of those age 75 years and over living in the
community reported having a limitation in their usual
activity due to a chronic condition.
○ In 1989 survey of 245 women with a disability: 40%
reported being abused; 12% reported being raped.
○ Survey of 90 men and women with a disability – 40%
experienced financial abuse.
 Dementia
○ Physical Abuse: 9.3%
○ Psychological Abuse: 41.8%
○ Caregiver Neglect: 16.9%
○ Any Abuse: 47.3%
 Long-term Care Facilities
Screening for Abuse and Neglect of People with Dementia
Wiglesworth, Mosqueda, et al. Journal of American Geriatric Society, March 2010

31. Risk Factors-Special Issues
 Dementia
Studies estimate any where from 1-13% for
those over age 65
Memory loss, other cognitive loss, functional
loss
 Undue Influence
“The substitution of one person’s will for the
true desires of another.”
Excessive pressure
Usually for financial gain

33. Consequences of Elder Abuse
 Financial—Income, savings, home
 Emotional—Feelings of self-worth,
safety
 Physical—Compromising health that
might already be vulnerable
 Cognitive—Depression, dementia
 Social—Family dynamics, community
safety, societal expectations of old age

34. Consequences of Elder Abuse
 Elder financial abuse costs older Americans more than $2.6
billion per year and is most often perpetrated by family
members and caregivers, according to the MetLife Mature
Market Institute (MMI) report, Broken Trust: Elders, Family and
Finances, MetLife Mature Market Institute, Broken Trust: Elders,
Family and Finances, March 2009.
 Physical and emotional recovery may take longer in older
adults. Sometimes, they never recover at all.
 Researchers at Baylor College of Medicine found a higher
prevalence of depression (62% vs 12%) and dementia (51% vs
30%) in neglected and self-neglecting patients compared to
patients referred for other reasons.
 Social consequences of abuse include emotional and financial
toll on family members, divisiveness between family members,
spreading crime in the community, lowering expectations for
what old age should be like

35. Consequences of Elder Abuse -
Testimonies
“She picked me up at the hospital. I said,
‘I’ll be so glad to get home.’ She said,
‘You’re not going home. I’ve moved you in
with me.’
“You don’t want to get close to another
person and call them your friend. You’re
afraid of it.”
○Mrs. Crewey, at age 90, lost her home and furniture to, and
had her bank account compromised by, her good friend
○(Elder Justice Now campaign by WITNESS and National
Council on Aging)

36. Consequences of Elder Abuse -
Testimonies
“I thought our marital problems were all
my fault... He had me so totally
brainwashed and convinced that I was
crazy, lazy, stupid, and worthless, that I
was a walking zombie.
I spent every waking hour trying to be a
better wife and mother but the harder I
tried, the worse I became.”
○Older woman in WI who had been married for 24
years to her abuser
○(Brandl & Spangler, National Clearinghouse on Abuse in Later Life,
“Golden Voices” 2003)

38. Role of the Health Care
Provider
 Barriers to detecting/reporting Elder
Abuse
Lack of knowledge
Legal concerns
Discomfort in showing ignorance
Sense of powerlessness
Fear of offending patient or the abuser
Minimization and denial
Reluctance to become involved
Time constraints

39. The role of the Health Care Provider–
Do we screen for elder abuse?
 Are you afraid of anyone in your family?
 Has anyone close to you tried to hurt or
harm you?
 Has anyone close to you called you
names or put you down or made you
feel bad recently?
 Does someone in your family make
you stay in bed or tell you you’re sick
when you know you aren’t?
 Has anyone forced you to do things
that you didn’t want to do?
 Has anyone taken things that belong to
you without your OK?
*Sengstock-Hwaleck, M., 1987. “A Review and Analysis of Measure for
the Identification of Elder Abuse.” Journal of Gerontological
Social Work 10 (3/4):21-36

40. The role of the Health Care Provider–
Do we screen for elder abuse?
 • The USPSTF found insufficient
evidence to recommend for or against
routine screening …of older adults or
their caregivers for elder abuse.
 ACOG and AMA45
recommend that
physicians routinely ask elderly patients
direct, specific questions about abuse
- Am Fam Physician. 2004 Aug 15;70(4):747-751.

41. The Role of the Health Care
Provider
 Do look for clues in the patient that may
make you think of abuse:
○ Flat affect, listless, apathetic
○ Hesitant, evasive
○ Fearful, anxious
○ Hostile, aggressive
○ Uncooperative, suspicious
 Abrupt change in a known patient

42. The Role of the Health Care
Provider– Injuries, Red Flags
 Bruises, Fractures, Pressure Sores
 Location and shape
 Multiple injuries
 Various healing stages
 Suspicious explanation
 Delay seeking care
 Circumstances/Events leading up to the alleged
abuse (inconsistent stories)
 Lack of concern on the part of the caregiver
 Interactions between patient and caregiver

43. Role of the Health Care
Provider
 History
 Physical
 Mental Status Exam
 Laboratory Exam
 How do we use this when thinking about
Elder Abuse?

44. Role of the Health Care
Provider
 Keep in mind Red Flags
 Open-ended questions
proceed to more specific questions
Avoid leading questions
 Separate the victim from the caretaker,
if needed
 Keep in mind cognitive ability/capacity
When to take it seriously? When unreliable?

45. Clues on Physical Exam: Neglect
 Pressure sores, Poor hygiene
 Unkempt appearance, Poor foot care
 Low weight, Dehydration
 Body language of patient
 Types of InjuriesTypes of Injuries
 Bruises
 Fractures
 Burns
 What to look for:
○ Location
○ Hx consistent with exam?
○ Old injuries
○ Delay in seeking care

46. Role of the Health Care
Provider
 Mental Status and Capacity
Evaluation and assessment:
○ History suggestive of loss of memory, other cognitive
domains, function
○ office tools: Mini-Mental State Exam, Mini-Cog, Six-
item screen, MoCA
 Clinician’s role: observe, provide opinion,
not make a specific diagnosis

47. The Role of the Physician –
Markers: Bruises
 Most common
 Hard to tell what’s
abuse and what’s not
 Age-related changes
 Medications
 Dating by color
 Multiple stages of
healing
 History consistent with
injury?
 Location

48. Bruising Study
- WIGLESWORTH ET AL. JAGS JULY 2009–VOL.
57, NO. 7

49. Location of Bruises Caused by Abuse

50. Bruising Study con’t

51. When is bruising suspicious trauma
versus accidental trauma? Which looks
more like abuse: A or B?
A B

52. Strangulation
 Difficulty breathing
 Hoarse voice
 “Sniffing position”
 Ask:
○ Did he/she
○ choke you?
○ Did you
○ lose consciousness?
○ Can be a medical emergency

53. Fractures
 Accidental or abusive
 May be due to medical condition
○ Osteoporosis
○ Cancer
 Many types of fractures
○ Correlate fracture type to mechanism of injury
○ Spiral fractures or fractures with a rotational
component are suspicious
○ Sites other than hip, vertebra, or wrist may
more likely be markers of abuse.

54. Burns
 Persons over the age of 65 have 2X the
national average death rate due to burns
 Seen in physical abuse, neglect and self
neglect
 Limited studies reveal that between 36-70%
of burns in adult abuse were due to abuse or
neglect (Bowden 1998; Burns 1998)

55. Pressure Sores
 Can be common
 Often preventable
 Usually treatable
 Things to think about
 Nutritional status
○ Able to get own food?
○ Able to feed self?
 Mobility status
○ Moved? Repositioned?
○ Tied down in one position
 Medical Followup

56. Are all pressure sores signs of
abuse???
 Pressure Sores: what an expert may be
able to tell you
Whether this was a high risk situation in
which a pressure sore may have been
inevitable
Whether this is typical in appearance
Whether this is typical in location
Whether treatment was sought or carried out
appropriately

57. Role of the Physician -
Laboratory tests
 Malnutrition
 Dehydration
 Bleeding times
 Medication levels

58. Medication Review: their role in
mistreatment
Can be:
○Overused: to sedate, cause
delirium
○Underused: to reduce mobility
(e.g., L dopa), cause illness
exacerbations (insulin, inhalers,
antibiotics)
○Misused: used for unapproved
effects (antihistamines to sedate)

59. Role of the Health Care
Provider
 Other Red Flags/clues
Sexual Abuse: bruising of the breasts,
unexplained STDs, perineal and inner thigh
bruising, inappropriate modesty, fear of
touch
Emotional abuse: withdrawn, evasiveness,
hostility
Neglect: absence of medical devices
Financial: not following medical regimens,
failure to get medicines, disparity between
assets and condition

60. Role of the Health Care
Provider
 Don’t forget the caregiver!
Majority = adult children & partners
Clues on observation:
○ speech, tone, touch interactions
○ stands watch, monitors interactions
○ overly protective or lacking concern
○ answers questions directed to patient
○ continually tests limits of the visit
○ refuses to leave room when asked
 Hostile and surly to staff

61. Role of the Health Care
Provider– Elder Abuse
 Proper Documentation/Medical Record
should include:
Date, time
Identifying information
Patient’s statements
Findings on physical examination
Medical opinion/diagnosis
Treatment record
Follow-up and referral plans
Reporting requirements fulfilled

62. Role of the Physician – Elder
Abuse
 Reporting
California:
○ Health practitioners are mandated reporters
○ legal protection of reporter
○ name not disclosed to victim, family, abuser
○ Requirements when abuse suspected:
abuse does not need to be confirmed
telephone when practically possible
formal written report [SOC 341], mail or fax within 2
working days
○ Financial institutions
Failure to report: jail, fine or both!Failure to report: jail, fine or both!

64. After the report
 APS involvement
Appropriate cross-reporting and referrals to
agencies to assist/investigate
○ Long-term care ombudsman
○ Family Caregiver Alliance
○ Law enforcement agencies
○ Emergency planning

65. After the report
• Adult day healthcare
• Meals on Wheels
• Senior centers
• Support groups
• Transportation
• Mental health
• Multipurpose senior
services program
(MSSP)
• Home equipment
• In home support
services (IHSS)
• Home repair

66. What APS May do -
• Recommend conservatorship
• Call the police
- Request a 5150 evaluation
- File a report
• Suggest, persuade, and bargain with the
client to get help
• Arrange for case management
• Work collaboratively with support
systems

67. What APS May NOT Do
• Enter the home without permission
• Remove the person from their
residence against their will
• Force a client to accept services

69. UCI Experience

70. UCI Experience
 During the calendar year 2011,
Orange County Elder Abuse Forensic
Center met 52 times (every week)
○ assisted with 78 new elder abuse/neglect
cases and reviewed 126 updates.
○ The Vulnerable Adult Specialist Team (VAST)
conducted 15 high intensity in-home medical
assessments, 19 high intensity in-home
psychological evaluations, performed 9
medium intensity medical record reviews,
and made 3 low-intensity doctor-to-doctor
consultations.

71. The Future
 What is our responsibility as a society?
 What role could/should the government
play in this issue?
 What policies currently exist that either
allow or prevent elder abuse?
Unifying terminology and definitions/policies
 Research:
How do we better screen and assess issues
such as capacity, forensic markers such as
bruising and sores?

72. Questions?Questions?
www.centeronelderabuse.orgwww.centeronelderabuse.org