Elder Abuse in the Community: Information and Reporting Requirements for Physicians
Elder abuse is common, but underreported, and reports by physicians make up a small percentage of all reported cases.
The 2010 United States Census recorded the greatest number and proportion of people age 65 and older in all of census history: 40.3 million, or 13 percent of the total population. This population explosion will continue as more Baby Boomers reach retirement age.
It is estimated that as many as 5 million Americans age 60 and over experience some form of elder abuse, including physical, emotional, financial and sexual abuse, as well as neglect, but only a small portion of these incidents are formally reported to authorities. Physicians in particular can be reluctant to report abuse because of a lack of training in recognizing abuse, discomfort around confronting the alleged abuser or lack of awareness about reporting requirements and procedures.
This article will define the different types of elder abuse, identify risk factors and warning signs and demystify reporting requirements so that physicians can better advocate for this vulnerable segment of our population.
Elder mistreatment: Categories and Definitions
Under California law, elder abuse can be both criminal and civil.
Criminal elder abuse occurs where any person who knows that a person is an elder and willfully causes or permits that elder to suffer, or inflicts unjustifiable physical pain or mental suffering on the elder. It also covers situations where a person willfully causes or permits an elder to be placed in a situation in which elder’s health is endangered. (Penal Code Section 368)
Civil law defines civil elder abuse to mean physical abuse, neglect, financial abuse, abandonment, isolation, abduction or other treatment resulting in physical harm or pain or mental suffering to an elder. It also means the deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering. (Welfare & Institutions Code Section 15610)
Risk Factors for Elder Abuse
Most elder abuse within the community is perpetrated by members of the victim’s family – spouses, adult children and other relatives. Factors that put elders at risk for abuse include cognitive and/or functional impairment, social isolation and dependence on the caregiver(s). Factors that make a caregiver more likely to engage in abuse include substance abuse, mental and/or physical health problems, stress, a history of violence and financial dependence upon the victim.
The American Medical Association (AMA) recommends that physicians routinely inquire about possible mistreatment of their older patients as much as they screen for other conditions, such as breast or colorectal cancer. Patients will not always be forthcoming, owing to diminished capacity and/or fear of retaliation by their abuser. Ideally, the patient and caregiver should be interviewed separately. Red flags for abuse can include reluctance of the caregiver to allow the patient to speak with the physician alone and discrepancies between objective data and what the caregiver says (e.g., the levels of medications in the blood vs. the caregiver’s report of medications administered).
Physical Suggestions of Elder Abuse or Neglect
Physicians must be aware of circumstances and presentations that could indicate abuse. Physical examination should be accompanied by laboratory and radiographic tests as indicated. Everything must be clearly documented as it could become evidence in a court of law; drawings and photographs are particularly helpful. Signs of elder abuse to look for include:
- General appearance: Poor hygiene, dirty clothing
- Vital signs: Low blood pressure, rapid pulse (may indicate dehydration, blood loss, risk of falls)
- Oral cavity: Ecchymosis (may indicate forced oral sex), cigarette burns on the lips and fingertips, tooth fractures, ill-fitting dentures, oral venereal lesions
- Ear, nose, and throat: Deviated nasal septum (from repeated trauma), finger imprints or rope marks around the throat
- Eye: Subconjunctival or vitreous hemorrhage (may indicate new trauma), retinal detachment,
orbital fractures, and traumatic cataracts (may indicate old trauma)
- Skin: Burns, lacerations, ecchymosis, pressure ulcers, bruises in various stages of healing, lesions suggestive of use of restraints on the extremities, immersion burns (glove-stocking distribution)
- Chest and abdomen: Rib fractures, pneumothorax, splenic rupture, and intra-abdominal hemorrhages (may be manifested as Cullen or Turner signs)
- Nervous system: Focal findings on examination, impaired mental status, impaired function, depression, anxiety
- Orthopedic: Impaired gait, leg length discrepancies due to fracture
If You See or Suspect Elder Abuse
Physicians not only have an ethical obligation to report suspected elder abuse, they are required to report by the laws of the State of California. Mandated reporters include administrators, supervisors and any licensed staff of a public or private facility that provides care or services for elder; any elder or dependent adult care custodian, health practitioner, clergy member or employee of a county adult protective services agency or a local law enforcement agency; any person who has assumed full or intermittent responsibility for the care or custody of an elder, whether or not he or she receives compensation. Officers and employees of financial institutions are mandated reporters of financial abuse. Mandated reporters MUST report actual or suspected physical abuse, abandonment, isolation, financial abuse, or neglect which is observed, evident or described. Form SOC 341 (Report of Suspected Dependent Adult/Elder Abuse) must be completed and signed by the mandated reporter.
Physicians should report abuse immediately or as soon as possible by telephone, followed by a written report or Internet report through the confidential Internet reporting tool within two (2) working days. If the suspected or alleged abuse is physical abuse and the abuse has occurred in a long-term care facility, a report has to be made to both the ombudsmen and law enforcement. When serious bodily injury occurs, the mandated reporter has to contact law enforcement within two hours and also make a report to the ombudsmen within 24 hours. Reports of less than serious bodily injury go to law enforcement and ombudsmen within 24 hours. Failure to report is a misdemeanor, punishable by six months in the county jail and a fine of one thousand dollars ($1,000). Any mandated reporter who willfully fails to report physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder, where that abuse results in death or great bodily injury, shall be punished by not more than one year in a county jail and a fine of five thousand dollars ($5,000). Failure of an officer or employee of a financial institution to report financial abuse is punishable by a $1,000 fine and $5,000 if the failure to report is intentional.
When abuse occurs in one’s home or apartment or the home or apartment of a family or friend, physicians should report it to local law enforcement and county district attorney's office and Adult Protective Services (APS) in the relevant county.
Victims of elder abuse tend to be isolated. Their interactions with physicians present critically important opportunities to recognize elder abuse and to intervene or refer the victims to appropriate providers. Family physicians in particular need to educate themselves about signs of elder abuse, risk factors and reporting requirements in order to be advocates for some of their most vulnerable patients.
References and Resources
“Elder Abuse,” by Mark S. Lachs, MD, MPH, and Karl A. Pillemer, PhD. New England Journal of Medicine. November 12, 2015.
“Elder Abuse and Neglect: What Physicians Can and Should Do,” by Mahnaz Ahmad, MD, MS, and Mark S. Lachs, MD, MPH. Cleveland Clinic Journal of Medicine. Volume 60, Number 10 (October 2002).
California Department of Social Services – Adult Protective Services
Form SOC 341 (Report of Suspected Dependent Adult/Elder Abuse)
California Elder Abuse Helplines, Hotlines, and Referral Sources
National Center on Elder Abuse
California Associates for Nursing Home Reform (CANHR) Elder Abuse Fact Sheet