Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0138cElder Abuse—Epidemiology, Recognition and ManagementMartin J. VernonSouth Manchester University Hospitals NHS Trust, Manchester, UKDuring the 1980s, elder abuse emerged as a health and social issueof international importance 1 . It is defined as ‘‘a single or repeatedact or lack of appropriate action occurring within any relationshipwhere there is an expectation of trust which causes harm ordistress to an older person’’ 2 . While most authorities include selfneglectwithin the broad definition, acts which threaten an elder’swell-being as a consequence of their competently made decisionsare specifically excluded.Abuse may occur in one of two settings. Domestic abuse isperpetrated within the home of the victim or a caregiver by eithera relative or other care provider. Institutional abuse occurs withina designated care facility (residential or nursing home or hospital),perpetrated by one or more individuals having an obligation tocare for and protect the victim.Five major categories of abuse have been identified 3,4 :1. Physical: any activity involving force to generate bodily injuryor pain, including striking or burning and the use of physicalor pharmacological restraint.2. Sexual: any form of non-consensual sexual contact, includingunwanted touching, rape, sodomy and coerced nudity.3. Psychological: the infliction of distress through verbal or nonverbalacts, including insults, threats, humiliation, infantilizationand harrassment.4. Financial: the improper use of an elder’s property or assets,including theft, deception, coercion and misuse of authority toact, such as power of attorney.5. Neglect: the refusal or failure to fulfil care obligations,including the provision of food, water, clothing, medication,comfort and protection.PREVALENCE AND INCIDENCEVariability in case definition obscures direct comparison, althoughthe prevalence of elder abuse is broadly similar throughout Europeand North America. To date there are few data from developingcountries (Table 138c.1). With the exception of the USA, a lack ofnational incidence data reflects widespread absence of formalmechanisms for case reporting and validation. American dataestimate the incidence of domestic abuse at 450 000 elderly people/year, of which only 16% are reported to statutory agencies 5 .VICTIM CHARACTERISTICSLikelihood of being abused increases with age 6 . Elders aged over85 are at particular risk of neglect 7 , financial abuse 8 and abuse bydesignated carers 9 . There is some evidence that minority ethnicityand non-White race represent risk factors for abuse 6,10 . Womenare more likely than men to be victims 11 but this observation maybe confounded by greater likelihood of living alone, which isassociated with financial abuse 8 . In contrast, victims of physical,sexual or psychological abuse are likely to live with others,particularly a spouse or child 12 . Poverty elevates the risk ofabuse 6 .The role of cognitive impairment is complex. Factors predictingabuse of dementia patients include behavioural disturbance, poorpremorbid relationship with a carer and psychological or physicalabuse by the patient 13 . The severity of cognitive impairment doesnot appear to be associated with abuse. Spouses caring fordementia patients are at particular risk of psychological andphysical abuse 35 . In one series, one-third of carers reportedphysical abuse by the patient, which in turn was associated withabuse of the patient by the carer 14 .Vulnerability to abuse has been associated with certainpersonality traits 15 . Victims of psychological abuse have lessability to control problem situations and tend to react aggressivelywhen feeling anger or frustration. In contrast, physical abusevictims pursue passive or avoidant behaviour, while financialabuse victims possess negative beliefs of self-efficacy and turnaggression or frustration on themselves.ABUSER CHARACTERISTICSGreater understanding of abusive situations has focused attentionon those perpetrating abuse. Carers who suffer social isolation,feel unsupported and are financially dependent are at risk ofabusing 13,16,17 . Men are more likely to abuse than women, andmore likely to cause physical abuse 18 . Psychological abuse is morelikely to be caused by women. Abusers tend to suffer declininghealth and mental illness increases the risk of perpetrating abuse 19 .In particular, depression and anxiety among carers are associatedwith abusive behaviour 20,21 .The role of drug and alcohol misuse is controversial. Abusersidentified as misusing substances are likely to be male children ofthe victim, less likely to provide care and more likely to causephysical or psychological abuse than financial abuse 22 . However,in one study of referrals to a community psychiatric service,consumption of alcohol by the carer was not associated withabuse 13 .Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd