DMEJ

Duke Medical Ethics Journal

The Overlooked Tragedy of Elder Abuse in America

By Anushka Goel

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No elderly person should ever have to suffer abuse and neglect. Yet, the bleak reality is that elder abuse in America is disturbingly common, with over 10% of individuals aged 65+ experiencing elder abuse in a given year [1].

“Elder abuse” refers to any intentional or unintentional acts that cause harm or serious risk of harm to an elder. It includes physical abuse, psychological abuse, financial exploitation, neglect or abandonment, and sexual abuse. The manifestations of elder abuse are multitudinous: nursing home staff mistreating a patient, children of an elder exerting domination over their lives, conmen befriending a senior and then seizing control of their assets… the list goes on [2]. Elder abuse exists virtually anywhere the elderly exist - their homes, nursing homes, assisted living facilities - and can be perpetrated by anyone they are in contact with - family members, friends, neighbors, caregivers, guardians/conservators, professionals, and strangers. Alarmingly, 90% of abusers are family members or trusted others [3]. Needless to say, elder abuse is not an isolated, haphazard phenomenon - it is part of an ecosystem that undermines the wellbeing of seniors and lets their abusers operate with impunity.

What is it about the ecosystem of old age care that lets elder abuse run rampant? For starters, the features of the elderly that make them prime targets: they may be physically frail, mentally unsound, facing cognitive decline, dependent on others, and thus vulnerable. Some, such as ALS patients, may not even retain the ability to communicate to others that they have been abused.

“Elder abuse is not an isolated, haphazard phenomenon - it is part of an ecosystem that undermines the wellbeing of seniors and lets their abusers operate with impunity.”

Cognitive deficits in particular help explain why so many seniors fall for financial scams. With reduced executive functioning on cognitive tasks and limited insight that those deficits exist, they are more prone to manipulation. Seniors are constantly bombarded with phone and internet scams that pressurize them to give up their money, which could sadly even be their life savings. Financial fraud is estimated to cost older Americans $2.6 billion to $36.5 billion each year [4]. This sort of crime is both lucrative and low-risk, explaining why it is so prevalent [5]. Of course, when it comes to financial fraud targeting the elderly, the fault does not lie with elders for falling for scams - rather, with the criminals that exploit them, the regulators who fail to protect them, and the criminal justice system that does not bring their cases to justice.

What makes financial fraud targeting seniors so difficult to crack down on? It stems from vast underreporting of these crimes, with only 1 in 44 cases ever being brought to light [3]. Reasons seniors may not report financial abuse include shame, affection for the perpetrator (who may be a loved one), and lack of knowledge on who to report to [6]. Even if the abuse is reported, very few perpetrators are charged/prosecuted, and a minuscule number of those are actually convicted. This has grave consequences: if abusers are not punished, there will continue to be more victims.

A key reason prosecution is difficult is that it may not be possible to provide “proof beyond reasonable doubt” of the crime as required by the court. Additionally, the senior may have given power of attorney rights to another individual, limiting their own legal agency [7]. Having to be physically present in court may itself present a major obstacle for seniors due to their health status. Unfortunately even in these circumstances, the Confrontation Clause of the Constitution can make elders’ attendance mandatory during legal proceedings [8]. A more subtle but insidious challenge is the delays inherent in the justice system - if an elder only has several months to live and their trial is scheduled after a year, how will they get justice? Taken together, these judicial and personal factors make financial scams targeting the elderly a difficult scourge to eliminate.

What about other forms of elder abuse - what systemic factors allow them to perpetuate? Regarding neglect or abandonment of the elderly, one driver may be cultural. Around the world, it is much more common for elders to live with an extended circle of relatives. But in the US, 27% of adults aged 60+ live alone. This is consistent with the US being a more economically developed nation [9]. Living alone or with only one other person (as the average American aged 60+ does) can lead to isolation and be a risk factor for abuse and neglect.

Neglect of an elder can be intentional in some cases, such as when a family member chooses to withhold medicine from them. It can also be unintentional, such as when a caregiver is themselves ill or too weak to provide assistance [10]. Caregiver burnout is a serious issue that deserves recognition of its known [11]. Along with individual coping strategies, it can be mitigated by family members and paid caregivers stepping in to help, who may be covered by Medicare, Medicaid, or private health insurance.

Related to skilled care, ~1.2 million older adults in the US are accommodated in nursing homes [12]. Sadly, these and other long-term care facilities are known to be hotspots of elder abuse. The predominant forms of mistreatment in nursing homes are physical abuse (29%), resident-to-resident abuse (22%), neglect (14%), financial abuse (7%), and sexual abuse (7%). One study that surveyed nursing home staff over a 12-month period found that over 40% admitted to committing at least one instance of psychological abuse, which included yelling or swearing at residents, inappropriately isolating them, and denying them food privileges. In another study, 50% of the nursing home staff admitted to mistreating residents and 17% of certified nursing assistants reported pushing, shoving, or grabbing a resident. In a survey of nursing home residents themselves, 44% said they experienced abuse and 95% said they were either themselves neglected or witnessed neglect of another resident [13].

What could be causing these clear breaches of medical ethics and the “do no harm” principle? Though there is no excuse for abuse, nursing home staff may be releasing increased frustration due to being overworked. Indeed, 90% of nursing homes are understaffed, leading to a worryingly high resident to nursing aide ratio [13]. These issues suggest the need for increased hiring in nursing homes and improved training and accountability of nursing home staff.

Though the issue of elder abuse is complex and has many underlying causes, it can be tackled. Confronting this widespread but hidden epidemic first and foremost requires awareness of the problem, not just among healthcare workers and professionals, but all of us. While some solutions require policy changes - such as legal remedies making it easier to pursue financial abuse cases and alterations in nursing home guidelines - others can be implemented by anyone with a senior in their life.

For example, learn to recognize the signs of elder abuse: unexplained wounds, lack of basic hygiene, not having medical aids (glasses, hearing aid, walker, teeth, medications), untreated bedsores, changes in emotional state (like being unreasonably fearful), and large bank withdrawals or unusual ATM activity [14]. Simple strategies like installing doorbell cameras and text alerts from the bank, and keeping in close touch with elderly loved ones can help catch concerns early on.

With compassion and vigilance, we can all help uphold the dignity of our beloved seniors. No elderly person should ever have to face abuse and neglect.

Review Editor: Vishruth Hanumaihgari
Design Editor: Jackie No

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