Analyze how that article applies to the topics being discussed in this class.
Also, include a conclusion based on your ideas, attitudes, and/or impressions about the topic or research the article covers.
Each article review should be typed, double spaced with 1-inch margins and 12-point font, 3 to 5 typed pages, reference page, numbered page
Topics we learned in class
Module 2: Life Course Transitions
Module 3: Theories of Aging
Module 4: Demography of Aging and Exam One
Module 5: Old Age and the Welfare State
Module 6: Biological Perspectives on Aging
Module 7: Psychological Perspectives on Aging and Exam Two
SPRING BREAK
Module 8: Family Relationships
Module 9: Living Arrangements
Article you go off of. This is where you get your info from. down below
Although it has probably existed since antiquity, elder abuse was first described in the medical literature in the 1970s.1 Many initial attempts to define the clinical spectrum of the phenomenon and to formulate effective intervention strategies were limited by their anecdotal nature or were epidemiologically flawed. The past decade, however, has seen improvements in the quality of research on elder abuse that should be of interest to clinicians who care for older adults and their families. Financial exploitation of older adults, which was explored only minimally in the initial studies, has recently been identified as a virtual epidemic and as a problem that may be detected or suspected by an alert physician.
In the field of long-term care, studies have uncovered high rates of interpersonal violence and aggression toward older adults; in particular, abuse of older residents by other residents in long-term care facilities is now recognized as a problem that is more common than physical abuse by staff.2,3 The use of interdisciplinary or interprofessional teams, also referred to as multidisciplinary teams in the context of elder abuse, has emerged as one of the intervention strategies to address the complex and multidimensional needs and problems of victims of elder abuse, and such teams are an important resource for physicians.4,5 These new developments suggest an expanded role for physicians in assessing and treating victims of elder abuse and in referring them for further care.
In this review, we summarize research and clinical evidence on the extent, assessment, and management of elder abuse, derived from our analysis of high-quality studies and recent systematic studies and reviews of the literature on elder abuse.610
Definitions and Estimates of Prevalence
Debates about how to define elder abuse and which types of behavior to include in the definition greatly inhibited progress during the early period of research on this topic. Initial formulations were overly broad and included types of behavior that are not typically part of definitions of domestic abuse, such as crime by strangers, age discrimination, and failure to care for oneself (referred to as self-neglect). Over the past decade, however, consensus has arisen about the inclusion of five major types of elder abuse1113: physical abuse, or acts carried out with the intention to cause physical pain or injury; psychological or verbal abuse, defined as acts carried out with the aim of causing emotional pain or injury; sexual abuse, defined as nonconsensual sexual contact of any kind; financial exploitation, involving the misappropriation of an older persons money or property; and neglect, or the failure of a designated caregiver to meet the needs of a dependent older person (Table 1).
When these types of abuse have been considered together, epidemiologic surveys have shown generally similar prevalences of elder abuse over a period of 12 months, as indicated by three high-quality epidemiologic studies of community-dwelling older people (60 years of age or older). In a survey of more than 4000 older people in New York State, the rate of elder abuse was found to be 7.6%16,17; in a national survey by Laumann et al., the rate was 9%,12 and in a national telephone survey by Acierno et al.,18 the rate was 10%. It is likely that these figures are underestimates; the reliance on self-reported information from persons who are able to participate in a survey excludes patients with dementia, and studies have shown that dementia places older persons at greater risk for mistreatment.19 When the available evidence is taken into consideration, an estimated overall prevalence of elder abuse of approximately 10% appears reasonable. Thus, a busy physician caring for older adults will encounter a victim of such abuse on a frequent basis, regardless of whether the physician recognizes the abuse.
Risk Factors
Most studies indicate that older women are more likely than older men to be victims of abuse.12 Among older adults, a younger age has been consistently associated with a greater risk of abuse, including emotional, physical, and financial abuse and neglect.12 One possible reason for this finding is that the young old more often live with a spouse or with adult children, the two groups that are the most likely abusers. A shared living environment is a major risk factor for elder abuse. In particular, living with a larger number of household members other than a spouse is associated with an increased risk of abuse, especially financial17 and physical20 abuse. Having a lower income has been associated with a greater likelihood of financial abuse, emotional and physical abuse,15,21 and neglect.18 Finally, studies consistently suggest that isolation and a lack of social support are important risk factors for elder abuse.22
With the exception of dementia, which is a documented risk factor for financial exploitation, specific diseases have not been identified as conferring a greater risk of abuse. In general, however, functional impairment and poor physical health have consistently been shown to be associated with a greater risk of abuse among older persons, irrespective of the cause of such limitations.12,21,23,24 Less is known about clinical risk factors for becoming a perpetrator of abuse. On the basis of the limited evidence available, perpetrators are most likely to be adult children or spouses, and they are more likely to be male, to have a history of past or current substance abuse, to have mental or physical health problems, to have a history of trouble with the police, to be socially isolated, to be unemployed or have financial problems, and to be experiencing major stress.12,22,2528
Sequelae
Elder abuse has a range of negative sequelae that extend well beyond the obvious traumatic injury and pain to which the victims may be subjected.29 Studies have shown that victims of elder abuse are at increased risk for death, after adjustment for any chronic illness they may have.30,31 Elder abuse greatly increases the likelihood of placement in a nursing home32 and of hospitalization.33 The psychological effects of abuse, including increased rates of depression, anxiety, and other negative outcomes, have been well documented.3436
Clinical Evaluation
Identification and Screening
Physicians may find the evaluation and treatment of elder abuse unfamiliar and even uncomfortable, since it presents several challenges. First, victims may conceal their circumstances or be unable to articulate them owing to cognitive impairment. Second, the high burden of chronic illness in older people creates both false negative findings (e.g., fractures misattributed to osteoporosis) and false positive findings (e.g., spontaneous bruising misattributed to physical abuse) in the evaluation. For these and other reasons, screening for elder abuse and neglect has not been recommended by the U.S. Preventive Services Task Force.37 Third, cultural and language barriers may hinder the disclosure of abuse. Fourth, in some cases, a definitive determination that abuse is taking place may take weeks or months, and physicians may be required to intervene before such a determination has been made a strategy that is not typically used in the management of medical conditions. Because of these complicating factors, a positive finding of any of the manifestations listed in Table 1 (bolstered by the physicians clinical judgment that something may be amiss) should lead to a thorough evaluation by various professionals involved with the patient.
Assessment Strategies
People suspected to be the victims or the perpetrators of elder abuse should be interviewed separately and alone, both because a relative or caregiver may be the abuser and because victims may be hesitant to reveal mistreatment when others are present because of embarrassment or shame. In addition, separate interviews may uncover differences between the patients explanations and those of the relative or caregiver with regard to physical findings (such as mechanism of injury) that increase the likelihood of abuse. Indirect questions can be used initially with the potential victim, since they may be less threatening (e.g., Do you feel safe at home? Does someone handle your checkbook?). Direct questioning, if necessary, should be similar to that in the investigation of other forms of domestic abuse and can include questions such as Does anyone in your home hurt you? and Has someone not helped you when you needed their help? Because dementia increases the risk of elder abuse and because depression is very common among older adults, no evaluation is complete without a formal assessment of cognition and mood, conducted by either the primary care physician or a mental health professional, neurologist, or geriatrician.
The interview of a suspected abuser is best conducted by professionals with expertise in this area. Aggressive accusations or confrontation may lead to an escalation of abuse, the isolation of the potential victim, or both. It is best for the physician to adopt a sympathetic, nonjudgmental approach until all the relevant facts have been ascertained. A detailed review of the patients medical records may reveal signs of elder abuse that were missed at the time but that in retrospect point to abuse.38 Ideally, the assessment of a case of suspected abuse should involve a home visit. Because it may not be feasible for a physician to conduct a home visit in each case, interprofessional involvement is an indispensable part of both assessment of the victim and intervention. Referral to Adult Protective Services (APS) typically leads to a home visit, which in turn can provide the physician with additional details about the case.
Assessment strategies can vary according to the type of abuse suspected. Descriptions of typical manifestations of the five common types and the methods of assessment that are useful in evaluating possible cases are provided in Table 1. With respect to physical abuse, researchers have been unable to identify injuries that are clearly diagnostic of abuse in older persons, as has been possible for child abuse. Although forensic research has demonstrated some emerging patterns of physical abuse (e.g., older victims are more likely to have bruising on the face, lateral aspect of the right arm, and posterior torso, including back, chest, lumbar, and gluteal regions, than older adults who have bruising unrelated to abuse),14 these findings are useful primarily to alert the clinician to the possibility of abuse and should not be viewed as diagnostic for either medical or legal purposes without other corroborating clinical findings or historical information.
Verbal and psychological abuse may be markers for other forms of abuse and may be the only form that can be observed by clinicians and office staff. The clinical manifestations of verbal and psychological abuse depression, anxiety, and other forms of psychological distress which may normally be amenable to pharmacologic and psychotherapeutic intervention, are not likely to remit unless the underlying abuse is detected and mitigated.
The neglect and financial exploitation of older persons share many similarities that make their detection and evaluation especially relevant to clinicians. Whereas signs and symptoms of physical abuse may be directly visible, the manifestations of financial exploitation and neglect can be subtle (e.g., failure to keep appointments or fill prescriptions, weight loss, and frequent visits to the emergency department for diseases that should be well controlled). Abrupt changes in either direction in the financial circumstances of the caregiver (e.g., sudden unemployment or extravagant purchases) may also herald an increased risk of financial exploitation or suggest that exploitation is already under way. In the case of neglect, a standardized assessment of functional status (i.e., dependence in activities of daily living39) should be augmented by asking whether a responsible caregiver or other person has failed to meet the patients needs with respect to care. Recent studies suggest that financial exploitation is emerging as the most prevalent form of abuse; by the time cases are detected, the older adults financial resources have often been drastically reduced a fact that makes swift detection and intervention critical.17
Interventions
There have been no large, high-quality randomized, controlled studies of specific and discrete inventions in cases of elder abuse9 a situation that has been identified as leading to a critical knowledge gap in the field.40 However, decades of clinical experience and documented best practices in the field provide guidance for practitioners in helping victims. Successful treatment rarely involves the swift and definitive extrication of the victim of abuse from his or her predicament with a single intervention. Instead, successful interventions in cases of elder abuse are typically interprofessional, ongoing, community-based, and resource-intensive. Although physicians have an important role to play in the medical components of those interventions, it will usually not be feasible for them to initiate or sustain successful interventions in cases of elder abuse on their own. Therefore, the most important tasks for the physician are to recognize and identify elder abuse, to become familiar with resources for intervention that are available in the local community, and to refer the patient to and coordinate care with those resources.
Table 2 lists services and organizations that are typically involved in intervention in cases of elder abuse and their roles; Figure 1 illustrates an overarching, interprofessional approach to intervening in the case of an identified or probable victim. APS is the federal program that receives mandatory reports of suspected abuse and is typically at the center of case investigations. Forty-nine states (New York is the exception) have mandatory reporting laws that require designated reporters (including physicians) to report even the suspicion of abuse to APS, law enforcement, or a regulatory agency. An APS worker then typically visits the home and conducts an investigation with the goal of verifying or refuting the concern. If abuse is identified, interventions are then undertaken that are both tailored to the circumstances of the victims situation and highly dependent on the resources of the local environment and on the resources and dynamics of the family. The physician can serve as a highly useful resource for APS workers as they pursue their investigation.
Different situations require different interventions in cases of abuse. Psychiatrically ill abusers may require mandated mental health treatment. Persons who abuse an older person as a result of the burdens of caregiving may need respite services or more home health care for an impaired family member. Elder abuse that is tied to substance abuse is treated with an entirely different series of interventions. Physicians have important roles to play in all these circumstances, and abuse need not be definitively proved before targeted geriatric services, such as physical therapy, home health care, mental health services, optimization of treatment for chronic diseases, coordination of care, and attention to restoration of the highest level of practical functioning, are initiated to relieve the situation in which the abuse occurred.
Because the prevalence of cognitive impairment from dementia (the most common cause of incapacity in the older adult population) is so high, a critical consideration in all cases of elder abuse is whether the victim has decision-making capacity and is able to accept or refuse intervention. Depending on the degree of impairment, as well as on the state laws governing who can make such determinations, assessment of such capacity typically requires the participation of a psychiatrist or geriatrician, either as part of the APS team or through private referral. Patients who refuse interventions and lack decision-making capacity often need legal interventions, such as the appointment of a guardian. In such a case, the physicians role is to provide evidence from the physical examination and history that support the presence or absence of decision-making capacity and sometimes to participate in guardianship proceedings so as to ensure that the alleged abuser does not become the guardian.
The most promising response to the complex nature of cases of elder abuse has been the development of interprofessional teams. Evidence suggests that interprofessional teams, also referred to as multidisciplinary teams, consisting of physicians, social workers, law-enforcement personnel, attorneys, and other community participants working together in a coordinated fashion, are the best practical approach to assisting victims.41,42 Led by a coordinator (typically a social worker or nurse), the interprofessional teams meet on a regular basis to discuss difficult cases in the local community and to coordinate an effective response. A plan of action is developed, with individual team members assigned to specific tasks, and a time frame for follow-up is specified (a mock interprofessional team meeting can be viewed at http://nyceac.com/clinical-services/mdts). The data on interprofessional teams suggest that the teams improve efficiency, coordination, and professional support among team members.43
Many physicians do not have the luxury of formal interprofessional teams to respond to elder abuse in their communities, but the presence of several of the necessary agencies (including APS) and professionals creates the potential for forming such a team. Physicians can cultivate these relationships, both to serve victims of elder abuse and as a step toward developing interprofessional teams in their communities. Indeed, one of the most helpful contributions a physician can make with regard to elder abuse is to serve as the catalyst for the formation of an interprofessional team in the local community. Detailed guidance on creating an interprofessional team is available from the National Center on Elder Abuse (http://ncea.aoa.gov/Stop_Abuse/Teams/index.aspx#traditional).
Elder Abuse in Long-Term Care Facilities
Concern about elder abuse in nursing homes first came to widespread public attention in the 1970s, when facilities were relatively unregulated and had little oversight. The Omnibus Budget Reconciliation Act of 1987, which created a federal framework for the standardized assessment and care of nursing home residents, heightened both awareness and reporting of elder abuse in nursing homes. Although no scientific studies of the prevalence of abuse have been conducted in these settings, the available observational and clinical evidence suggests that mistreatment of residents by staff members occurs with sufficient frequency to be of concern to physicians.44 Studies have pointed to the very high prevalence of mistreatment of nursing home residents by other residents, in the form of physical, verbal, and sexual aggression.2,3,45 Physicians should be alert to this possibility when examining and treating nursing home residents, because clinically significant injuries have been found to result from resident-to-resident aggression.46
Whatever the cause of the abuse, physicians may encounter abused patients in nursing homes when serving either as primary care physicians in the facility or as consultants when patients are transferred to emergency departments or hospitals. Every state has a reporting mechanism whereby the suspicion of abuse in nursing homes (or in other types of long-term care facilities) can be reported and investigated, and physicians should report their concerns accordingly. The National Center on Elder Abuse maintains a website with contact numbers and a directory of ombudsman offices in each state for this purpose at http://ncea.acl.gov/Stop_Abuse/Get_Help/State/index.aspx.
Conclusions
Because victims of elder abuse tend to be isolated, their interactions with physicians, which may be intermittent or rare, present critically important opportunities to recognize elder abuse and to intervene or refer the victims to appropriate providers. Advances in our understanding of the many manifestations of elder abuse and the emergence of interprofessional-team approaches also point to an important role for physicians in addressing this major public health problem. Both research and clinical experience suggest that cases of elder abuse can rarely, if ever, be successfully treated by the physician alone. Therefore, the response of the medical professional must include connecting with specialists in other disciplines, including social work, law enforcement, and protective services, ideally in the context of an interprofessional-team approach.
