Hidden in the Shadows: Detecting and Addressing Elder Abuse

Mandated Reporting

All 50 states and the District of Columbia have an APS agency designated to investigate reports of elder abuse and provide victims and their families with treatment and protective services. In general, APS offers case management, emergency medical services, alternative housing arrangements, and help in obtaining Medicare, Medicaid, and aging services.6

Elder abuse laws differ from state to state, so it is important for practitioners to become familiar with the laws that apply in their particular state. Additional information about reporting elder abuse can be found in Table 4.

Several barriers have been identified with regard to practitioner reporting of suspected elder abuse. One is that many clinicians do not have a clear understanding of how APS operates or are not familiar with elder abuse reporting laws or who to contact if they were to make a report.6

Other barriers include “fear of losing the therapeutic relationship, fear of causing offense, and fear of being wrong — meaning, reluctance to ask about abuse without strong evidence,” Cooper said.

She noted that some clinicians have “empathy with the perpetrators” and a belief that procedures designed to deal with the abuse may be “inappropriate and punitive.”

Although empathy for caregivers is important and can inform the therapeutic relationship and planned interventions, it cannot cloud the judgment of a clinician who is concerned about the safety and well-being of the elder.

The Role of Psychiatrists

Education: Psychiatrists and other healthcare professionals play an important role in education and dissemination of information by providing the victim with information about the nature of the problem, the options, and by reassuring the person that he or she is not responsible for what has happened.6 Victims should also be made aware of emergency community resources (eg, lock replacements, counseling, hotlines, shelters, meals on wheels, visiting nurse, adult daycare, and homemakers).6 The clinician should refer the elder to services (eg, social or legal services) that can help with safety planning.

Supporting caregivers: “Family members require information and support,” Dr Cooper declared.

Referring family members to social services that can assist with respite care and practical challenges can take the burden off overstressed caregivers; however, “without additional interventions, respite care may not be sufficient,” she noted.

Initiating a discussion with caregivers can be helpful, although “you should ask about abuse in a sensitive way,” she advised.

“You can emphasize how stressful it is to be a carer and ask, ‘Have you ever been so stressed that you have screamed or shouted at the person you care about? Are you concerned that you might physically hurt him or her?’”

She added, “Actually, most caregivers of people with dementia are often willing to report abuse.”

Assessing capacity for decision-making:A fundamental issue in managing abuse of people with dementia and other psychiatric illnesses is whether they have the capacity to make decisions about their abusive situation,” Dr Cooper commented.

For example, an elder may decline assistance and refuse interventions deemed appropriate by an abuse investigation, such as moving to alternative housing.

“People with capacity have the right to make decisions that involve risk and that risk has to be made clear by the relevant agencies via an open discussion,” Dr Cooper said.

However, in people “who lack capacity to make decisions around the abuse, usually due to dementia but sometimes due to other serious mental illness, decisions must be made in their best interests, taking into account their current views and their previous wishes where these can be known,” she added.

Psychiatric interventions: Providing interventions for mistreated older adults “may reduce the emotional consequences of abuse — for example, depression and anxiety — since psychological therapy to allow discussion of the impact of abuse is likely to be helpful,” Dr Cooper said.

Decreasing isolation may also “help treat psychological symptoms, rebuild confidence, and reduce the risk for being victimized again.”

She added that psychological or other interventions “may also be indicated for abusers, especially where this is a family member, in which case family therapy may be helpful.”


The problem of elder abuse will likely increase in tandem with increases in the number of older people. Psychiatrists can be instrumental in detecting abuse in older adults, in both those with and without cognitive impairment or neurodegenerative disorders, and arranging appropriate referrals and interventions.


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4. National Council on Aging (NCOA). Elder Abuse Facts. https://www.ncoa.org/public-policy-action/elder-justice/elder-abuse-facts/. Accessed February 12, 2019.

5. United States Census Bureau. Facts for Features: Older Americans Month: May 2017. https://www.census.gov/newsroom/facts-for-features/2017/cb17-ff08.html. April 10, 2017. Accessed February 12, 2019.

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10. Kennedy RD. Elder abuse and neglect: the experience, knowledge, and attitudes of primary care physicians. Fam Med. 2005;37(7):481-485.

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12. Cooper C, Selwood A, Blanchard M, Walker Z, Blizard R, Livingston G. The determinants of family carers’ abusive behaviour to people with dementia: results of the CARD study. J Affect Disord. 2010;121(1-2):136-142.

13. Sengstock MC, Barrett SA. Abuse and neglect of the elderly in family settings. In: Campbell J, Humphreys J (eds). Nursing Care of Survivors of Family Violence. St. Louis, MO: Mosby; 1993:173-208.  

14. National Center on Elder Abuse (NCEA). Elder Abuse Screening Tools for Healthcare Professionals. http://eldermistreatment.usc.edu/wp-content/uploads/2016/10/Elder-Abuse-Screening-Tools-for-Healthcare-Professionals.pdf. 2016. Accessed February 12, 2019.

This article originally appeared on Medical Bag