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Screening for Elder Abuse and Neglect

The Affordable Care Act guarantees “from an individual perspective the recognition of an elder’s rights including the right to be free from abuse and neglect and exploitation.”Elder abuse constitutes a significant problem for older adults; an estimated 7.6% to 10% of people aged 60 and older experienced abuse in 2014. This incidence rate would appear to justify screening for such a problem that frequently goes unreported, but screening the general population is not justified. The focus of this article is on generalized screening for elder abuse in individuals who present for care in healthcare facilities, as opposed to active case-finding in situations in which abuse or neglect is more likely to occur, such as in older women who are vulnerable as a result of mental or physical infirmity. Screening for elder abuse in healthcare settings is a challenge given the low priority accorded to care of older individuals, as the lack of individuals willing to devote their careers to elder care indicates. Elder abuse is the orphan in terms of abuse when compared with domestic and child abuse. Of almost 54 million older people eligible for screening when visiting their physician, fewer than 1,500 were screened. This is also evident when comparison is made in terms of research support and general acceptance by the medical community. Federal funding for elder abuse prevention has remained static since the 1990s and is miniscule, specific for elder abuse services research, compared with funding for child abuse and domestic violence. Elder abuse contributes to morbidity and mortality and robs victims of quality of life during their final years. Does elder abuse qualify as a condition worthy of being screened? This can be examined using the Wilson and Jungner criteria to justify screening (Table 2). Consistent with the analysis in Table 2, the U.S. Preventive Services Task Force concludes that “the current evidence is insufficient to assess the balance of benefits and harms of screening all elderly or vulnerable adults (physically or mentally dysfunctional for abuse and neglect.” This conclusion is based on a variety of factors. Although a number of screening instruments are available, not all are appropriate in different settings, and there is inadequate evidence on their accuracy or that screening or early detection reduces exposure to abuse. Most communities lack resources and programs to alleviate an abusive situation that are acceptable to the victim, particularly because placement in a long-term care facility as a solution may be the least-desirable option for the victim, who may choose to remain in an abusive situation. Many other factors militate against screening. The elderly adults at highest risk include those with dementia who may be incapable of reporting or corroborating the presence of abuse. Similarly, individuals with dementia most of whom develop psychosis and paranoia may wrongfully accuse the caregiver of theft or abuse. Not infrequently, the individual with dementia is abusive toward the caregiver. Those who screen and report to an overstretched Adult Protective Services (APS) may be dissatisfied with the response and so may refuse to report in the future. Introducing screenings in medical settings is equally problematic in primary care settings, where already practitioners are pressured with meeting performance measures, and trying to cope with a distraction (the electronic health record) that may impede observation of signs or indicators of abuse. Even if staff are trained to screen, it falls on the physician to intervene. Most physicians have no training or expertise in intervening and may fear repercussions if they report to APS. In addition, definitions of abuse vary from state to state and are often difficult to interpret. Given all this, it is unlikely that physicians will embrace the notion of incorporating screening into busy practice sites without the benefit of a significant increase in reimbursement.