This type of mistreatment is defined as the misuse or exploitation of or inattention to an older person’s possessions or funds. Abusive behavior includes conning, pressuring the victim to distribute assets, or irresponsibly managing the victim’s money
This type of mistreatment causes emotional stress or injury to an older person. Examples include verbal abuse—threatening remarks, insults, or harsh commands—and remaining silent or ignoring the person. Another form of psychologic abuse is infantilism (a form of ageism), whereby the elderly person is treated as a child, which both patronizes and encourages the person to passively accept a dependent role.
The three general types of abuse and neglect are physical, psychologic, and financial. All can be intentional or unintentional.
Physical abuse and neglect: This type of mistreatment includes striking, shoving, shaking, beating, restraining, or feeding improperly. Sexual assault requires special emphasis, because many health care providers find this form of violence inconceivable when an older person is involved. Sexual assault refers to any form of sexual intimacy without consent or by force or threat of force.
When family members depend on elders for housing, financial support, emotional support, or other needs, the dependent family members may become/esentful and predisposed to abusive and neglectful behavior. This theory also suggests that elders who are functionally or cognitively impaired and dependent on their families for care are at increased risk for abuse and neglect.
This theory postulates that violence is a learned response to difficult life experiences and a learned method of expressing anger and frustration. The theory has been hard to substantiate because information about family violence that occurred years ago is difficult to obtain.
Financial problems, death in the family, the responsibilities of caregiving, and other tensions may create frustration and anger that some people express through acts of violence. New studies have investigated the relationships between the care recipient’s degree of cognitive impairment and the occurrence of abuse and neglect by the caregiver. A recent study conducted at the University of Medicine and Dentistry of New Jersey associated mistreatment of persons with dementia with the psychologic and physical demands placed on family caregivers. Another study from Cornell University and Louisiana State University found that a caregiver being married to the care recipient is a risk factor as are previous acts of abuse perpetrated by the care recipient on the caregiver.
Many abusers have been hospitalized repeatedly for serious psychiatric disorders (eg, schizophrenia and other psychoses). Many abuse alcohol or other drugs.
When an adult child has a mental illness requiring inpatient psychiatric care, the parents’ home is often the discharge site of last resort. Out of concern that the child will be homeless or have to stay in a shelter, or just out of love, parents often agree to take the child into their home. With the trend toward deinstitutionalization, psychiatrists who discharge a dependent child to the parents’ home must be aware of the possible effects on the parents. Patients who are not violent in an institution may be violent in the home. When the potential for domestic violence is not scrutinized and provisions for follow-up are not made, elder abuse may occur.
The epidemiology of elder abuse and neglect has been better understood since the publication of the 1986 survey by the Family Research Laboratory at the University of New Hampshire. In this survey of 2020 randomly selected elderly people living in the Boston metropolitan area, 3.2% reported being abused. Abuse was defined as physical abuse, which included hitting, slapping, and pushing; neglect, which involved depriving a person of something needed for daily living; and chronic verbal aggression, which included verbal threats and insults. Because the survey did not cover all forms of elder mistreatment (eg, financial exploitation), the 3.2% figure underestimates the problem.
Recently, the Women’s Initiative of the American Association of Retired Persons categorized elder abuse and neglect as follows: (1) early onset spousal and partner abuse and neglect continuing into later life, (2) late onset spousal and partner abuse and neglect during later life, and (3) abuse and neglect by adult children and other relatives.
The Family Research Laboratory investigators found that most abuse is committed by one spouse against another; 65% of abuse cases were between spouses, and only 23% involved an adult child abusing a parent. Elderly husbands were abused twice as often as elderly wives. It is not known whether the abuse perpetrated by wives is a continuation of early onset spousal abuse done in a spirit of retaliation or self-protection. It is known that elderly wives are more seriously injured by their husbands than elderly husbands are by their wives.
This study also found that the abusers usually were dependent on the person they abused. The study indicates that a significant risk factor for abuse and neglect is a close proximity of living arrangements of victim and abuser. In the study, abuse occurred at all economic levels and in all age groups among the elderly.
ELDER ABUSE AND NEGLECT
Each year, many older Americans are physically injured, psychologically debilitated, financially exploited, or neglected by family members. Much of this abuse and neglect constitutes criminal offenses. Because much of it is perpetrated by spouses, it also must be viewed in the context of domestic violence.
Elderly men and women, whether or not they have impairments or are dependent on family members, are vulnerable to mistreatment. Besides suffering physical injuries, these victims often develop overwhelming feelings of fear, isolation, and anger and need extensive counseling to regain their independence. Given the incidence of mistreatment and the projected growth of the elderly population, the problem is significant enough that those who care for the elderly must learn to recognize mistreatment and intervene. The health professional is well positioned to screen, diagnose, and intervene and may be the only person outside the family who has contact with the elderly victim and established relationships with the victim and family members. However, there may be many barriers to establishing the diagnosis and successfully intervening.
Information about elder abuse and neglect is limited, and more research is needed to better understand the causes and preventive measures as well as the appropriate interventions
THE OLDER DRIVER
Safe driving involves the integration of complex motor, visual, and cognitive activities. A single traffic movement results from many decisions and reactions to myriad visual (and often auditory) stimuli.
In the USA, more than 13% of drivers are over age 65. Despite moderate deterioration of mental, motor, optic, and auditory functions, the elderly usually drive safely, probably because most driving patterns are learned and become second nature. Thus, performance is impaired only after considerable loss of function. Furthermore, the elderly tend to drive fewer miles, shorter distances, less at night, seldom in rush hours, and more slowly and cautiously. Average annual mileage declines steadily with age, decreasing 64% from age 65 to age 85.
Despite these compensations, elderly drivers have higher rates of traffic violations, collisions, and fatalities per mile than younger drivers. Two of the most common violations, failure to yield the right-of-way and failure to obey a traffic sign, probably result from functional deficits and often lead to collisions, mainly at intersections (see FIG. 112-1). Older drivers have higher collision rates per mile than any other age group, except for the youngest drivers (those < 24 yr), as shown in FIG. 112-2. However, these rates do not really begin to increase until age 70; after age 80, they increase rapidly.
Older drivers tend to fare worse in collisions. The collisions are more likely to involve multiple vehicles (which may reflect the patterns of driving, such as more daytime than nighttime driving) and to result in serious injuries and fatalities (which probably reflects underlying frailty, concurrent illnesses, and impaired recovery).
In assessing an elder’s ability to drive, the physician must consider both public safety and the patient’s independence. Many states have laws concerning the obligation of physicians to report impaired drivers. Yet an inability to drive means a loss of independence because public transportation is usually impractical for essential trips, such as food shopping and medical visits. Elders forced to stop driving rely more on their family for essential trips and reduce their social activities. These elders become depressed more often than those who continue to drive.
The elderly also require careful assessment before undertaking certain other potentially hazardous activities, such as piloting aircraft or boats. These activities are regulated by local, state, and federal authorities. Physicians must be aware of their legal role and their social and medical obligations before advising elderly persons as to their fitness to undertake such activities.
Evaluation of older drivers should include a functional assessment as well as a consideration of the impact of illnesses and medications on driving.
