The four major etiologic theories that help practitioners understand and diagnose elder abuse and neglect focus on psychopathology of the abuser, stress, transgenerational violence, and dependency.
Psychopathology of the abuser: Many abusers have been hospitalized repeatedly for serious psychiatric disorders (eg, schizophrenia and other psychoses). Many abuse alcohol or other drugs.
When an adult child has a mental illness requiring inpatient psychiatric care, the parents’ home is often the discharge site of last resort. Out of concern that the child will be homeless or have to stay in a shelter, or just out of love, parents often agree to take the child into their home. With the trend toward deinstitutionalization, psychiatrists who discharge a dependent child to the parents’ home must be aware of the possible effects on the parents. Patients who are not violent in an institution may be violent in the home. When the potential for domestic violence is not scrutinized and provisions for follow-up are not made, elder abuse may occur.
Stress: Financial problems, death in the family, the responsibilities of caregiving, and other tensions may create frustration and anger that some people express through acts of violence. New studies have investigated the relationships between the care recipient’s degree of cognitive impairment and the occurrence of abuse and neglect by the caregiver. A recent study conducted at the University of Medicine and Dentistry of New Jersey associated mistreatment of persons with dementia with the psychologic and physical demands placed on family caregivers. Another study from Cornell University and Louisiana State University found that a caregiver being married to the care recipient is a risk factor as are previous acts of abuse perpetrated by the care recipient on the caregiver.
Transgenerational violence: This theory postulates that violence is a learned response to difficult life experiences and a learned method of expressing anger and frustration. The theory has been hard to substantiate because information about family violence that occurred years ago is difficult to obtain.
Dependency: When family members depend on elders for housing, financial support, emotional support, or other needs, the dependent family members may become resentful and predisposed to abusive and neglectful behavior. This theory also suggests that elders who are functionally or cognitively impaired and dependent on their families for care are at increased risk for abuse and neglect.
Classification
The three general types of abuse and neglect are physical, psychologic, and financial. All can be intentional or unintentional.
Physical abuse and neglect: This type of mistreatment includes striking, shoving, shaking, beating, restraining, or feeding improperly. Sexual assault requires special emphasis, because many health care providers find this form of violence inconceivable when an older person is involved. Sexual assault refers to any form of sexual intimacy without consent or by force or threat of force.
Psychologic abuse and neglect: This type of mistreatment causes emotional stress or injury to an older person. Examples include verbal abuse–threatening remarks, insults, or harsh commands–and remaining silent or ignoring the person. Another form of psychologic abuse is infantilism (a form of ageism), whereby the elderly person is treated as a child, which both patronizes and encourages the person to passively accept a dependent role.
Financial abuse and neglect: This type of mistreatment is defined as the misuse or exploitation of or inattention to an older person’s possessions or funds. Abusive behavior includes conning, pressuring the victim to distribute assets, or irresponsibly managing the victim’s money.
Diagnosis
The difficulty of detecting abuse and neglect varies, depending on how subtle the signs are and how willing the victim is to talk. Many victims do not disclose abuse. Some tend to hide it out of shame. Others may either feel an obligation to protect the abuser or fear retaliation. Sometimes when elderly victims do seek help, they encounter ageist responses. For example, a health care worker may unquestionably accept a relative’s statement that an elderly parent has Alzheimer’s disease (supporting the stereotype that everyone > 65 yr has some degree of dementia). Or health care personnel may dismiss the possibility of abuse because they cannot believe that an 80-yr-old husband is capable of beating his 79-yr-old wife.
Health professionals must always be alert to the possibility of elder abuse and neglect–even when the symptoms and signs are not readily apparent. A failure to be alert to these problems may mean missing the diagnosis, even when symptoms and signs are obvious. For example, a relative may bring a patient with a fracture to the emergency department and attribute the injury to a fall caused by poor balance. Although falls and osteoporosis are common in the elderly, each new fracture should be thoroughly assessed, and the possibility of abuse should be considered. Medical personnel should ask specific questions about how the injury occurred and should avoid making assumptions based on an incomplete history or ageist stereotypes.
Isolation of the elderly victim is a common formidable barrier to detection. Factors such as retirement, loss of friends and relatives because of death and relocation, and disabilities that limit mobility tend to leave older people more isolated than younger people. Isolation tends to increase when the person is being abused because the abuser typically limits the victim’s access to the outside world (eg, denying visitors, refusing telephone calls). Indeed, the health care worker is often the only person to whom the victim has access, which emphasizes the need to be alert to the possibility of abuse. For at least part of the interview, the health professional and the elderly patient should be alone, especially if the patient is always accompanied by a relative or caregiver. This gives the health professional a chance to ask about the patient’s life and establish the rapport and confidentiality that are essential for accurate detection.
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