by Bryan Kemp

Elder abuse is a relatively new issue confronting people who work with older individuals, not because it hasn’t existed before now, but because it’s finally receiving the attention it merits. Whereas recognition of the problem of child abuse goes back to at least the 1920s, only since about the 1980s has elder abuse become a national and local issue in the United States.

Four types of elder abuse are commonly identified: physical, psychological, sexual and financial. An elder may experience any or all of these types of abuse. Policy responses have included legislation outlawing elder abuse, establishment of adult protective services in all the states and funding for increased research.

Professionals working with older adults -- social workers, psychologists, nurses and physicians -- can play important roles in detecting, reporting and evaluating cases of suspected abuse and neglect. First, such professionals must be able to detect and recognize the symptoms. Most states require that licensed professionals report suspected elder abuse either to the police or to adult protective services. Gerontological mental health professionals are not obligated to prove the existence of abuse, but rather to report instances where the suspicion or possibility of abuse exists.

Altogether, the four kinds of elder abuse affect a reported 3 percent to 4 percent of the older population. For every case reported, however, an estimated four to five similar cases go unreported. The consequences of abuse can be devastating for the older person. All forms of abuse can lead to increased disability, emotional trauma, changes in personal residence, the need for more care and the loss of needed assets. In addition, it has been estimated that being abused shortens an elder’s life expectancy by up to 25 percent.

Recognizing the Signs

Mental health professionals who work with older adults should be alert to the signs of each of the four classes of abuse:

Physical. Signs of physical abuse or neglect may include bruises or injuries on the elder’s body, evidence the older adult is receiving poor or inadequate care, indications that the elder has been deprived of food or water, evidence that the elder has poor hygiene and indications that the older adult is experiencing excessive pain.

Psychological. Signs of psychological abuse may include an elder manifesting fear or lack of responsiveness when with particular people, changes in the older adult’s frequency of going out of the house, an older adult showing symptoms of depression, or statements indicating that the elder is being verbally assaulted or threatened.

Sexual. Signs of sexual abuse can be seen upon physical examination of the elder. In addition, an older person may directly report inappropriate touching or forced sexual relations.

Financial. Signs of financial abuse often include the elder losing money, misuse of the older adult’s credit and credit cards, changes to documents such as wills and trusts, isolation of the older person, or statements indicating that the elder is giving assets to someone else.

Understanding and Responding

To fully understand and appreciate the phenomenon of abuse, professionals in aging need to consider three factors: the older person’s vulnerability to abuse, the psychology of the perpetrator and the transactional dynamics between the two. All elders who are abused are vulnerable in one way or another -- generally due to their medical condition or disability, their cognitive or psychiatric status, recent stressors in their lives, their personality or their decreased physiological reserves. To put this knowledge into practice, gerontological mental health professionals should profile each of their clients or patients to help determine that person’s susceptibility to abuse. This will help such professionals flag high-risk individuals for more careful monitoring.

Perpetrators of abuse tend to be uninformed but well-intentioned caregivers who are under a great deal of stress themselves, people with personality disorders who take advantage of others or people who use a trust relationship with an older person for inappropriate financial gain. The transactional elements of abuse include isolation of the older person from others, some form of dependency between the victim and the perpetrator, greed and opportunity on the part of the perpetrator when it comes to financial abuse, and control over the actions of the older person. A vital task for mental health professionals is therefore to ask about these issues in the assessment of all older individuals. To ensure that the elder feels safe answering the questions, professionals should make sure that at least part of the interview process occurs in private.

Mental health professionals may at times be asked to testify about elder abuse among clients or patients they have seen. As a consequence, such professionals should keep good records of their clients’ or patients’ medical, psychiatric, cognitive, functional and social-interaction status. These records can be helpful in both criminal and civil resolution of elder abuse cases.

Treatment for Abused Elders

Finally, gerontological mental health professionals can make a vital contribution to the treatment of older people who experience abuse. Many such elders have a difficult time finding a way out of the abuse situation or the abusive relationship. Issues of dependency, codependency, intimidation and loss of support play key roles in keeping an older person in an abusive situation. Helping to resolve these issues through counseling or psychotherapy is necessary but often difficult. It is important for mental health professionals to remember that all cases of suspected elder abuse are not easily resolved.

Given the interpersonal dynamics between the victim and the perpetrator, repeated attempts at resolution frequently are necessary. This is especially evident where one or both of the parties have personality issues such as dependency which prevent the individual from expecting or providing suitable care. Mental health professionals should follow up on such cases on a regular basis with repeated attempts at intervention.

In cases of this sort, another role of the gerontological mental health professional is to help evaluate whether the older person has the capacity to make independent decisions or whether the elder is being unduly influenced. If an older person in fact has decision-making capacity and is not being unduly influenced, the individual has the right to make decisions -- even bad decisions. Such elders nonetheless need ongoing mental health treatment to help them realize they can make better decisions. By contrast, older adults who lack capacity or who are being unduly influenced by others need both mental health and legal interventions to protect them and their assets from harm and abuse.

Bryan Kemp is professor of medicine and psychology in the Program in Geriatrics at the University of California, Irvine (UCI). In addition, he serves as a psychologist for the UCI/Orange County Elder Abuse Forensics Center in Irvine, Calif.

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