Elder abuse, self-neglect, and related phenomena

INTRODUCTION — The problems of elder abuse, self-neglect, and related phenomena are common [1]. Health professionals who take care of older adults have a legal and moral obligation to identify and report suspected victims to appropriate authorities and so initiate investigation and needed interventions.

This topic discusses elder abuse, self-neglect, and related problems as addressed in civil statutes or governmental regulations, but not criminal statutes.

DEFINITIONS — Definitions vary among jurisdictions and authorities who have written on these phenomena [2-5]. The National Center for Injury Prevention and Control, Division of Violence Prevention, an organization within the Centers for Disease Control and Prevention (CDC), has published uniform definitions for elder abuse, self-neglect, and related phenomena [6]. We will use these definitions in this chapter.

●Older adult/elder – Persons 60 years of age or older (in some jurisdictions, the age is 65).

●Elder abuse – "An intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult." This has also been called elder mistreatment in some literature, but elder mistreatment is not mentioned in the uniform definitions supplied by the CDC.

Elder abuse, as defined in these uniform definitions, includes physical abuse, sexual abuse, emotional/psychological abuse, neglect, and financial abuse/exploitation. All of these involve a perpetrator who is in a trust relationship with the older adult.

•Physical abuse refers to the intentional use of physical force.

•Sexual abuse refers to behaviors toward an older adult that are forced, unwanted, or not consented to. If an older adult is unable to give effective consent for the sexual behavior due to incapacity, it is sexual abuse. Verbal or behavioral sexual harassment has been included in this definition.

•Emotional/psychological abuse includes verbal or nonverbal behavior perpetrated by a caregiver or other person that results in anguish, mental pain, fear, or distress to the victim.

•Neglect refers to a failure of a perpetrator in a trust relationship with the victim to protect that older person from harm or provide for the essential needs of that older person.

•Elder financial abuse/exploitation refers to the nonconsensual appropriation of an older person's resources, for the benefit of someone other than that older person, by a perpetrator in a trust relationship with the victim. Elder financial fraud and scams is a separate category where the acts are "perpetrated by a stronger or someone else outside of a conventional or legally defined trust relationship" [7].

Phenomena related to elder abuse:

•Self-neglect – The uniform definitions referred to above do not attempt to define self-neglect. One definition of self-neglect is failure of an older adult to provide for their own care and protection. Self-neglect is said to be a failure of the older adult to thrive in their environment due to this failure to self-care and self-protect [8].

Most experts define self-neglect as excluding cases of intentional self-neglect where the older adult who has the capacity to make and carry out decisions regarding self-care and protection and who freely and knowingly chooses not to provide adequately for such care and protection [9]. Other definitions include intentional self-neglect [10]. When an older adult is neglecting their needs, an effort is made to determine if that person is making a free and knowing choice to do so, with intervention potentially necessary when they are not able to make that choice.

•Abandonment – "The desertion or willful disregard of an older adult by anyone having care or custody of that person under circumstances in which a reasonable person would continue to provide care and custody."

Other definitions:

●Consensual – This refers to decisions freely and knowingly made by a person with capacity to make such decisions.

●Capacity for self-care and protection – Ability to make and carry out decisions regarding one's self-care and protection. It has two aspects: decisional capacity and executive capacity [11].

•Decisional capacity – The ability to [12]:

-Communicate a choice

-Understand the relevant information

-Appreciate the situation and its consequences

-Reason about treatment options

•Executive capacity – The ability to execute one's decisions [13].

●Vulnerable elder – An older adult with an impairment, usually cognitive, that renders them unable to arrange for adequate self-care and protection; a vulnerable elder is one who has diminished capacity for self-care and protection as defined above [5].

●Caregiver or caretaker – A person or entity who has a duty, or whom it would be reasonable to conclude has taken on a duty, to care for and protect an older adult.

●Polyvictimization – Polyvictimization occurs when a person aged 60 or older is harmed through multiple co-occurring or sequential types of elder abuse by one or more perpetrators, or when an older adult experiences one type of abuse perpetrated by multiple others with whom the older adult has a personal, professional, or care recipient relationship in which there is a societal expectation of trust [14].

●Multidisciplinary teams – A team of professionals from various disciplines most commonly medicine, nursing, Adult Protective Services (APS), law enforcement, and social work that works collaboratively to intervene and resolve elder mistreatment cases. The teams may include ethicists, prosecutors, civil attorneys, and ad hoc experts to address case-specific issues.

REGULATORY AND SUPPORT SERVICES (UNITED STATES) — All states and territories of the United States, including the District of Columbia, have enacted legislation providing for protection of elders found to be abused, neglected, and financially exploited. In addition, most have statutes or regulations specifically providing for protection of older adults from self-neglect [15].

Community-dwelling older adults may be offered resources and protection in the United States by state Adult Protective Services (APS) agencies. These agencies receive and investigate allegations or complaints, and provide social, legal, medical and material interventions to help the victims. This offer of help extends to older adults found to be in a state of elder abuse or self-neglect, whether or not the older adult is vulnerable or cognitively impaired. APS does attempt to facilitate the accomplishment of essential needs for the health and welfare of the victim.

The Long-Term Care Ombudsman programs (LTCOP) provide protection to older adults in institutional settings in all states. They receive complaints and advocate on behalf of long-term care residents. The state LTCOP may have authority to investigate and intervene as needed, or it may refer the case to another agency (an APS agency or licensing agency for the involved facility) [16].

APS and LTCOP agencies are designed to protect older adults from mistreatment by non-strangers, such as family members, non-family caretakers, or employees of the facility where older adult victims reside.

EPIDEMIOLOGY

Prevalence — Prevalence estimates of elder abuse vary widely, depending on definitions, populations, and settings and the means of ascertaining abuse (surveys, self-reports to regulatory agencies, etc). Elder abuse is often undisclosed and prevalence data are likely underestimations. The highest rates of elder abuse are in women and in persons 80 years of age and older. The abuser is a family member (usually a spouse or adult child) in approximately 90 percent of cases [4,17]. Other prevalence data include:

●In a systematic review of elder abuse from 2015, prevalence for abuse in North and South America was reported to range from 10 percent in cognitively intact older adults to 47 percent in adults with dementia [18].

●A systematic review from 2008 found that 6 percent of older people surveyed in a wide range of countries (including European countries, Korea, the United States, and Canada) reported abuse [19]. Psychological abuse was reported by nearly one-fourth of older people who were dependent on caregivers.

●In 2005, 41 percent of community-residing Medicare beneficiaries over 65 years of age had difficulty performing activities of daily living (ADLs) or instrumental ADLs (IADLs) and potentially needed support from paid or unpaid caregivers [20].

Community settings — Data regarding elder abuse and neglect in the community are somewhat limited due to differences in definitions and data collection across the different jurisdictions in the United States. Lack of training in recognition of elder abuse and neglect, as well as reluctance to report due to fear of retaliation, a desire to protect the abuser, a fear of being removed from their home, or lack of cognitive ability to report the abuser also reduces the number of cases reported [21].

In general, studies have confirmed the expectation that cases of abuse and self-neglect are underreported to Adult Protective Services (APS) and that self-neglect is the most common condition among reported cases. Some estimates of the prevalence of elder abuse in the community range from 2 to 10 percent [22]. Reports of several studies are as follows:

●The National Center on Elder Abuse (NCEA) surveyed all United States APS agencies in 2004 [3]. Among slightly more than 250,000 reports involving adults over 60 years of age and older, self-neglect was the most common type (39 percent), followed by caregiver neglect (21.5 percent) and financial exploitation (14 percent).

●The National Social Life, Health and Aging Project, a nationally representative study in the United States, asked community-living older adults (aged 57 to 85) about experiences of elder abuse [23]. Among 3000 survey respondents, 9 percent reported verbal mistreatment, 3.5 percent reported financial mistreatment, and only 0.2 percent reported physical mistreatment.

●The National Elder Mistreatment Study published in 2010 showed that 1 in 10 adults greater than 60 years of age reported emotional, physical, or sexual mistreatment or potential neglect (defined as a need for assistance that is not being addressed) in the prior year [24].

●In a systematic review of physical abuse, neglect, self-neglect, and exploitation from 2015, prevalence for elder abuse and self-neglect in North and South America was reported to range from 10 percent in cognitively intact older adults to 47 percent in adults with dementia. Estimates for other regions ranged from 2 to 60 percent [18].

●In a survey of 220 family caregivers of British older adult patients newly referred for dementia, 34 percent reported abusive behavior "at least sometimes" (most commonly verbal) and only 1.4 percent acknowledged occasional physical abuse [25]. Another study of 129 persons with dementia and their caregivers detected mistreatment in nearly half (47.3 percent of sample, with abuse categorized as psychological only for 60 percent, neglect 20 percent, and some physical component 20 percent); participants had been informed prior to study consent that suspected elder mistreatment would generate mandated reporting [26].

In a review of 18 articles of community-based surveys of elder abuse, the prevalence of 10 or more instances within a year of physical abuse had a mean of 2.8 percent, sexual abuse 0.7 percent, financial abuse 4.7 percent, emotional/psychological abuse 3.3 percent, and neglect 3.1 percent [1].

●A meta-analysis of 52 elder abuse prevalence studies published between 2002 and 2015 from around the world showed the global prevalence of elder abuse and self-neglect as being 15.7 percent per year. In this study, neglect and self-neglect were reported together. Geographical differences were found, with Asia at 20.2 percent, Europe at 15.4 percent, and the Americas at 11.7 percent [27].

Institutional settings — In the United States and other countries, large numbers of persons are receiving long-term care services at nursing home or some form of assisted living where help with activities of daily living are given. Such persons tend to be older, have functional limitations, and heavy disease burdens [28].

Nationwide collection of data on complaints of institutional elder mistreatment is limited. State Long-Term Care Ombudsman programs (LTCOP) are federally mandated to report data via the National Ombudsman Reporting System (NORS) [29-31]. The state LTCOP may not receive reports of institutional elder mistreatment that are directed to the agency that licenses and regulates the facility [32]. Additionally, underreporting by the facilities is suspected. Supporting this suspicion is the fact that most complaints to the state ombudsman programs are filed by facility residents, family, or friends rather than by facility personnel.

Besides the risk to residents of abuse from staff, there is sometimes maltreatment from other residents. Poor staffing, negligence in the management of resident behaviors, or failing to exclude dangerous residents from the resident population may result in abuse from other residents.

In a systemic review of 26 studies from the United States and other countries , the estimated frequency of resident-to-resident aggression in long-term care facilities was 12 to 23 percent. In the included qualitative studies, the number of care staff reported observing resident-to-resident aggression ranged from 18.7 to 98 percent. Physical and verbal abuse were the most commonly reported, but sexual abuse, psychological abuse, financial abuse, invasion of privacy, and other aggressions were also reported [33].

ADVERSE CONSEQUENCES — Several prospective studies have identified a significant association between elder abuse and increased risk for morbidity and mortality risk, although autopsy data are often not available to determine the cause of death [34]. Representative studies include the following:

●A prospective cohort study of community-dwelling adults age 65 and older, with nine years of follow-up, found that referral to Adult Protective Services (APS) for physical abuse, neglect, self-neglect, and financial exploitation was associated with shorter survival after adjusting for other factors associated with increased mortality [35]. The risk of death was increased threefold (odds ratio [OR] 3.1), compared with other members of the cohort, for those who experienced elder abuse and somewhat less (OR 1.7) for those identified with self-neglect.

●In another cohort study of older adults followed for a median of seven years, reported self-neglect increased the risk of mortality almost sixfold in the first year, and risk remained increased but at a lower rate after one year (hazard ratio [HR] 5.82 and 1.39 respectively) [36]. Reported elder abuse was also associated with an increased mortality rate (HR 1.39). The increased mortality risk was seen in patients at all levels of cognitive and physical functioning.

●Among community-dwelling women ages 50 to 79 participating in the Women's Health Initiative, women who reported physical abuse in the prior year had the highest age-adjusted mortality rate, and women who reported either physical or verbal abuse also had higher mortality risk than women who did not report abuse [37].

The health consequences of self-neglect by vulnerable older adults who are incapable of adequate self-care and protection may be untreated medical conditions, poor nutrition, and other health risks unless appropriate intervention takes place [38].

Elder abuse and self-neglect may also involve administration of inappropriate medications, inappropriate doses of medications, or failure to monitor drug therapy [39]. This can occur in both community and institutional settings [39]. Medication regimen complexity may be associated with nonadherence in self-neglecting older adults [40].

Financial exploitation is emerging as a risk factor for death. In an analysis of five-year all-cause mortality in cases reported to Texas APS, individuals exposed to financial exploitation, caregiver neglect, or polyvictimization had lower survival rates than individuals exposed to physical or emotional abuse [41].

Elder abuse can have a severe impact on the vulnerable older adult who has poor social, financial, and functional reserves. Elder abuse is associated with multiple hospitalizations, medical nonadherence, pressure ulcers, untreated psychiatric and medical illness, and falls. An incident of financial exploitation may cause the older adult victim to lose independence and lose needed support, and these losses may result in morbidity and perhaps death [34].

Risk factors — Several risk factors have been identified, but the strength of evidence varies. In a review of population-based studies of risk factors based on characteristics of the victim, perpetrator, relationship, and community, strong risk factors were victim functional dependence; victim poor physical health; victim cognitive impairment; victim poor mental health; victim low income; perpetrator mental illness; perpetrator substance abuse; and perpetrator dependence on the victim. Social embeddedness/social support lowered the risk of elder abuse. However, a shared living arrangement is a risk factor for physical and financial abuse [1].

Representative research results include:

●Age – Advanced age was associated with substantiated self-neglect in a prospective study of 2812 community-dwelling adults older than 65 who had been the subject of reports to APS agencies in Connecticut [42].

●Male sex – Male sex was a significant predictor of substantiated reports of self-neglect in a cohort of older adult patients in urban Connecticut [42].

●Disability – Self-neglect was associated with impairment in instrumental activities of daily living (ADLs) in a study comparing 100 community-living older adults referred by APS for self-neglect and 100 matched adults from a community geriatrics clinic [43]. Residents of long-term care facilities who have disabilities in self-care (eg, eating, toileting, transfers, and mobility) are at increased risk for morbidity and mortality from neglect [32].

●Dementia – Dementia increases the risk for abuse, neglect, and financial exploitation as well as self-neglect [26,34,44,45]. Behavior problems such as vocalizations and aggression increase the risk of abuse by caregivers. Dementia was more prevalent among older adults referred to a multidisciplinary geriatrics clinic for self-neglect compared with older adults referred for other reasons (51 versus 30 percent) [46]. Cognitive impairment was found to be a predictor of a substantiated report of self-neglect [42]. Harm as a result of self-neglect was found to be best predicted by poor performance in the domains of verbal recognition memory, executive function, and conceptualization [47].

●Depression – Depression may cause a loss of capacity for self-care and protection and is associated with elder abuse [34] as well as self-neglect [42]. The prevalence of depression was significantly higher for patients referred to a multidisciplinary geriatric clinic for self-neglect compared with those referred for other reasons (62 versus 12 percent) [46].

●History of hip fracture and history of stroke – These historical factors have been found to be associated with an increased risk of self-neglect in community-dwelling older adults [42].

●Social isolation [22,42,48] – Feelings of loneliness have been associated with self-reported elder abuse as well as abandonment [49]. This isolation may lead to poor support.

●Low socioeconomic status (lower education and income levels) [42]. Lower income has been associated with neglect and emotional abuse [50]. This also impacts upon the level of support available.

●External family stressors – Illness, low socioeconomic status, death in the family, or other stressful life events involving caretakers can be risk factors for elder abuse and self-neglect [51].

●Intrafamily conflict – Conflict within families can precipitate abuse [52].

●Unfavorable caretaker characteristics – Caretaker mental illness, substance abuse, history of violent or antisocial behavior, depression, or financial dependency on the victim increase the risk of elder abuse [22,51].

●Institutional staffing shortages [32], declining resident cognition, challenging resident behavior, physical impairment, excessive caregiver burden, and caregiver burnout are among the risk factors for abuse or neglect in institutional settings [53].

●A personal history of child abuse or intimate partner violence has been associated with an increased odds of elder abuse in a Chinese American population [54].

EVALUATION AND CLINICAL ASSESSMENT — Elder mistreatment is a major public health concern. Clinicians often take care of vulnerable patients and are best-qualified to distinguish normal aging from the manifestations of abuse [8,22,55]. In addition, they have legal obligations to report abuse and self-neglect in most United States jurisdictions. However, many clinicians in the emergency department and other outpatient settings indicate that they receive insufficient training in the diagnosis of elder abuse and self-neglect, as well as insufficient knowledge of the appropriate interventions for such patients [56].

The United States Medicare program requires nursing facilities to monitor residents for signs of abuse and neglect with implementation of their minimum data set (MDS) instruments [57]. The American Medical Association (AMA) [58] and the Joint Commission [59] also acknowledge that elder mistreatment is a major public health concern and that health care workers and institutions should do what they can to identify cases so that affected older adults can be helped.

Our approach to evaluation for elder abuse and self-neglect — Our approach to surveillance and evaluation is to determine, with an awareness of risk factors and warning signs, if the patient's needs are being met, if the patient has an impaired capacity for self-care and protection, if the patient is neglecting themselves, and/or if someone who is expected to help the patient is abusing, neglecting, or exploiting them.

If the patient has injuries, we look to the social and medical history, the physical exam, any laboratory studies, and known risk factors and warning signs of abuse or neglect to determine if the offered explanation for the injury is consistent with the injury observed [60-62].

A comprehensive history and can be done, with attention to functional and cognitive ability, particularly since deficits in these areas have been associated with a risk of self-neglect [63]. (See "Evaluation of cognitive impairment and dementia" and "Failure to thrive in older adults: Evaluation".)

This evaluation may substantiate the presence of elder abuse or self-neglect. A comprehensive geriatric assessment (CGA) is a model for such an evaluation and has been studied for outcomes in identifying elder abuse as well as self-neglect [8,39,64,65]. (See "Comprehensive geriatric assessment".)

Observation is often more reliable than questioning the patient, although both questioning and observation are needed. Observation of the conditions the patient is living in are valuable to help understand the patient's functional abilities and needs. Asking about abuse will often need to be done when the patient is apart from their caretaker.

Warning signs — Warning signs are discussed below and are listed in the table (table 1). The presence of these warning signs should raise the clinician's concern for elder abuse or self-neglect if a more benign explanation does not appear to be reasonable.

Physical examination findings

●Skin findings – Skin tears, abrasions, lacerations, and bruises that are inadequately explained or occur in unusual locations may suggest elder physical abuse. Some suspicious injury patterns include injuries to the head and neck without injury to other areas of the body, injuries to the neck or ear, injuries to the torso, and ligature marks or injuries in the shape of a weapon [66]. Burns may also be suspicious if not adequately explained.

●Fractures – Falls are common in older adults. While vertebral fractures are common and can be spontaneous, hip fractures and other osteoporotic fractures may indicate accidents or self-neglect. Spiral fractures of long bones and fractures in sites other than the wrist, hip, or vertebrae in a non-alcoholic older adult may be suspicious for physical abuse [39]. Fractures of the face, ulna, posterior ribs, upper ribs, or multiple fractures at various stages of healing [67].

●Malnutrition – Malnutrition may indicate neglect (including self-neglect), if the community-dwelling older adult is unable to procure their own meals or if staff do not take time to feed nursing home patients who cannot feed themselves. Malnutrition in an older adult may also be a manifestation of financial exploitation if the older adult is left without resources to purchase food [39]. Below normal BMI, muscle wasting, or low prealbumin may be suspicious in some circumstances [68].

●Dehydration – As with malnutrition, dehydration may be a sign of elder neglect if the older adult needs assistance to be able to take in sufficient fluids [39]. Fecal impaction, dry mucous membranes, sunken eyes, orthostatic changes, tachycardia in the absence of dysphagia, or decreased thirst may be suspicious for neglect [68].

●Poor personal care – Bugs in the hair, dirty/long nails, caked feces on skin, or poor dentition may be seen in neglected patients.

●Pressure ulcers – Pressure ulcers do not necessarily indicate neglect but may occur more readily if the standard of care for prevention is not adhered to in a patient at risk. Intentional or negligent failure to follow the standard of care is elder abuse [39]. Pressure ulcers are a common condition in older patients who are acutely hospitalized or require long-term institutional care. (See "Epidemiology, pathogenesis, and risk assessment of pressure-induced skin and soft tissue injury".)

●Indicators of sexual abuse – If there is no other reasonable explanation, the following may raise a suspicion of sexual abuse:

•Pain or soreness in the anal-genital area

•Evidence of venereal diseases in the oral or anal-genital regions

•Vaginal or rectal bleeding

•Bruises or lacerations on the vulva, abdomen, or breasts [34,69]

Indicators of financial exploitation — Financial exploitation is suggested by a change in the ability of an older adult to pay for medical services, medications, utilities, housing, or food [70]. Another sign is transfer of property by an older adult who lacks the capacity to consent to such a transfer. Five domains of financial exploitation have been identified: stolen money or property, coercion to surrender money or property, impersonation to obtain money or property, inadequate household contribution, and lack of family financial contribution to destitute older relative [71].

Age-associated financial vulnerability may affect many older adults, even those who are cognitively intact, and relates to social isolation and aggressive profit-seeking enterprises marketing to those with a disparate portion of wealth [72]. If the older adult is exploited by a person in a trust relationship with that older adult, it is a form of elder abuse as defined by the Centers for Disease Control and Prevention (CDC). It the older adult is exploited by a stranger, it is most likely a crime, but it may not be considered elder abuse as defined in this chapter.

Laboratory findings — These findings alone are not specific or pathognomonic for elder abuse but should raise suspicion and be correlated with history and physical findings [68]:

●Dehydration

•Hypernatremia Na >145 mmol/L

•Elevated blood urea nitrate (BUN)/creatinine ratios >20

•Elevated uric acid

•Elevated hemoglobin

●Malnutrition

•Low cholesterol

•Low total lymphocyte count

●Physical abuse

•Elevated creatine kinase

•Urine myoglobin

●Sexual abuse

•Positive sexually transmitted disease test results

●Medical neglect

•High HbA1c

•High TSH

Screening — Organizations vary on whether they recommend screening. The American Medical Association (AMA) [55] and the American Academy of Neurology (AAN) [73] specifically advise screening individuals age 65 years and older for abuse. The US Preventive Services Task Force (USPSTF), however, notes the lack of validated screening instruments and inadequate evidence that screening reduces harm related to abuse of older and vulnerable adults [74,75]. The USPSTF also found no evidence that screening causes harm and thus does not recommend for or against screening.

American Medical Association — In 1992, the AMA proposed that clinicians in all practice settings screen geriatric patients to identify abuse [55]. In 2019, the AMA reiterated its advice to inquire of all patients regarding family violence history (including elder abuse) [76].

Components of the AMA proposal include:

●Patients should be interviewed by themselves to avoid intimidation by possible abusers

●Patients should be questioned about family composition and living arrangements

●Patients should be asked directly about abuse, neglect, or exploitation

●Clinicians should look for indicators of abuse, including poorly explained injuries; evidence of neglect (dehydration, malnutrition, poor hygiene, lack of medical compliance); isolation; fear of a caretaker; or transfer of funds to a caretaker

Screening instruments — A variety of screening instruments have been developed to identify elder mistreatment [77]. However, some of them are not practical for everyday clinical practice as the following problems affect their implementation or reliability:

●Overly complex and require too much time to administer

●Need for training to administer

●Need for accurate responses from a cognitively impaired or fearful victim

●Need for accurate responses from a defensive or possibly abusive caregiver

●Inadequate validation in representative populations

Tools for use in the emergency department are being developed and tested [78]. The Elder Abuse Suspicion Index is fairly short and has been validated to use with cognitively intact patients in outpatient settings [79]. A screening tool called the elder abuse through emergency care technicians (DETECT) is being studied. It is an observation-based screening tool designed to be used by medics responding to 911 calls to the community setting [80].

Self-neglect is difficult to identify away from the home environment [81]. A specific screening tool, the Self-Neglect Severity Scale, was evaluated, but it has not been shown to be sufficiently sensitive or specific [82].

INTERVENTIONS — The first obligation of the health care worker, social worker, community agency, or member of the public, is to assure the safety of the at-risk older adult. If the older adult is in immediate danger of harm, a report to the police may be the first intervention to make.

A 2016 systematic review of interventions for preventing elder abuse found that there was no trustworthy evidence to assess the effects of elder abuse interventions on the occurrence or recurrence of elder abuse [83].

An approach to identifying the presence of elder mistreatment and inappropriate interventions is the Abuse Intervention Model (AIM), which identifies factors making older adults vulnerable and at risk for abuse or neglect and identifies potential interventions [84]. Risk factors for elder mistreatment are identified in the individual case for the suspected victim, the trusted other, and the context of their interaction, such as the quality of the relationship or social isolation. This analysis leads to interventions that may benefit the victim, such as reduction of isolation.

In a small study using volunteer medical students, the students made unstructured social phone calls to victims of elder abuse or neglect, as validated by Adult Protective Services. Victims participating in the study reported reduced feelings of depression and loneliness, while the medical students reported enhanced appreciation for the social needs of older adults [85].

Reporting — If a health care worker has reason to believe that an older adult is in a state of elder abuse or self-neglect, appropriate medical interventions should be offered and reporting should be promptly initiated. Adult Protective Services (APS) and Long-Term Care Ombudsman programs (LTCOP) exist in all United States jurisdictions. If there is doubt about where and how to report, one of these agencies or law enforcement can provide the needed information regarding how to report suspected elder abuse or self-neglect.

Reporting of elder abuse or self-neglect is said to be an effective and important intervention in the management of elder mistreatment [86]. We agree with this assessment.

●Reporting suspected elder abuse or self-neglect gives government agencies an opportunity to investigate the situation with home visits, financial record reviews, discussions with community contacts of the older adult, and other measures that a clinician does not usually have access or time to review.

●Prompt medical evaluation may be needed to stabilize the victim and reporting to APS may facilitate such an evaluation and treatment, either with or without the assistance of local law enforcement or courts [87].

●When elder abuse and self-neglect is identified, older adults at risk for poor health consequences are identified, giving APS, law enforcement, and sometimes the courts the opportunity to intervene to protect the victims. (See 'Adverse consequences' above.)

●Investigations by APS workers in 58 California counties over a period from January to December of 2013 showed that of the total cases completed by APS (77,812), 34 percent confirmed the allegations of elder abuse or self-neglect, 16 percent found the allegations to be unfounded, and 50 percent found the allegations were inconclusive [88].

●Referral of identified victims of financial exploitation to multidisciplinary teams that include APS, clinicians, law enforcement, and prosecutors has increased the prosecution of financial abuse cases [89]. Similar multidisciplinary teams exist in different states to which APS may present cases of elder abuse. Reporting to APS may also result in a court's finding of incapacity to live independently and result in a needed guardianship for supervision [90,91].

According to the Stetson Center for Excellence in Elder Law, there are statutes for mandatory reporting for elder mistreatment in every state but not in every territory [92]. Some jurisdictions require reporting by anyone who suspects elder abuse or self-neglect, while most jurisdictions only require reporting by members of certain named occupations, including by health care workers [93]. There are penalties for failure of clinicians to report suspected abuse exist in most states and in the District of Columbia [93]. Mandatory reporting requires a clinician to report suspected abuse, even if a competent older adult patient specifically asks that the abuse not be reported [94].

The statutes in almost all of the US states specifically provide for immunity from any civil or criminal liability for reporting and testifying about suspected elder abuse, neglect, self-neglect, or exploitation, so long as the communications are made in good faith [95].

If reporting is motivated by the reporter's reasonable suspicion, governmental resources will assist with investigation, assessment, and case confirmation. Reporting also helps mobilize resources and interventions from the APS agency, such as reactivation of utilities, medications, safety repairs of the home, and personal care services.

Web resources — There is no single website that provides information about abuse laws for each state. Helpful resources for the clinician include:

●American Bar Association Commission on Law and Aging – Provides contact information by state (https://www.americanbar.org/groups/law_aging/)

●National Center on Elder Abuse – Lists phone numbers to report suspected abuse cases by state (https://ncea.acl.gov/suspectabuse#gsc.tab=0)

●Long-Term Care Ombudsman Resource Center (https://ltcombudsman.org/)

Documentation of findings — Careful and immediate documentation should be made of observations that support a finding of elder abuse. What the victim or the alleged perpetrator says should be dutifully recorded.

Conclusions and general statements do not make good evidence for governmental agencies, law enforcement, or the courts. Specific details of observations are helpful. For physical evidence of abuse, photographs may be the best evidence. The reporter should carefully record size, color, and induration of lesions, preferably with an accompanying drawing when photographs are not possible. Instead of documenting that the alleged perpetrator "confessed" to the abuse, it is best to record carefully the exact words of the perpetrator.

Interacting with law enforcement and the courts — Once a report has been filed, the allegation or suspicion will be directed to a designated resource, either the APS agencies for community-dwelling older adults, or the state LTCOP (or agency that licenses the facility) for residents of long-term care institutions.

At times, immediate reporting to law enforcement is indicated. If an observer is concerned that abuse or exploitation is ongoing and requires interruption to prevent further harm, law enforcement, as well as the state protective agencies, must be notified urgently.

As mentioned above, the role of the clinician is to report the suspected elder abuse or self-neglect. From this point, medical, social, and legal interventions may be offered when an older adult is determined to be the victim of elder abuse or self-neglect. Older adults who are deemed to have the capacity to understand and consent to protective services may reject offered interventions from an APS agency. If the agency determines that the victim lacks the capacity to understand and consent to protective services and that a situation is unsafe, the agency may petition the courts for an emergency order for protective services. Most of the US states and territories have statutes providing for these emergency or involuntary protective services for those without capacity to consent [96]. The court may require a statement from a clinician to support a finding of the lack of capacity to consent to protective services before such an emergency order is issued.

Clinicians who are able and willing to assess the ability of APS clients to make decisions regarding the acceptance or refusal of protective services, or their ability to live independently without supervision, are limited, especially in rural areas. One statewide program uses telecommunication to provide these assessments for APS clients in order to extend this service to underserved areas [90]. The process used by this program for the remote and in-person evaluation of capacity for self-care and self-protection of the clients of APS has been published [91].

The APS agencies and the courts are obliged to use the least restrictive alternative when an individual's autonomy is impacted in order to protect that person. The government must explore all options and choose those that accomplish the needed protection while being no more restrictive than necessary. For example, if durable powers of attorney are in place and the designated power of attorney can effect needed decisions, guardianship should not be pursued [97].

Guardianship — Clinicians are often asked to make determinations of the need for guardianship in cases where the older adults have diminished capacity for self-care and protection [97]. Legal provisions for guardianship vary among US state jurisdictions. A conceptual model, based upon legal statutes in the United States and expert consensus opinion, identifies six key domains to be evaluated for determination of need for guardianship [98]:

●Presence of a medical condition that may produce functional disability

●Cognitive impairment (short-term memory, communication, attention, executive function, and others)

●Difficulty involving everyday functioning (ability to provide nutrition, shelter, and safety)

●Consideration of the individual's values and preferences

●Risk of harm and level of supervision needed

●Determination of whether less restrictive alternatives to guardianship are feasible

Decisional and executive capacity — Ultimately, the court must determine whether the older adult has sufficient capacity to self-care and self-protect to avoid danger, and whether alternative measures to the appointment of a guardian are available. The presence of such problems as disorganized thinking, hallucinations, delusions, lack of insight, and refusal to accept help are important in the determination of need for guardianship.

The capacity for self-care and self-protection depends on whether an individual can both make and implement decisions regarding personal needs, health, and safety [13]. This requires both intact decisional and executive capacity in relation to multiple functional domains: personal needs and hygiene, condition of home environment, activities for independent living, medical self-care, and managing financial affairs. Assessment of decision-making capacity is discussed in detail separately. (See "Assessment of decision-making capacity in adults".)

Components of decisional capacity are the ability to [51]:

●Communicate a choice

●Understand the relevant information

●Appreciate the situation and its consequences

●Reason about treatment options

Executive capacity requires executive function. Executive function refers to the ability to develop a plan, adapt to circumstances, and implement the plan.

Decisional capacity and executive capacity can be evaluated during the history and physical examination, with further input from geriatric assessment tools; information from APS agencies, family, police agencies; or evaluation of the home environment by members of a geriatric assessment team. Neuropsychological testing may be useful in cases where the capacity of the older adult for self-care and self-protection remains in question.

The capacities to consent to sexual activity, to make a will, to vote, to drive, to transfer property, to consent to participation in research, and to consent to treatment are capacities of importance to older adults that a clinician may be asked to specifically assess. Some of these more specific capacities, especially the capacities to transfer property, consent to sexual activity, and consent to treatment, may be needed to possess the more global capacity for self-care and self-protection.

There are several tools available to assess the ability to make financial decisions [99]. Marson et al have developed an eight-item tool for clinicians called the Semi-Structured Clinical Interview for Financial Capacity (SCIFC) [100].

PREVENTION — A 2011 report from the World Health Organization (WHO) notes that there is a lack of high-quality studies of interventions designed to reduce or prevent elder maltreatment [45]. Outcomes were variable for multiple interventions that involved courses for professionals to heighten awareness of elder abuse or legal, psychological, and educational support programs for older individuals and their caregivers. A subsequent systematic review in 2016 also reported inadequate evidence to assess the effects of interventions to reduce the occurrence or recurrence of abuse [83].

Prevention of abuse may be promoted by programs that provide respite for caregivers, support for informal (nonprofessional) caregivers, and encourage positive attitudes towards older people within a culture. The authors of this topic propose several approaches to target different groups and employ a variety of strategies that can play a role in the prevention of elder abuse.

●Recognition that clinicians from any discipline who have contact with older adults, not just geriatricians or those working in elder care institutions, are in a position to make an important impact. Education regarding the risk factors and warning signs of elder mistreatment and the appropriate interventions (especially reporting to the appropriate governmental agencies) when elder mistreatment is suspected should involve all clinicians.

●Education to address and overcome the barriers to reporting suspected elder mistreatment. These barriers include failure to recognize the ethical and often legal obligation to report, not knowing which agencies to report to, not realizing that only a reasonable suspicion of mistreatment is sufficient to trigger the duty to report, not understanding that there is protection from legal liability for the reporter who does so in good faith, not realizing that the report can be made confidentially, and thinking that the reporter needs the permission of the suspected victim of elder mistreatment in order to report [101].

●Education targeting clinicians as well as nonclinical personnel who have contact with older adults, including individuals in the banking industry, mail carriers, salespersons, emergency medical services workers, police officers, and long-term care facility employees. The educational efforts for non-medical personnel can be very similar to those used with clinicians. There should be a focus on risk factors, warning signs, the agencies to report suspicions to, and, as with clinicians, education designed to remove some of the barriers to reporting caused by ignorance.

●Education and administrative interventions to address conditions in institutions that may promote resident elder mistreatment by staff members. Factors that increase the likelihood that a staff member may mistreat a resident include excessive work pressure, having negative attitudes toward older adults, having negative attitudes toward their jobs, limited training, a history of drug or alcohol dependence, a staff member with a criminal record, a facility culture that tolerates placing staff and facility convenience before patient needs, and a low staff-to-resident ratio [102-104].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Elder abuse (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – Elder abuse refers to actions or failures to act, perpetrated by those with an ongoing relationship involving an expectation of responsibility toward the victim. (See 'Definitions' above.)

●Resources – Community-dwelling older adults may be offered resources and protection in the United States by state Adult Protective Services (APS) agencies. This offer of help extends to elders found to be in a state of elder abuse or self-neglect regardless of whether the older adult is vulnerable or cognitively impaired. APS does attempt to facilitate the accomplishment of essential needs for the health and welfare of the victim. Long-Term Care Ombudsman programs (LTCOP) or licensing agencies for the institution address issues in institutional settings. (See 'Regulatory and support services (United States)' above.)

●Risk factors and warning signs – The presence of risk factors and warning signs should prompt a clinician to evaluate a patient for elder mistreatment (table 1). (See 'Risk factors' above and 'Warning signs' above.)

●Approach – A comprehensive history and physical with attention to the functional and cognitive assessment, considering risk factors and warning signs of elder abuse and self-neglect, should then take place. Patients may need to be interviewed by themselves to avoid intimidation by possible abusers. (See 'Our approach to evaluation for elder abuse and self-neglect' above and 'Screening' above.)

●Interventions – The first obligation of the health care worker, in conjunction with social workers and community agencies, is to optimize the safety of the at-risk older adult. (See 'Interventions' above.)

●Reporting and documentation – If a health care worker has reason to believe that an older adult is the victim of elder abuse or self-neglect, appropriate reporting should be promptly initiated. Careful and immediate documentation should be made of observations that support a finding of elder abuse. The APS agencies and the courts are obliged to use the least-restrictive alternative when an individual's autonomy is impacted in order to protect that person. (See 'Reporting' above and 'Documentation of findings' above.)

●Guardianship – Clinicians may be asked to make determinations of capacity in cases where the older adults have diminished capacity for self-care and protection. (See 'Guardianship' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Carmel Dyer, MD, FACP, AGSF (deceased), who contributed to an earlier version of this topic review.