III. Identifying Elder Abuse
Estimates from the National Center on Elder Abuse show that a number of different groups are involved in identifying elder abuse. The following estimates show how often different representatives reported suspected elder abuse cases to state reporting systems:
- Health care providers reported 22.5% of elder abuse cases to protective services.
- Family members reported 16% of elder abuse cases to authorities.
- Service providers (including paid and volunteer workers) reported 15% of the cases.
- Friends and family members reported 8% of elder abuse cases to protective services.
- Adult protective services workers reported 6% of cases to authorities.
- Law enforcement officials reported 4.7% of cases to protective services.
- An unrelated caregiver reported elder abuse in 3.3% of cases.
- The victim reported the elder abuse in 3.8% of cases.
Given that just 1 in 25 reports is made by the victim him- or herself, it is imperative that those who are in situations where elder abuse might be present are able to identify the cases. Warning signs are related to types of abuse. One set of warning signs demonstrates the possibility of physical abuse, while other sets of warning signs exist for sexual abuse, neglect, financial abuse, and so on.
The California Department of Justice (2002) classifies warning signs into categories of physical, isolation, and behavioral. Physical warning signs of elder abuse include the following:
- Uncombed or matted hair
- Poor skin condition or hygiene
- Unkempt or dirty appearance
- Patches of hair missing or bleeding scalp
- Any untreated medical condition
- Malnourished or dehydrated
- Foul smelling
- Torn or bloody clothing or undergarments
- Scratches, blisters, lacerations, or marks
- Unexplained bruises or welts
- Burns caused by scalding water, cigarettes, or ropes
- Injuries that are incompatible with explanations
- Any injuries that reflect an outline of an object—for example, a belt, cord, or hand (p. 3)
Isolation warning signs refer to instances when older persons are physically separated from others. Experts suggest that abusers use isolation as a strategy to hide the abuse and promote the victim’s dependence on the abuser. Signs of isolation include the following:
- Family members or caregivers have isolated the elder, restricting the elder’s contact with others, including family, visitors, doctors, clergy, or friends.
- Elder is not given the opportunity to speak freely or have contact with others without the caregiver being present. (California Department of Justice, 2002, p. 4)
Behavioral warning signs refer to behaviors of the elder or caregiver that indicate abuse. Consequences of virtually any form of abuse may result in victims acting or behaving differently. Behavioral warning signs for elder physical abuse include instances when the older victim appears to exhibit the following behaviors:
- Fear to communicate
- Fear in general (California Department of Justice, 2002, p. 5)
A different set of warning signs might arise for other forms of elder abuse. For example, discussing ways that health care professionals can identify financial abuse in Crime in the Home Health Care Field, Brian Payne (2003) suggests that the warning signs of financial abuse include the following:
- Sudden changes in banking practice
- Abrupt changes in a will or other documents
- Abrupt and unexplainable disappearance of money or other assets
- Additional names on elder’s bank signature card
- Poor care provided although adequate resources available
- Previously uninvolved relatives become involved and make claims to assets
- Unpaid bills although funds are available
- Sudden withdrawal from accounts
- Extraordinary interest by others in elderly person’s assets
To be sure, when searching for signs of abuse, individuals should focus on all forms and recognize that it is not their job to determine that elder abuse occurred; instead, it is their job to determine if it might have occurred. Investigators are given the task of substantiating the abuse. As an illustration, the American Medical Association suggests that health care practitioners ask the following questions of vulnerable patients who exhibit risk factors for abuse:
- Does anyone hit you?
- Are you afraid of anyone at home?
- Does anyone take things that don’t belong to you without asking?
- Has anyone ever touched you without your consent?
- Are you alone a lot?
- Does anyone yell at you or threaten you?
If a patient answers yes to any of these questions, it does not necessarily mean that abuse occurred. However, it does mean that abuse might have occurred, and health care professionals or other individuals should report their suspicions to social services.
While signs of elder abuse exist and practitioners are given a set of questions to ask to identify the possibility of abuse, the reality is that elder abuse is drastically underreported. Estimates from the National Center on Elder Abuse suggest that anywhere from 1 in 5 to 1 in 14 cases of elder abuse are reported. To address underreporting and other issues related to elder abuse, Attorney General Janet Reno asked a group of 27 experts to participate in a round table in October 2000. The round table was titled Elder Justice: Medical Forensic Issues Relating to Elder Abuse and Neglect. The panel suggested that elder abuse was unreported and undiagnosed for the following reasons:
- No established signs of elder abuse and neglect. There is a paucity of research identifying what types of bruising, fractures, pressure sores, malnutrition, and dehydration are evidence of potential abuse or neglect. This impedes detection and complicates training. Some forensic indicators, however, are known. For example, certain types of fractures or pressure sores almost always require further investigation, whereas others may not require investigation if adequate care was provided and documented.
- No validated screening tool. There is no standardized, validated screening or diagnostic tool for elder abuse and neglect. Such a tool could greatly assist in the detection and diagnosis of elder abuse and neglect and would serve to educate and, where appropriate, to trigger suspicion, additional inquiry, or reporting to Adult Protective Services (APS) or law enforcement. Research is needed to create and validate such a focus.
- Difficulty in distinguishing between abuse and neglect versus other conditions. Older people often suffer from multiple chronic illnesses. Distinguishing conditions caused by abuse or neglect from conditions caused by other factors can be complex. Often the signs of abuse and neglect resemble—or are masked by—those of chronic illnesses. Elder abuse and neglect are very heterogeneous; medical indicators should be viewed in the context of home, family, care providers, decision-making capacity, and institutional environments.
- Ageism and reluctance to report. Ageism results in the devaluation of the worth and capacity of older people. This insidious factor may result in a less vigorous inquiry into the death or suspicious illness of an older person as compared with someone younger. Such ageism may impede and result in inadequate detection and diagnosis, particularly where combined with physicians’ disinclination to report or become involved in the legal process.
- Few experts in forensic geriatrics. In the case of child abuse, doctors who suspect abuse or neglect have the alternative of calling a pediatric forensic expert who will see the child; do the forensic evaluation; do the documentation; and, if necessary, do the reporting and go to court. This eliminates the responsibility of primary care physicians to follow up and relieves them of the burden of becoming involved in the legal process. It increases reporting because the frontline providers feel like they have medical experts backing them up. Training geriatric forensic specialists to serve an analogous role should similarly promote detection, diagnosis, and reporting and increase the expertise in the field.
- Patterns of problems. In the institutional setting, data indicating a pattern of problems may facilitate detection. For example, the minimum data set (MDS) of information for a single facility or for a nursing home chain may include an unacceptably high rate of malnourishment that—absent an explicit formal diagnosis—should trigger additional inquiry. Similarly, a survey may cite a facility for putting its residents in “immediate jeopardy” as a result of providing poor care. Or emergency room staff may identify a pattern of problems from a particular facility. In these examples, the data itself may be a useful tool in facilitating detection of abuse and neglect. This type of information is accessible not only to health care providers but also to others (U.S. Department of Justice, 2002, p. 2).
Mandatory reporting laws and training have been used to improve the ability of professionals to identify suspected cases of elder abuse. Mandatory reporting laws are those that state that certain professionals must report suspected cases of elder abuse to the authorities (which in most cases means social services). In all, 42 states have some form of mandatory reporting law. Mandated reporters include health care professionals, social services professionals, long-term care employees, criminal justice professionals, financial employees, and other professionals who might come into contact with older persons vulnerable to victimization.
Mandatory reporting laws have both strengths and weaknesses. Supporters of the laws contend that they are necessary in order to offer protection to older persons at risk of victimization. They further contend that the laws offer a strategy to educate different groups about elder abuse. In addition, those who support these laws suggest that they send a message to the public that elder abuse will not be tolerated. Finally, supporters note that the laws offer immunity to those who report in good faith. Consequently, the laws protect reporters, thereby removing their concerns about being sued for reporting misconduct.
A number of criticisms have been levied against mandatory reporting laws. Some have pointed out that the laws were developed based on child abuse models and that there was no evidence that elder abuse dynamics were similar to child abuse dynamics. In addition, the lack of research on the need for the laws has been cited as problematic. Critics also note that the laws are ageist because they assume that at a certain point in the life course, individuals are in need of help. A lack of understanding about the laws also has been offered as a criticism. In addition, some have argued that there is no evidence that the laws work; in fact, some have suggested that mandatory reporting laws create more problems then they solve. Also, some have criticized the laws on the grounds that they are not responsive to the actual dynamics of elder abuse. On a similar point, some have noted that the laws were actually unfunded mandates because no funding came along with the passage of the laws. As well, the laws have been criticized for being politically motivated as an ineffective strategy to respond to elder abuse. Finally, some have pointed out that the lack of awareness about how to abide by the law has been problematic.
The development and implementation of different training programs has been one strategy to increase adherence to mandatory reporting laws and promote detection of elder abuse. The United States Department of Justice has provided federal funding to support the development of training curricula on elder abuse. The Office for Victims of Crime has distributed the funding so that the training could actually be carried out. The American Probation and Parole Association recently developed a training curriculum to encourage better responses to elder abuse among probation and parole officers. As well, advocates at the local level have developed training packages and programs.
Despite this increased use of training, a number of concerns have made it difficult to train criminal justice professionals about elder abuse. First, the lack of adequate state laws makes it difficult to train regarding appropriate responses. Second, a lack of specific policies and protocols creates situations where curricula are more emotionally driven, rather than empirically grounded. Third, a lack of concern about elder abuse has made it difficult to get police recruits, law enforcement officers, police executives, court officials, judges, prosecutors, probation and parole officers, and other criminal justice officials willing to participate in the training. Fourth, training is typically given a lower priority when funding decisions are made. Fifth, elder abuse training curricula are not truly based on evidence-based practices simply because no such practices have been developed to guide the criminal justice response to elder abuse. Sixth, it has sometimes been assumed that training will improve the response to elder abuse, yet no evidence has actually made this connection. Finally, curricula are often developed that are devoid of criminological theory. Failing to understand the potential causes of elder abuse results in training packages that are destined for problems.