The US Congress during the 70s and 80s held hearings on elder abuse, and reported the magnitud of the problem.³ The American Medical Association in 1992 defined and classified elder abuse and more recently, a panel of the National Academy of Sciences defined elder abuse and neglect as (1) intentional actions that cause harm or create a serious risk of harm (whether or not harm was intended) to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, and (2) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.⁴, ⁵

As early as 1974, the federal government addressed elder abuse in Title XX of the Social Security Act, and Adult Protective Service Agencies were created in multiple individual states. Specific definitions and laws vary by state. A comprehensive summary of state laws is available.⁶

In clinical medicine, recognition and concern for elder abuse dates back to 1975, when the first articles on “granny battering” were published.⁷, ⁸ Elder mistreatment is primarily a social rather than a medical problem, and physicians, especially forensic pathologists, see only the tip of the iceberg of mistreatment. In common with child abuse, the most likely victims of elder abuse are both the most dependent and the least able to complain when abuse occurs. But unlike the young, who have a universal need for total care, the needs of the old are heterogeneous, and age per se does not imply dependency. The change from a healthy independent adult to an elderly individual in progressively greater need of care may not be seen or recognized by the elder, the relatives, the social circle surrounding him or her, or society at large. Individuals may not have, or want, relatives to help with their care, a caregiver may not be clearly defined, needs may not be identified or recognized, and the responsibility for protection from harm or neglect may not be easily adjudicated. Unless an elderly individual is declared incompetent, his or her decisions must be respected, even when those choices provide less than what is considered adequate care or protection.

The National Center on Elder Abuse estimated an incidence of 550, 000 cases of abuse or neglect occurring in domestic settings⁹ in 1996. The true incidence of elder mistreatment is unknown, but estimates calculated from the number of complaints indicate that between 700, 000 and 2.5 million people older than 65 years of age may be abused per year.¹⁰ Estimates of the prevalence of abuse in the elderly range from 2% to 8%, ¹¹, ¹², ¹³ but most experts believe that the prevalence is underestimated, as abuse is both under recognized and underreported.¹⁴ The National Center for Elder Abuse estimated that approximately 84% of cases are not reported.⁹ Despite increased awareness, economic support for the study of elder mistreatment is lacking. In 2002, funding for elder abuse research and programs was one-third that of programs for violence against women and little more than 2% of the funding provided for child abuse programs.¹⁵

Most states require physicians to report suspicious cases of elder abuse (contact information is available by state¹⁶, ¹⁷), but the actual number of physician-initiated complaints is low, and prosecution for not reporting is nonexistent.¹⁰ Physicians may not detect most victims of abuse even though they are seeing them as patients while they are suffering the abuse. Lachs et al.¹⁸ found that more than 60% of elder abuse victims had at least one visit (median of three) to the emergency department in a 7-year period, 15.4% had an injury-related hospital admission, 19.4% an injury-related discharge diagnosis, and most had at least one injury-related visit to the emergency room. A Michigan study showed that of all cases reported as suspicious for elder abuse during a 5-year period, 41% had been brought to attention by someone in the community, 26% by health care providers (not doctors), 5% by
law enforcement personnel, and only 2% by physicians.¹⁹ A 2002 study from a Paris suburb showed that physicians, even though they may see the victims repeatedly, rarely initiate reporting.²⁰ A number of barriers prevent adequate reporting of suspicious cases. Physicians may be afraid of opening a Pandora’s box and of doing more harm than good when reporting cases¹³; they may be ignorant of reporting laws, unaware of resources, constrained for time, or concerned about offending their patients. Abuse is also underreported by victims themselves. For victims, barriers to reporting abuse may include a lack of recognition of the abusive situation, social isolation, the need to protect the abusive caregiver when the person is a relative, a sense of guilt or embarrassment for a situation that is considered private, feeling responsible for the abuse, and fear of retaliation from the care provider or the perceived threat of institutionalization as a final solution for the abuse.²¹, ²² In the majority (90%) of cases, the patient was abused by a person known to the victim in the domestic setting; in half of the cases, the perpetrator is either a son or a daughter, and in one of five cases, the spouse is the abuser.^22.b Neglect is the most common form of elder mistreatment, ⁹ and its recognition is the most challenging, because it depends on poorly defined social expectations. Questions and an impetus for global soul-searching arose after several thousand elderly deaths followed a heat wave in Europe in the summer of 2003.²³ Most deaths were due to dehydration and other complications of hyperthermia and resulted when elderly persons were left at home unattended while their relatives left the city for summer vacation. Abandonment is a type of neglect, but application of general principles to specific situations is challenging. The American Health Care Association has provided guidelines on elder abuse, ²⁴ and specific guidance for abuse in institutions is available from the Interpretive Guidelines for Surveyors.²⁵

Analyses of proven cases have identified risk factors for abuse or neglect. Risk factors have been classified regarding characteristics of the victim or characteristics of the perpetrator.²⁶, ²⁷

Aging is accompanied by a progressive loss in function, and as function declines, the boundaries between health and disease become blurred. The three most common types of accidental traumatic injuries in the elderly are falls, injuries suffered as drivers or passengers of motor vehicles, and those caused when pedestrians are hit by cars. Most falls are from a standing position, not from great heights, and 10% to 25% of them may result in significant
injury. Of all the falls resulting in death, 70% occur in geriatric patients, ³⁷ and injuries resulting from falls are the sixth leading cause of death in the elderly.³⁸ A study with a follow-up period of a year found that elderly individuals were four times more likely than younger adults to die after a fall.³⁹ More than one-third of all cross-walk fatalities occur in the elderly.¹ Reasons for the increased prevalence of pedestrian accidents among the elderly include eyesight and confusion about traffic regulations.³⁹

Some of the physiopathologic changes of aging may simulate or obliterate signs of mistreatment.¹, ²², ³⁷ Specifically, the following have been noted with aging:

To diagnose abuse, clinicians must consider it in the differential diagnosis. The literature emphasizes the need to educate physicians in the detection of elder abuse and in the laws for mandatory reporting. According to some investigators, ⁴³ the current state of research in elder abuse is where child abuse was 30 or 40 years ago. There is no general agreement among the medical community regarding what constitutes abuse or neglect, there is no gold standard for the diagnosis, ⁴⁴ and the umbrella term “inadequate care” has been used.^22.b The most recognizable forms of abuse are physical abuse and serious neglect. Physical abuse is the deliberate infliction of harm, and includes not only striking with objects, most commonly the perpetrator’s hands, but also rough handling, pushing, force-feeding, and using physical or chemical restraint. Neglect may be active or passive. It is defined as the failure of the caregiver to provide for the needs of the elder (hydration, nutrition, clothing, and daily living activities) as well as to protect from harm (safety measures). Physical findings are not pathognomonic of abuse or neglect, and physical or emotional illnesses and accidental injuries may show signs similar to inflicted injuries or neglect. For example, an elderly individual was admitted to the hospital with an inflicted cardiac contusion masquerading as a myocardial infarction by clinical history and laboratory analysis⁴⁵; another case report was that of a woman presenting with repeated bouts of hypoglycemia as the result of Munchhausen by proxy.⁴⁶ When the physician suspects elder abuse on the basis of clinical history or physical findings, the diagnosis may be aided by observing the victim, the care provider, and their interaction, including the body language and eye contact, and by comparing the clinical history given by the patient with information provided by the caregiver.¹³