Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made.  (Formerly, these situations were captured under a "C Recommendation".)  This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade.  For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Secondary Prevention of Elder Abuse

Overview
Elder abuse and mistreatment has emerged as a significant health problem, affecting all types of older individuals. While obvious cases of physical abuse are readily recognized by professionals and the lay public, subtle degrees of neglect, sexual abuse and other types of mistreatment may go unrecognized. Although it is now known to be common, affecting 4% or more of older people in Canada, the scope and definition of elder abuse lack precise boundaries, detection maneuvers are not well evaluated and there is no clear evidence that interventions are effective. For this reason, there is insufficient evidence to support inclusion or exclusion of case finding for elder abuse in the periodic health examination (C Recommendation). However, it is prudent to advise physicians to be alert for indicators of elder abuse and, if discovered, to institute measures to prevent further abuse.

Burden of Suffering
Elder abuse may be simply defined as "any act of commission or omission that results in harm to an elderly person".<1> The Department of National Health and Welfare<2> has categorized abuse and neglect as follows:

1. Physical abuse: Involves assault, rough handling, sexual abuse, or withholding of physical necessities such as food, personal care, hygiene care or medical care.
2. Psychosocial abuse: Involves verbal assault, social isolation, lack of affection, or denying the person the chance to participate in decisions in respect to his or her own life.
3. Financial abuse: Involves the misuse of money or property. This can include fraud or using the funds for purposes contrary to the needs and interests (or desires) of the older person.
4. Neglect: Can lead to any of these three types of abuse. It can be passive neglect if the caregiver does not intend to injure the dependent senior; or active when the caregiver consciously fails to meet the needs of the senior.

There have been three studies of community prevalence of elder abuse.<4-6> Gioglio and Blakemore<4> interviewed a stratified random sample of community-dwelling people aged 65 years and older in New Jersey. Only 1% of the 342 respondents admitted to being victims of some form of abuse.<4> In a stratified random sample of all community-dwelling elderly persons in the Boston Metropolitan area, 72% of 2,813 eligible respondents were interviewed, and the prevalence of all types of elder abuse was 3.2%.<5> Podnieks and colleagues conducted a cross-Canada telephone survey of 2,000 randomly chosen elderly persons living in private houses. About 4% (95% confidence interval ± 1.5%) had experienced some form of maltreatment since their 65th birthday.<6> Two point five percent reported material abuse. Chronic verbal abuse was reported by 1.4% of the sample, 0.5% experienced family violence and 0.4% neglect. Different profiles emerged for different types of abuse. For material abuse, men and women were equally likely to be victims. They tended to live alone, and the perpetrators were often distant relatives or non-relatives. Chronic verbal abuse tended to occur between spouses, men and women being equally affected. Physical violence was most likely to occur between spouses. While men were more likely to be victims, violence perpetrated by men tended to be more severe. Prevalence estimates for elder abuse as high as 10% have been claimed.<7> While the exact prevalence of abuse and mistreatment within institutions is not clear, when a random sample of staff from 31 nursing homes in New Hampshire was interviewed, 36% reported that they had witnessed physical abuse in the preceding year.<8> Psychological abuse had been observed by 81% of staff.

Risk factors for abuse in the victim include dependency, lack of close family ties, a culture of family violence, lack of financial resources, lack of community support and factors such as low pay and poor working conditions in institutions.

The perpetrator is most often a relative, living with the victim, and may have cared for the victim for a long period of time.<9> The perpetrator often has a psychological disturbance and may be subject to external stresses such as employment loss, divorce, or illness.

Elder abuse does not usually resolve spontaneously. Abusive events tend to be repetitive, and abuse tends to continue unless a major change occurs in the milieu. In many cases victims or families have refused help. Victims are particularly afraid of reprisals, loss of autonomy or relocation.

Maneuver
Detection of elder abuse is notoriously difficult, often complicated by denial by the individual and caretaker. The victim is often reluctant to admit to abuse, for fear of abandonment, reprisal, institutionalization, or to avoid embarrassment or shame. The caretaker is often reluctant to admit abuse for obvious reasons, although given appropriate circumstances (privacy and a non-judgmental listener, preferably on home territory) the caretaker is often willing to talk about difficulties and may express relief at sharing their problems with somebody else.<10> Direct questions have been suggested for incorporation in routine encounters with older people<11> in order to determine risk of abuse:

• "Has anyone at home ever hurt you?
• Has anyone ever touched you without your consent?
• Has anyone ever made you do things you didn’t want to do?
• Has anyone taken anything that was yours without asking?
• Has anyone ever scolded or threatened you?
• Have you ever signed any documents that you didn’t understand?
• Are you afraid of anyone at home?
• Are you alone a lot?
• Has anyone ever failed to help you take care of yourself when you needed help?"

While physical findings are rarely specific, unusual trauma, signs of hair pulling, human bites or unusual behaviour between client and caregiver may raise the suspicion of abuse. Social factors which may signal increased likelihood of abuse include: recent deterioration in health of patient or caregiver, evidence of increasing stress in caregiver, and unsatisfactory living arrangements.

While a number of elder abuse identification measures have been developed, an authoritative review<12> concluded that there were few items to measure categories of abuse other than physical, that the distinction of effects of disease from potential abuse was not addressed, and that assessment protocols were conceptually and operationally suboptimal, and had not been empirically tested. The Elder Assessment Instrument (EAI) has shown some promise in distinguishing individuals subsequently found to show evidence of abuse.<13>

Effectiveness of Intervention
Decisions about how and when to intervene in cases of elder abuse and neglect are among the most difficult for service providers. The causes for abuse are complex, little is really known about the causes and risk factors in the individual case. Legal and ethical issues add to this complexity. On the one hand the individual must be protected from harm, on the other, autonomy in decision making must be respected. The Criminal Code of Canada provides the legislation necessary to deal with physical, sexual and financial abuse. However, individuals are often reluctant to press charges against a close relative or caregiver.

Mandatory reporting of abuse exists in several Atlantic provinces. However, it appears that elder abuse laws have had little impact on the performance of physicians in detecting or reporting abuse in the United States. There is no evidence that mandatory reporting is effective in enhancing the treatment of elder abuse. It has been estimated that only one in 14 elder mistreatment cases is reported to a public agency.<14>

Because of the complexity of elder abuse a team approach has been advocated. The principles of intervention are to protect the victim and prevent further abuse. Principles of dealing with the abused victim include a) recognition of the problem, b) provision of information, c) assessment of decision making capacity and d) facilitating choices. After recognizing that abuse or mistreatment may be present, the physician must make an adequate assessment including determination of the safety of the victim and potential risk. Analysis of risk will include a review of the frequency and severity of abuse, and whether intent is thought to be present. The degree of stress of the perpetrator should also be assessed.

Usually when an abusive situation is uncovered, the physician will include other health care professionals in management, most frequently a social worker and visiting nurse. In some jurisdictions multidisciplinary geriatric assessment teams may be called upon to sort out complex cases of abuse. The cognitive state must be adequately evaluated, as decision making capacity is an important factor in planning management. Evaluation of social and financial resources must also be made. Adequate documentation should occur, and where visible injuries are present, drawings or preferably colour photographs should be taken. When the victim has the capacity to make decisions about his or her actions, choices should be outlined to enable the situation to be defused. This may involve temporary relocation, involvement of community agencies, or provision of home supports. If the victim is unable by reason of temporary or permanent cognitive impairment, to make decisions about his or her future, it may be necessary to intervene and relocate the individual while appropriate arrangements for advocacy can be made. There have been no rigorous studies evaluating the outcome of interventions for elder abuse.<15> In case series where outcome has been reported,<16-19> the results have generally been disappointing. In dealing with the abuse situation the needs of the perpetrator as well as the victim should be recognized.

Recommendations of Others
The American Medical Association recommendations include incorporating routine questions related to elder abuse and neglect into daily practice.<14> The U.S. Preventive Services Task Force does not recommend routine screening interviews or examinations for evidence of violent injuries.<20> The elderly who present with multiple injuries and unplausible explanations should be evaluated with attention to possible abuse or neglect.

Conclusions and Recommendations
Elder abuse is being recognized increasingly as a health and social phenomenon. There is poor agreement on the definition and categorization of abuse. Estimated prevalence is between 1 and 10% in the community, possibly higher within institutions. There are no well-validated protocols for detection in primary care. Despite these shortcomings, the physician is uniquely equipped to recognize and address elder abuse. The primary care physician should maintain a high index of suspicion, seeking inconsistencies and anomalies in the history, and using direct questions to explore possible abuse or mistreatment. The physician should be alert to physical and psycho-social findings suggesting physical, sexual or neglectful abuse. Upon discovery of abuse, intervention may be hampered by an unwillingness on the part of the individual or the caregiver to comply with recommendations. As the causes are often complex, a team approach has been suggested, and the importance of the advocacy role of the physician is emphasized. There is insufficient evidence, however, to favour any specific protocol of treatment, and intervention should be individualized in accordance with the many factors operating in each case. A prudent recommendation is to advise physicians to be alert for indicators of elder abuse, and to institute measures to prevent further abuse. However, there is insufficient evidence to recommend for or against a search for elder abuse in the periodic health examination (C Recommendation).

Unanswered Questions (Research Agenda)
The following are research priorities:

1. To determine the causes of elder abuse in different ethnic and cultural groups in Canada.
2. To determine the prevalence of abuse in Canadian institutions.
3. To develop valid, reliable assessment tools for use in different settings (primary care, hospital emergency departments, institutions, etc.).
4. To evaluate the effectiveness of interventions for elder abuse.

This review was initiated in June 1991 and the recommendation was finalized by the Task Force in June 1993.

Acknowledgements
The author wishes to acknowledge Elizabeth Podnieks, PhD (candidate), Professor, Ryerson School of Nursing, for her comments and critical review of the draft report. Funding for this report was provided by Health Canada under the Government of Canada’s Family Violence Initiative.

Full Citation
Patterson C. Secondary prevention of elder abuse. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 922-9.