Note the Signs of Elder Abuse

Elder abuse is a problem that is often ignored.¹ Public policy developments have brought increased awareness to the issue since the 1970s, but there is still a significant deficit in health care professionals’ knowledge about elder abuse. Each year in the United States, 1 million to 2 million adults over age 65 are injured, exploited, or mistreated by caregivers. Currently, more than 36 million people in the US are older than 65 and 600,000 older adults require assistance with activities of daily living.² The number of American adults older than 60 is expected to double by 2050,³ with adults over age 85 serving as the fastest growing cohort.⁴ This aging population is at risk for abuse and neglect, which are frequently underreported, underestimated, undetected,⁵ and often perpetrated by family members.⁶

Health care professionals must be aware of the possibility of elder mistreatment among their patients.¹ Oral health professionals typically see patients every 3 months to 6 months, while patients may see their primary care physicians much less.⁵ Dental hygienists have frequent interaction with older adults and are well positioned to provide risk assessment, detect signs and symptoms of mistreatment, and promote strategies to improve patients’ quality of life.⁴

THE NATURAL AGING PROCESS

Older adults are retaining their natural dentitions longer, which means dental hygienists need to become knowledgeable of the unique needs of this patient population. Young-old adults are those between ages 65 and 75; old-old adults are between 75 and 84; oldest-old adults are older than 85; centenarians are older than 100; and supercentenarians are older than 110.⁷

Oral health professionals need to understand the natural physiological changes associated with aging, in addition to medication side effects in order to differentiate these from signs of abuse.⁶ Primary changes associated with aging are those that occur naturally. Aging-related secondary changes result from outside factors and acceleration of chronic disease.

As adults age, the skin becomes thin, wrinkled, and dry and is less tolerant of extreme temperatures. Functional capacity of most organs and cell metabolism gradually decreases. Bone mass and muscle function gradually decrease and joints may stiffen. There is a decline in cardiac output and the blood vessels become less elastic; lumen of vessels also decreases in size, resulting in reduced circulation to organs and decreased oxygen-carbon dioxide exchange. Respiratory muscles weaken, which limits chest expansion and effective coughing and increases the possibility of infection. The gastrointestinal system produces less hydrochloric acid, and peristalsis and absorptive functions decrease. The central nervous system slows and intellectual or cognitive function may decline; this may make complex tasks more difficult. Short-term memory functions decline, but long-term memory remains, except in cases of dementia. With slowing of the peripheral nervous system, tactile sensation decreases, increasing the risk for falls.

Age-related vision changes include needing more light, decreased peripheral vision and pupil dilation, and problems distinguishing between the colors blue and green. Age-related hearing changes include thicker and dryer ear wax, ringing in the ears, and diminished ability to hear high-frequency tones. The thyroid has decreased efficiency, increasing cold sensitivity. This may make patients less able to respond to infection with an increased body temperature.

The immune system declines gradually with age. Age-related changes to skin and mucous membranes make patients more susceptible to infection and increase the risk for autoimmune disorders. The thymus gland begins to atrophy and T-cell function is diminished. Excess light and noise can be distracting and decrease concentration. The degree of decline in body systems and functions varies greatly from patient to patient.⁷

ABUSE

Abuse is defined as the inflection or injury, confinement, intimidation, or punishment that results in physical harm, pain, or mental distress (Table 1).⁸ Elder abuse is a single or repeated act or lack of responsibility occurring where there was an expectation of trust, which causes harm or distress to an older person.⁸ Assessing the prevalence of abuse is difficult because each state has different regulations and legal definitions of abuse.⁴

Physical abuse causes unnecessary physical harm. It includes hitting, biting, pushing, kicking, beating, burning, or improperly medicating. It may also involve the use of restraints or exposure to severe weather.

Emotional abuse involves name-calling, insults, threats, isolation from friends or family, manipulation, or treating an older adult like a child; it usually results in fear or mental anguish for the elderly adult. Sexual abuse is any nonconsensual sexual contact; this can involve touching, photographing, unwanted sexual advances, rape, sodomy, or coerced nudity. Neglect is failure to provide life necessities or assistance with activities of daily living; it can range from withholding attention to intentionally ignoring the physical, social, or emotional needs of an older adult. Failure to maintain medical and dental needs is considered neglect.⁹ Financial abuse includes fraud, forgery, forced property transfers, using an older adult’s money to make unapproved purchases, or denying the adult access to his or her own money. Exploitation also involves misuse of legal guardianships, powers of attorney, and scams.⁸ Financial abuse is the fastest growing form of elder abuse. In 2010, older adult victims of financial abuse lost more than $2 billion.⁴

The first reported case of elder abuse was referred to as “granny battering” and occurred in the United Kingdom in the 1970s. In the 1980s, studies confirmed that elder abuse was also a problem in the US. In the late 1980s, the federal government established the National Center on Elder Abuse under the Department of Health and Human Services.²Additionally, the World Health Organization (WHO) and United Nations support annual World Elder Abuse Awareness Day and the International Network for the Prevention of Elder Abuse.¹ In 2016, the WHO adopted the Global Strategies and Action Plan on Aging and Health to provide guidance for countries addressing elder abuse.³ Further advances have been made over the past 30 years with all states now having Adult Protective Service (APS) programs and laws requiring health care professionals to report suspected cases of abuse.²Despite these advances in legislation, 63% of family physicians report never having asked older adults about mistreatment.⁵They may be afraid of offending patients or they are just uncomfortable talking about such issues. Communicating with patients who have dementia can also be difficult.⁵

Most elderly Americans live in their homes. Some will require help with their activities of daily living, which may be provided by family members, friends, or home health aides. As aging Americans continue to live at home and require assistance, the prevalence of elder mistreatment is likely to increase.⁴

A systematic review found the prevalence of elder abuse in the US ranges from 3.2% to 27.5%.¹⁰ The WHO estimates that one in six older adults is mistreated in some form.³ One in 10 older adults reported being emotionally, physically, or sexually abused, or neglected between 2009 and 2010.¹¹ The more vulnerable a patient is, the more likely he or she is to be abused and the more serious the nature of abuse. Of the 17% of adults who are mistreated, 11.6% are psychological/emotional abuse, 2.6% are physical abuse, 6.8% are financial abuse or extortion, 0.9% are sexual abuse, and 4.2% are neglect. It is estimated that only 1% of abuse cases are reported.⁹ More than 90% of abuse cases are perpetrated by a family member,² usually an adult child acting as a caregiver.⁴ Underreporting is common and it is estimated that for every case of elder mistreatment reported to APS, there are another 23 unreported cases. Elder mistreatment spans every race, ethnicity, gender, and socioeconomic status.⁴

CHARACTERISTICS AND SIGNS OF MISTREATMENT

There are multiple risk factors that contribute to elder mistreatment.¹ Older adults depending on care from family members are at higher risk for abuse than those in assisted living or long-term care facilities.¹⁰ The risk of abuse also significantly increases as the level of dependence on the caregiver increases.⁵ Common risk factors are: physical or cognitive impairments, mental health problems, and little social interaction. Elder pa­tients with limited social exposure and previous traumas are also at high risk for abuse and neglect.⁴ Chronically ill older adults may have a frail physique which makes them vulnerable to abuse; visual and hearing impairments also in­crease a patient’s vulnerability. Adults with cognitive impairment from stroke or dementia may not recognize they are being mistreated or remember occurrences.⁵ 

Some research associates the burden of caregiving with elder mistreatment.⁵ Family caregivers with histories of mental illness or substance abuse or who are unemployed are more likely to perpetrate abuse. Research also finds that a caregiver’s social isolation (fewer than three friends) increases the likelihood of mistreatment and the severity of abuse or neglect.⁵ Men are more likely to abuse older adults than women. Perpetrators are also frequently unemployed, unable to live independently, and financially or emotionally dependent on the older adults they abuse.⁴

Dental hygienists should assess a patient’s medical and dental history, emotional status, physical characteristics, and extra- and intraoral manifestations (Table 2).² Patients who appear anxious, withdrawn, depressed, overly eager to cooperate,² aggressive, irritable, or note that they may not be in control of their own finances may be experiencing some form of mistreatment.⁴ Patients experiencing abuse will often provide illogical explanations or quickly jump or dodge motions from another person.⁶

Signs of physical abuse include: bruises at various stages of healing, welts or patterned marks from rope or belt, repeated injuries, burns, bite marks, facial or mandible fractures, facial or eye bruising, lip trauma, temporomandibular pain, traumatic alopecia, avulsed or fractured teeth, and fractured dentures.² Unresponsive attitude, lack of communication, unreasonable fear, evasiveness, and lack of social interest are common signs of emotional abuse.⁶ Signs of sexual abuse are self-reporting of sexually transmitted infection (STI) or medications prescribed for an STI, or intraoral signs of STI, such as condyloma acuminatum, syphilis chancre, or primary herpetic gingivostomatitis. Palatal petechiae or bruised edentulous areas are signs of forced oral sex.⁶ Signs of neglect include sunken eyes, extreme thirst, unexplained weight loss, poor personal or oral hygiene, inappropriate clothing for the season, dirty clothing, rampant decay, untreated perio­dontitis, lack of denture, ill-fitting denture causing lesions and sore areas like epulis fissuratum or atopic candidiasis, untreated medical conditions, malnutrition, and dehydration.^2,4,6

SCREENING FOR MISTREATMENT

Elder abuse is frequently unreported due to lack of proper screening procedures within health care settings. Identifying older adults at high risk for abuse or neglect is often challenging for the health care professional. Older adults bruise easier and heal slower than younger adults, making it difficult to accurately determine causes and timing of visible injuries or bruises. Many abusers are family members and victims are reluctant to admit that a family member is hurting them; they also feel ashamed, embarrassed, and are afraid of being abandoned. Physical and cognitive barriers may present in medically compromised patients where they do not understand their own mistreatment. Screenings also fail when health care professionals do not recognize the signs and symptoms of abuse and neglect.⁴

The dental hygienist is crucial in gathering information for assessments in the dental and public health settings.⁶ Screening protocols are easy to incorporate into patient assessment at routine appointments. Questions in private, away from the caregiver, determine the need for further referral and legal reporting, and increase patient safety.¹²

Several abuse screening mechanisms are available through the American Psychological Association.¹² A four question general abuse screening was presented for use in nursing practice, and is also applicable for dental hygiene. The assessment questions include:¹³

• Do you feel safe at home?
• Who is responsible for your care?
• Do you often disagree with your caregiver? If so, what happens?
• Does anyone shout at you, slap, hit, or criticize you, leave you alone, or make you wait for food?¹¹

If the dental hygienist is suspicious based on these answers, four further questions provide insight into the nature of the mistreatment:¹³

• Has anyone ever touched you without consent?
• Has anyone made you do things you don’t want to do?
• Has anyone ever taken something that was yours without asking your permission?
• Have you ever signed any documents that you didn’t want to sign or didn’t understand?¹³

It is not the responsibility of dental hygienists to prove that abuse occurred, but it is their duty to document, refer for necessary medical or psychologic treatment, and report suspected abuse to proper state authorities.¹² Documentation should include answers to screening questions, patient’s physical and emotional state, and provider’s observations. Drawings or photos should be taken of lesions of bruises that are extra- or intraoral.² Photo evidence often becomes crucial for protective services and law enforcement to further investigations of suspected abuse.¹²

REPORTING REQUIREMENTS

The dental hygienist who suspects a patient is in an abusive or neglectful situation should decide if contacting authorities is the proper decision and, if so, make the proper report immediately. A reasonable suspicion about a patient’s physical or mental condition is all that is necessary to initiate an APS report. APS is designed to receive reports of potential elder abuse or neglect, investigate allegations, determine if the allegations are valid, and arrange for victims’ services, if needed. APS also provides medical, social, legal, financial, housing, and other resources to abuse victims. Additionally, APS provides family services and supportive measures to ensure healthy living environments for older adults and their caregivers, when allegations are not sustainable, but the family or older adult may be at risk for an abusive or neglectful situation. APS procedures for dealing with abuse allegations vary from state to state.⁴

Oral health professionals should be familiar with their state’s laws about elder abuse and neglect and the procedures for how to report suspicions of abuse. Each dental office should have written procedures for documenting and reporting elder mistreatment. Multiple trainings are available to help dental hygienists learn to recognize signs of abuse; some of these are mandatory in certain states. Preventing Abuse and Neglect through Dental Awareness (PANDA) is a public-private partnership committed to educating dental professionals about recognizing and reporting abuse and neglect. “Ask, Validate, Document, Refer Tutorial for Dentists” (AVDR) uses case-study tutorials to demonstrate a four-step process in response to abuse: ask, validate, document, and refer. The RADAR Project helps individuals recognize sexual abuse and violence, and it provides information on best practices, trainings, educational materials, and current evidenced-based research.⁶

Reporting procedures specific to each state can be found by visiting eldercare.gov or calling 800-677-1116. When making a report, it is essential to know the potential victim’s name, age, and address, the caregiver’s name and address, and the nature of the person’s condition, including professional documentation taken during the visit. It is also helpful to provide any information that may establish the cause of the mistreatment or the suspected perpetrator.⁶

With most elder mistreatment occurring in the home, understanding abuse factors may help oral health professionals recognize situations that can potentially become violent and aid in preventing mistreatment.² Dental hygienists are in an ideal position to detect, document, and report suspected cases of elder mistreatment and the dental hygiene profession has the duty to protect patients from possible harm.⁶ Knowing what to look for and where and how to report allows dental hygienists to prevent harm and secure safety and improved living conditions for patients.⁴

REFERENCES

1. McAlpine CH. Elder abuse and neglect. Age Ageing. 2008;37:132–133.
2. Muehlbauer M, Craine PA. Elder abuse and neglect. J Psycholog Nursing. 2006;44:43–48.
3. World Health Organization. Elder Abuse Fact Sheet. Available at: who.int/mediacentre/factsheets/ fs357/en/. Accessed May 10, 1018.
4. Manning M. Addressing elder abuse. Dimensions of Dental Hygiene. 2015;13(5):61–64.
5. Shamaskin-Garroway AM, Giordano N, Blakley L. Addressing elder sexual abuse: The critical role for integrated care. Traditional Issues on Psychological Science. 2017;3:410–422.
6. Ridilla PS. Family abuse and neglect. In: Wilkins EM, ed. Clinical Practice of the Dental Hygienist. 12th ed. Philadelphia: Lippincott, Williams, & Wilkins; 2017:1047–1056.
7. LaSpina LM, Towle JH. The older adult patient. In: Wilkins EM, ed. Clinical Practice of the Dental Hygienist. 12th ed. Philadelphia: Lippincott, Williams, & Wilkins; 2017:899–916.
8. American Psychological Association. Elder Abuse and Neglect: In Search of Solutions. Available at: apa.org/pi/aging/elderabuse.html. Accessed May 10, 2018.
9. Centers for Disease Control and Prevention. Elder Abuse. Available at: cdc.gov/violenceprenention/ elderabuse/defintions/html. Accessed May 10, 2018.
10. Cooper C, Selwood A, Livingston G. The prevalence of elder abuse and neglect: a systematic review. Age Ageing. 2008;37:151–160.
11. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, financial abuse and potential neglect in the United States. Am J Public Health. 2010;100:292–297.
12. Jackson SL. Detection and legal obligations to report. In: Understanding Elder Abuse: A Clinician’s Guide. Washington, DC: American Physiological Association; 2018:55–75.
13. Wieland D. Abuse of older persons: An overview. Holistic Nursing Practice. 2000;14(4):40–50.

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From Dimensions of Dental Hygiene. June 2018;16(6):36-39.