Elder Abuse and Neglect: Appearances Can Be Deceptive
By J. Halphen, JD, MD and J. Burnett, PhD; August 28, 2014; http://www.psychiatrictimes.com

Each year many older adults experience abuse, neglect, and exploitation by non- strangers that are expected to safeguard them and protect their interests. Self- neglect, where the elderly person doesn't have any effective caregivers, is another commonly reported condition. The number of persons impacted by elder mistreatment and self-neglect is growing, with consequent increases in morbidity and premature mortality.

Because elder mistreatment and self-neglect often occur in domestic settings, the likelihood of detection are limited. Unlike abused children who've more frequent exposure to individuals outside their homes, older adults might not exactly see anyone aside from their abusive/neglectful caregiver until they search for a physician or emergency department. Self-neglecters might have even less contact with others. For these reasons, it is important that surveillance for elder mistreatment and self-neglect is completed with each clinical encounter.

The most regularly reported form of elder mistreatment is self-neglect. The following Case Vignette illustrates how misleading the individual interview may be in a clinical environment when the person does not appreciate his / her circumstances. Elderly patients might have neither sufficient appreciation of their circumstances nor the ability to make decisions regarding living arrangements. Moreover, they frequently lack the ability to take reasonable steps to improve their situation.


Mr X is really a divorced 75-year-old who lives alone. He has been delivered to an outpatient clinic with an evaluation by Adult Protective Services (APS). Although thin, he could be well-groomed and clean; he sits in the wheelchair. He is pleasant with good his full attention, talkative, and engaging. He reports that they had been hospitalized but recovered and was discharged to go home. He has past multiple sclerosis, which affects his hands, making it hard to write; he doesn't have other medical problems. He explains that although he is in a wheelchair, he or she is able to walk well with no wheelchair which is able to get about in the home without an issue. He suggests that he has no problems with day to day living activities (eg, bathing, grooming, banking, transportation) and it is able to take care of himself.

Although he does well on his mental status exam, he won't do any writing or drawing tasks, saying that writing is hard for him. He is not delirious, and he does not exhibit abnormality of thought or memory. On physical examination, it really is noted that his legs are atrophic. Asked to steer, he earnestly tries to check out instructions, apparently thinking that he can stand up, but he is unable to lift himself from the wheelchair.

The APS worker provides additional information: Mr X has previous falling and being unable to wake up; there was times when his utilities were stop; he's often without food; and his home is cluttered and filthy. He has also had episodes of confusion.

Elder mistreatment and neglect

Elder mistreatment takes place when a caregiver or person in a very trust relationship with an elderly person engages in actions or omissions that cause harm or discomfort; caregiver neglect may be the omission of needed care; financial exploitation will be the misappropriation in the elderly person’s resources. Types of elder abuse include physical abuse, emotional abuse, sexual abuse, and abandonment. The most recent US national elder mistreatment prevalence study reported that approximately 11% of cognitively intact older adults reported at least 1 kind of elder mistreatment in the previous 12 months. This number is likely an underestimate because many cases go unreported or undetected and abuse is more common among cognitively impaired older adults who may be can not report the incident.

Elder self-neglect

Elder self-neglect is described as the inability of your older adult to arrange for what he needs for safe and independent living. It will be the most frequent situation reported to APS nationwide and in some areas is the reason for approximately 70% from the referrals. Elder self-neglecters are often found living alone along with squalor, with untreated or poorly managed medical conditions, functional impairments, and little social support.

Study findings indicate that elder abuse is assigned to increased probability of mortality. Participants have been referred to APS for mistreatment and self- neglect had poorer survival. The referred persons will often be suffering from poor nutrition and unmanaged medical problems, unsafe living conditions, depletion of irreplaceable resources, and other circumstances that lead to morbidity and loss of independence. Often elderly persons below the knob on reserves physically, psychologically, cognitively, socially, and financially, thus the impact of elder mistreatment and self-neglect is amplified.

Screening, risk factors, and clinical manifestations

Since elder mistreatment and self-neglect have this kind of large negative impact, it could be the ethical responsibility from the clinician to become alert for and attempt to screen because of these conditions. The AMA along with other groups advise screening of elders for abuse in most practice settings.

Screening starts with being alert for risk factors and also the clinical manifestations of elder mistreatment and self-neglect. Risk factors of those conditions include isolation, unfavorable caregiver characteristics (drug use or mental illness), cognitive impairment, and mental illness. Cognitive impairment due to a progressive dementia or stroke is often a frequent reason behind vulnerability to elder mistreatment and self-neglect. Depression, schizophrenia, and psychosis involving delusions may also render the individual vulnerable by preventing him from appreciating his true circumstances.

Signs of elder mistreatment and self-neglect could possibly be poor hygiene; deficiency of medical adherence; poor living conditions; dehydration; demonstrated fear of caregivers; or poorly explained injuries, including bruising and scarring. Pressure ulcers and malnutrition could possibly be signs of elder abuse or neglect and call for inquiry. Keep in mind, however, the signs may not always indicate that the person is inside a state of elder mistreatment or self-neglect. There may be other explanations, and also the clinician should be in the best position to distinguish illness or normal aging from abuse or neglect. Non-physical indications of elder mistreatment include depression, thoughts of suicide, avoidant behavior, anxiety, and fear.

The patient could possibly have been cleaned up with a caregiver or hospital employee before the physician sees him. This is illustrated inside case of Mr X—the condition of the sufferer in the clinical setting may well not reflect reality. If there is suspicion of abuse/neglect, the person should be thoroughly examined to check for the stigmata of abuse that may be hidden by clothes. If injuries are located, these ought to be photographed to preserve evidence.

Talk privately with the person (faraway from potential abusers)—ask about his family and living arrangements, and ask if he could be being abused, neglected, or exploited. Unfortunately, many abused, neglected, or self-neglecting elderly patients have cognitive conditions prevent them from giving reliable accounts of their circumstances.

Brief screening instruments can also be of worth. The Table provides an overview of several tools that might be used during brief clinical assessments. These screening tools vary from 5 to 12 questions with varying reliability and validity. The majority in the assessments include self-report questions regarding current or past physical abuse, emotional abuse, and financial exploitation. Positive screens should raise the suspicion for abuse or potential self-neglect.

The case of Mr X illustrates difficulty with the evaluation of patients inside the usual clinical situations. The clinician often has unreliable reports from impaired patients and a not enough reliable information to try for validity. A patient are able to do well on cognitive screening tests and yet have a profound lack of insight and appreciation for his circumstances. There might be abhorrent and perhaps abusive situations that the person is not able to talk about that might not exactly be evident in the usual clinical setting.

It just isn't unusual on an articulate yet incapable self-neglecter to convince a physician that there are nothing wrong with his capacity to live independently without supervision. It is also normal for a neglectful relative to convince a physician that there is no neglect or abuse happening in the home. Checking with independent sources (if available) that what the sufferer and/or caregiver is saying is true may be valuable in confirming suspicions of abuse or neglect. A home safety evaluation coming from a home health company can help the clinician get a more complete picture. The best info on the true situation could be from APS—they will investigate the home environment and may assess how well the person is being cared for or whether the sufferer is able to safely continue to exist his own.


If, after performing a careful assessment of the patient and documenting your findings, elder mistreatment or self-neglect is suspected, more knowledge about legal and community resources and ongoing support must be offered. However, the most critical intervention is always to report the suspicion. The clinician should make a report to APS inside jurisdiction if the sufferer is living inside the community. If the individual lives in a facility (elderly care or personal care home), a report should be made to the company that regulates that form of facility within the jurisdiction.

These agencies are experienced with evaluating cases. They have the resources to interview family members and neighbors, visit the home environment with the patient, get financial records, and otherwise investigate more completely the patient’s home circumstances. If the clinician’s evaluation raises suspicion the elder mistreatment amounts to a crime and the individual is in danger of additional harm, it is advisable to report the facts supporting the suspicions to the police as well. APS staff will report whatever they think are crimes on the police, but earlier reporting with the clinician may help police officers prevent further harm to the individual.

Barriers to reporting

Some clinicians are not wanting to report a suspicion of mistreatment. They may mistakenly believe that reporting is punitive. The point of reporting is always to give the specialized social services agency a chance to stop the damage being done towards the elderly person. APS is mandated to use the least restrictive alternative had to stop the injury, as well as the agency has plenty of to do, so that it will not interfere greater than is absolutely necessary.

Clinicians may believe that they have to have permission to report; however, in all of the but 6 states, reporting is specifically required by law regardless with the desires of the sufferer or family. The clinician may fear civil or criminal liability for reporting if his suspicions aren't correct. However, most US jurisdictions specifically protect the good-faith reporter even if your mistreatment just isn't substantiated. Reporting can even be done anonymously to APS so the relationship of the clinician towards the family or patient is just not disrupted. If the clinician really wants to notify the patient or family, he can explain which a social services agency is arrested for assisting people who need help, along with the agency doesn't have a police or prosecutorial function.


Elder abuse, neglect, financial exploitation, and self-neglect are growing problems worldwide. They cause great hardship and suffering for many of the elderly. Clinicians have an obligation to become alert because of these problems and intervene by reporting reasonable suspicions to the appropriate government agencies. In the rushed clinical environment, it really is easy to miss the person who desperately needs this help. It often takes help from reliable organizations, for example APS, to collect the information needed to fully appreciate the difficulties faced by elderly patients.




“Under the care of Leo J. Borrell, M.D. since December 2001, I have seen a remarkable improvement in my mother’s condition. She is responding dramatically to the new regiment Dr. Borrell has prescribed”

- Beth Rose


Feb 3, 2008

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