Ask the Expert: Recognizing and preventing elder mistreatment

Julia Hiner, MD, associate professor of geriatric and palliative medicine, director of the Geriatric Medicine Fellowship program, and geriatrician at McGovern Medical School at UTHealth Houston

Welcome to "Ask the Expert," a new UTHealth Houston newsroom series where our leading physicians examine pressing health challenges. In this edition, we address elder mistreatment, what it means, how it happens, and signs to look for.

Identifying elder mistreatment

Elder mistreatment is the abuse, neglect, and/or financial exploitation of an adult age 65 years or older. Common forms of elder mistreatment include physical, emotional, and sexual abuse; self-neglect or a caregiver’s neglect of physical, medical, and mental health needs; and scams, theft, forgery, and unauthorized creation of medical or legal documents and lines of credit. Neglect, emotional abuse, and exploitation are most frequently reported.

Elder mistreatment affects up to 10% of cognitively healthy older adults and up to half of older adults with dementia or other cognitive impairments, like severe mental health diagnoses, traumatic brain injury, or intellectual and developmental disabilities. Despite these high numbers, the vast majority of cases are not reported to Adult Protective Services, the Department of Health and Human Services, or law enforcement. Only an estimated 1 in 14 cases reach authorities. 

In addition to negative impacts on the elderly, elder mistreatment increases health care demand at hospitals, emergency rooms, and nursing homes; exacerbates acute and chronic medical conditions; costs billions of dollars; significantly elevates risk of dying (especially in the first year); and requires caregiver time and energy to address.

Raising awareness

Some older adults don’t realize or even believe they are experiencing mistreatment, while others  self-report abuse, neglect, and exploitation. Cultural and generational norms can make it hard to differentiate what behaviors are and are not acceptable (and thus reportable), but cognitive impairment is a universal risk factor that impedes an elder’s ability to recognize and understand mistreatment. For some elders, cognitive decline is so substantial as to render them incapacitated and thus incapable of reliably making and carrying out decisions. This incapacity makes them vulnerable to financial exploitation or self-neglect while they also lack awareness of their situation and the next best steps to manage it. When this happens, surrogate and supportive decision-making assistance — as well as mobilization of community resources, supports, and services — may be needed for an elder’s safety.

In capable older adults with intact cognition, many factors can influence their willingness to understand the harms happening to them and accept help. Unfortunately, not all elders believe experts when they explain that a scam or other exploitation is happening, nor may elders want to accept resources or services due to a belief that those resources could fundamentally change their life or living situation. As a result, physicians and other professionals must carefully balance respect for autonomy with beneficence when caring for older adults who have experienced mistreatment.

Elder mistreatment can happen anywhere that older adults live, work, and play. Many forms of mistreatment involve another individual (like a family member, caregiver, friend, or neighbor) who has access to the older adult. Thus, while an older adult’s home or a facility like a nursing home are common settings for mistreatment, banks and financial institutions, social media websites, and telephone calls are frequent sources of risk, too. Ultimately, it takes a vigilant community to detect and respond to elder mistreatment.

Looking out for loved ones

Trusting your instincts and staying aware of and involved in the care of older adults in your life is important to helping them stay safe. The old adage of “If you see something, say something” rings true. You can always ask questions about care, discuss treatment plans with the health care team, and suggest accommodations for the individual needs and desires of your loved one. If you see something that isn’t right, you have recourse and avenues of support. Long-term care ombudspeople, social workers, case managers, uninvolved clinicians, Health and Human Services (akin to Adult Protective Services, but for mistreatment in facilities), and law enforcement are all good options.

However, prevention is always preferable. Your visibility in your loved one’s life at a facility is important for their safety and well-being. In addition to reducing their loneliness and social isolation, your familiar – and if needed, vocal – presence and advocacy matters for those you love. This doesn’t stop at your loved one: If you see something harmful, inappropriate, dangerous, or otherwise not okay, you can speak up for any older or disabled adult you encounter. Reporting suspicions is key; confirmation of your concern is not required. Investigation is the purview of Health and Human Services and isn’t something a family member or friend must do alone. All Texans are mandatory reporters. Whether you are a health care professional or not, reporting elder mistreatment is a legal requirement we all share.

Resources to help

In the Houston area, we have the Senior Justice Assessment Center, which is a multidisciplinary team that addresses the complex needs of adults age 60 and older living in Harris County who have experienced elder crime or elder mistreatment. This collaborative group provides a voluntary way of seeking help and justice, connecting with resources, and healing from elder mistreatment trauma. UTHealth Houston employees can use the center’s referral form to refer patients who meet the above criteria to the Senior Justice Assessment Center for expert support.

Julia Hiner, MD, associate professor, director of the Geriatric Medicine Fellowship program, and geriatrician in the Department of Internal Medicine at McGovern Medical School at UTHealth Houston. All quotes should be attributed to her.

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