Vol. 332 No.

7 CURRENT CONCEPTS 437

REVIEW ARTICLES

widely differing definitions of abuse. Although it is not

possible to resolve the taxonomic problems here, a gen-
CURRENT CONCEPTS eral description of types of abuse emerges from a re-
view of recent research.
First, all discussions of abuse of older adults include
physical violence, meaning acts carried out with the in-
ABUSE AND NEGLECT OF ELDERLY
tention of causing physical pain or injury. The most
PERSONS common violent acts toward elderly persons include
MARK S. LACHS, M.D., M.P.H., slapping, hitting, and striking with objects. Frequent
results of such mistreatment are bruises, sprains, abra-
AND K ARL P ILLEMER , P H .D.
sions, and occasionally skeletal fractures, burns, and
other wounds.14,15

T HE metaphor of domestic violence as chronic dis-

ease is a useful one for clinicians. Studies of do-
mestic violence over the life span suggest that, like
Second, much of the literature includes psychological
or emotional abuse as a category of maltreatment. Usu-
ally defined as an act carried out with the intention of
many ongoing illnesses that are typified by periods of causing emotional pain or injury, psychological abuse
quiescence and exacerbation, abuse is more often epi- often accompanies physical abuse. Examples include
sodic and recurrent than an isolated event.1-3 This met- habitual verbal aggression in the form of threats and
aphor may also help to remind physicians that elderly insults, as well as statements that humiliate or infan-
patients are at risk; a report from the House Select tilize the elderly person. The threat of abandonment or
Committee on Aging has suggested that between 1 mil- institutionalization is another important form of psy-
lion and 2 million older Americans experience mis- chological abuse.
treatment each year.4 Third, many definitions of abuse include acts of ma-
Given the scope of this clinical and public health terial exploitation or the misappropriation of money or
problem, what has been the response of physicians who property. Examples include the theft of social security
care for older adults? Authorities suggest that their re- or pension checks, the use of threats to enforce the
sponse has been disappointing,5 and previous studies signing or changing of wills or other legal documents,
have found physicians to be unfamiliar with mandato- and coercion in any financial matter.
ry-reporting laws and less effective than other profes- Finally, neglect of the elderly — the failure of a des-
sional groups in identifying cases of abuse of elderly ignated care giver to meet the needs of a dependent
persons.6,7 A five-year literature search limited to core elderly person — is generally accepted as a form of
journals in the Index Medicus under the subject “elder maltreatment. Neglect may be intentional, as when a
abuse” yielded 26 articles, only 4 of which contained care giver deliberately fails to fulfill caretaking respon-
primary data. For the same period, there were 248 re- sibilities in order to harm or punish the elderly person
ports concerned with child abuse. (for example, willfully withholding food or medication),
In this article we review what is known about the or it may be unintentional, stemming either from igno-
clinical epidemiology of abuse and neglect of the elder- rance or from a genuine inability to provide care.
ly and outline strategies for evaluation and manage- Much of the controversy about definitions focuses on
ment that should be of interest to physicians caring for neglect. Cases of neglect of older adults frequently raise
older patients. difficult questions about who exactly the responsible
caretaker is, what his or her precise responsibilities are
DEFINITIONS AND EPIDEMIOLOGIC FEATURES
to the neglected person, and whether the neglect was
What Constitutes Abuse of the Elderly? intentional or unintentional. Some have argued that the
Case reports of abuse of elderly persons first ap- attempt to divide abuse of elderly persons into subtypes
peared in the literature 20 years ago.8 Soon thereafter, is an academic exercise that ignores the needs of the
researchers attempted to determine the clinical scope victim. The final result of neglect is the failure of an
and prevalence of the problem.9-13 The chief impedi- older adult to thrive in the community, and initial inter-
ment to rigorous epidemiologic research has been the ventions should be directed at improving function and
the quality of life rather than assigning blame. For this
From the Geriatrics Unit, Division of General Internal Medicine, Department reason, many authorities prefer to avoid the terms
of Medicine, New York Hospital–Cornell University Medical Center, and the “abuse” and “neglect” and prefer instead to frame the
Amsterdam Nursing Home Corporation, New York (M.S.L.); and the Department
of Human Development and Family Studies, Cornell University, Ithaca, N.Y. problem as “inadequate care of the elderly” or “mis-
(K.P.). Address reprint requests to Dr. Lachs at the Geriatrics Unit, Division of treatment of the elderly,” which includes acts of both
General Internal Medicine, New York Hospital–Cornell University Medical Cen-
ter, 515 E. 71st St., Rm. S912, New York, NY 10021.
omission and commission.16,17
Supported in part by the Florence V. Burden Foundation, by the Ittleson Foun- Aside from the definitions used by researchers, the
dation, and by a grant (1 R01 MH2613) from the National Institute of Mental state agencies charged with the identification of and re-
Health (to Dr. Pillemer). Dr. Lachs is an American College of Physicians Teach-
ing and Research Scholar and the recipient of a National Institutes on Aging Ac- sponse to abuse of elderly persons also use differing
ademic Award (1K0800580). definitions of such abuse.18 In Connecticut, for exam-

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438 THE NEW ENGLAND JOURNAL OF MEDICINE Feb. 16, 1995

ple, abuse is defined as “the willful infliction of physical Table 1. Risk Factors for Abuse of the Elderly.
pain, injury, or mental anguish, or willful deprivation RISK FACTOR MECHANISM
by a caretaker of services necessary for physical and/or
Poor health and functional im- Disability reduces the elderly person’s ability
mental well being.”19 Many states also include the cat- pairment in the elderly to seek help and defend himself or herself.
egory of “self-neglect” in their statutes and reporting person
statistics to describe the status of older adults who are Cognitive impairment in the Aggression toward the care giver and disrup-
elderly person tive behavior resulting from dementia may
living alone in the community and are unable to pro- precipitate abuse. Higher rates of abuse
vide for themselves the services necessary to maintain have been found among patients with
physical or mental health, or both. Although some ar- dementia.
Substance abuse or mental ill- Abusers are likely to abuse alcohol or drugs
gue that such persons should not be included in studies ness on the part of the abuser and to have serious mental illness, which in
of the epidemiology of abuse of elderly persons, they turn leads to abusive behavior.
Dependence of the abuser on Abusers are very likely to depend on the vic-
constitute a substantial proportion of the caseload of the victim tim financially, for housing, and in other
Adult Protective Services and represent a large popula- areas. Abuse results from attempts by a
tion with unmet needs.20 relative (especially an adult child) to ob-
tain resources from the elderly person.
Shared living arrangement Abuse is much less likely among elderly peo-
Incidence and Prevalence ple living alone. A shared living situation
In one random-sample community-based epidemio- provides greater opportunities for tension
and conflict, which generally precede
logic study of abuse of elderly persons, 2020 older res- incidents of abuse.
idents of Boston were asked about three forms of mal- External factors causing stress Stressful life events and continuing financial
strain decrease the family’s resistance and
treatment: physical violence, psychological abuse, and increase the likelihood of abuse.
neglect.21 Of the subjects, 3.2 percent reported having Social isolation Elderly people with fewer social contacts are
experienced some form of maltreatment since they more likely to be victims. Isolation reduces
the likelihood that abuse will be detected
turned 65 years old. In this study, physical abuse and stopped. In addition, social support
emerged as the most prevalent type (2.2 percent), fol- can buffer the effects of stress.
lowed by habitual verbal aggression (1.1 percent) and History of violence Particularly among spouses, a history of vio-
lence in the relationship may predict abuse
neglect (0.4 percent). Of the abusers, two thirds were in later life.
spouses, and the remainder were adult children. The
low rate of neglect probably reflects the narrow defini-
tion used by the researchers. Very similar rates of mal- tors from the literature.33-36 Relatives with mental ill-
treatment were found in two epidemiologic studies car- ness or substance-abuse problems are more likely to
ried out in Canada and Great Britain using similar become abusive. Family members who are excessively
methods and measures.22,23 Although it is impossible to dependent on the elderly person for financial assist-
determine whether the rates of abuse are increasing, ance, housing, or other necessities have a higher risk of
virtually all state agencies charged with the identifica- becoming abusive. A history of violence or antisocial
tion, investigation, and prevention of abuse of the eld- behavior in other contexts outside the family also often
erly report increases in their caseloads over the past characterizes abusers.
decade.24
THE CLINICAL EVALUATION
Risk Factors General Considerations
Several characteristics of elderly persons and their The issue of when to evaluate an elderly person for
family members may heighten the risk of maltreatment possible mistreatment is hard to resolve, but recent
(Table 1). Although anecdotal and clinical reports have guidelines from the American Medical Association sug-
long suggested that the frailty of elderly persons in it- gest that all older adults be asked by their physicians
self is a risk factor for abuse, recent studies have gen- about family violence, even in the absence of symptoms
erally failed to find a direct relation between abuse and potentially attributable to abuse or neglect.37 This rec-
poor health, functional impairment, or excessive de- ommendation is reasonable, given the prevalence of the
pendence on the abuser.21,25-29 Nonetheless, it is likely problem and the tendency for “asymptomatic” family
that increased frailty in older people does play at least violence to go unrecognized. Although standardized
some part in maltreatment; a clearer answer to this evaluations for the identification of abuse and neglect
question will probably require longitudinal cohort stud- have been devised for patients strongly suspected of
ies.30 Rather than increasing risk in and of itself, great- being mistreated,16,38-40 their sensitivity as screening
er impairment may diminish the elderly person’s ability tools as compared with a reference standard is un-
to defend himself or herself or to escape the situation. known.
It seems reasonable to consider problems of physical Physicians are not alone in facing these difficult and
health as a predisposing factor in maltreatment of the complex cases, but they are often unaware of appropri-
elderly, one that may increase their vulnerability in the ate resources existing within the community or of how
presence of other risk factors. Among the other risk to gain access to these resources. Unless there is some-
factors in the victims, cognitive impairment and a liv- thing to suggest a life-threatening injury or imminent
ing arrangement shared with the abuser have the danger of serious harm, a proper evaluation can span
strongest empirical support.15,21,25,29,31,32 several visits and should include information obtained
Three characteristics of abusers emerge as risk fac- from as many sources as possible, including other fam-

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Vol. 332 No. 7 CURRENT CONCEPTS 439

ily members, neighbors, visiting nurses, and other very difficult. Do you ever lose control?” In interviewing
home care personnel. Reporting suspected abuse to both parties, it is crucial to identify specific factors
state authorities, either in accordance with legislative causing stress (for example, dementia-related behavior-
requirements or voluntarily, enlists the assistance of al problems and arguments about finances) that tend to
the Adult Protective Services, whose professional staff provoke the abuse. This gives the clinician a sense of
members have expertise in this area. The ideal evalua- the pattern and frequency of the mistreatment and sug-
tion includes a home visit; when this is not feasible for gests which interventions are likely to be effective.
the physician, the Adult Protective Services staff is an Psychological abuse can be difficult to identify in an
especially valuable resource. Geriatric assessment clin- interview, but it is probably a common form of mis-
ics, which conduct multidisciplinary evaluations that treatment. In addition, there is substantial variability in
are typically focused on the patient and care giver, are what different ethnic groups consider abuse.42 A func-
also appropriate for this purpose if they are available. tional definition might be acts that cause substantial
Remedial interventions can be well under way during distress to the older patient. The clinical manifestations
the evaluation, since taking steps to improve the qual- of this distress include social withdrawal, long-standing
ity of life for the older person requires only that unmet or recalcitrant depression, and anxiety disorder.
needs be recognized and resourcefully addressed; there
is no immediate need for definitive diagnosis or the as- Physical Findings
signment of blame. Dramatic cases of physical abuse rarely present a di-
agnostic challenge. The diagnosis of abuse should be
Interviewing Techniques considered whenever an older adult presents with mul-
A careful history is crucial in screening for possible tiple injuries in various stages of evolution or when in-
maltreatment, and clinicians should familiarize them- juries are unexplained or the explanations provided are
selves with interviewing techniques likely to elicit the implausible. Similarly, the diagnosis of severe neglect
most accurate information. First, both the patient and should be considered whenever a dependent patient
the suspected abuser should be interviewed separately with adequate resources and a designated provider of
and alone. These interviews may reveal disparities be- care presents with gross inattention to nutrition, hy-
tween the two accounts (for example, of how injuries giene, or established medical needs (such as missed ap-
were sustained). Older adults who have been abused pointments or unfilled prescriptions). In a review of
may also be reticent about disclosing information in the emergency-department records in 36 cases, neglect was
presence of staff members or other patients. The inter- a more frequent manifestation of mistreatment than in-
view can begin with general questions about the pa- jury.38 The most common physical injuries were unex-
tient’s perceptions of safety in the home or neighbor- plained bruises, lacerations, or abrasions, head injury,
hood (“Do you feel safe where you live?”) and then and unexplained fractures. The most common clinical
move on to inquiries about who is responsible for ren- manifestations of neglect were dehydration and malnu-
dering care or assistance (“Who prepares your meals? trition. On the basis of this experience, several clinical
Who handles your checkbook?”). The discussion should presentations have been suggested that should alert the
then turn to specific questions about maltreatment: clinician to the possibility of abuse of an elderly patient
“Do you have frequent disagreements with your son or (Table 2).43
daughter? When you disagree, what happens? Are you However, outside the emergency department, the
yelled at? Made to wait long periods of time for food physician is more likely to encounter subtle forms of
or medicines? Made to stay in your room? Slapped, ongoing mistreatment in which neglect, psychological
punched, or kicked?” Clinicians are clearly uncomfort- abuse, or both predominate. The task of correctly iden-
able with such avenues of inquiry,41
but the only remedy for this discom- Table 2. Presentations That Suggest Abuse or Neglect of an Elderly Patient.
fort is practice.
The interview of the person sus- PRESENTATION* EXAMPLE

pected of abuse or neglect is chal- Delays between an injury or illness and the seek- Lacerations healing by secondary intention, radio-
lenging; when possible, it is best left ing of medical attention graphic evidence of healed but misaligned frac-
tures, presentation in extremis with decompen-
to those with specific expertise in sated chronic disease when care giver has been
this area. When the physician does monitoring patient
conduct such an interview, it is es- Disparity in histories from the patient and the sus- Different mechanisms of injury offered, different
pected abuser chronology of injuries
sential to avoid confrontation in the Implausible or vague explanations provided by Fractures that are not explained by the purported
data-acquisition phase of the evalua- either party mechanisms of injury
tion,39 since confrontation generally Frequent visits to the emergency room for exac- Exacerbations of chronic obstructive pulmonary dis-
erbations of chronic disease despite a plan for ease or congestive heart failure due to lack or mis-
yields less information than a meas- medical care and adequate resources administration of medicines
ured, nonjudgmental approach. Em- Presentation of a functionally impaired patient Patient with advanced dementia who presents to the
without his or her designated care giver emergency room alone
pathy and understanding of the bur- Laboratory findings that are inconsistent with the Subtherapeutic levels of drugs (e.g., digoxin) despite
dens shouldered by care givers can history provided compliance reported by care giver, toxicologic
go a long way toward obtaining an evidence of psychotropic agents that have not
been prescribed
accurate history: “Caring for your
mother with her arthritis must be *The indicators of possible abuse or neglect are from Jones. 43

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440 THE NEW ENGLAND JOURNAL OF MEDICINE Feb. 16, 1995

tifying these more insidious presentations is complicat- tions with their alleged abusers can be extremely tell-
ed by a high burden of chronic disease among the eld- ing. A full examination of the entire body-surface area
erly, which is rare in younger victims of domestic is crucial, because the size, location, and number of
violence. The manifestation of these illnesses may mim- skin lesions are often revealing. Brief but formal men-
ic mistreatment (leading to false positive assessments), tal-status testing should be part of the evaluation.45,46
or lower the clinical index of suspicion (leading to false Cognitive impairment suggests the possibility of de-
negatives). For example, Kane and Goodwin described mentia (or delirium), which may in and of itself be a
six patients who had spontaneous long-bone fractures risk factor for abuse of the elderly.32 Moreover, patients
in nursing homes with no evidence of physical abuse with cognitive impairment may be unable to give accu-
noted, yet the families alleged abuse in four of these rate histories because of short-term memory loss. Cog-
six incidents.44 Conversely, a hip fracture that results nitive impairment severe enough to compromise deci-
from family violence can erroneously be ascribed to os- sion-making capacity will also be a consideration if
teoporosis. interventions are undertaken that require the consent
How, then, should the clinician proceed in the ab- of the victim.
sence of pathognomonic presentations of abuse similar Finally, in evaluating the possibility of abuse and ne-
to those described for child abuse? Once abuse is sus- glect, the clinician should have some familiarity with
pected on the basis of screening questions, a longer in- the patient’s social and financial resources. Such re-
terview, or obvious physical findings, a thorough, struc- sources are of crucial importance when interventions
tured evaluation is mandatory. Table 3 shows common are contemplated — such as alternative living arrange-
components of protocols for the systematic detection ments or paid care-giving services — that might defuse
of mistreatment. Careful documentation (for example, an abusive situation. Furthermore, the availability of
verbatim descriptions of events or drawings of injuries) financial resources in the presence of unmet needs
is crucial, since the medical record may become part of suggests the possibility of exploitation. Detailed as-
a legal record. The general appearance of patients (in sessment of the patient’s financial situation and the po-
terms of dress, hygiene, and the like) and their interac- tential for financial exploitation generally goes beyond
the scope of the physician’s evalua-
tion. The clinician should be alert,
Table 3. Clinical Procedures for the Detection of Abuse of an Elderly Patient.
however, to information volunteered
FOCUS PROCEDURE OR ITEM TO BE NOTED by the patient. For example, a pa-
tient may express fears that some-
History Interview the patient and the suspected abuser separately and alone. Make
direct inquiries about physical violence, restraints, or neglect. Request thing is amiss in his or her financial
precise details about nature, frequency and severity of events. Assess the situation (perhaps in the context of
patient’s functional status (independence, activities of daily living). In- worrying about paying medical
quire who is the designated care giver if impairment in activities of daily
living is present. Assess recent psychosocial factors (e.g., bereavement, bills) or talk about being forced to
financial stress). Elicit care giver’s understanding of patient’s illness sign documents or to provide loans
(care needs, prognosis, etc.).
Behavioral observation Withdrawal.
or gifts of money. The staff mem-
Infantilizing of patient by care giver. bers of Adult Protective Services
Care giver who insists on providing the history. programs have expertise in the in-
General appearance Hygiene.
Cleanliness and appropriateness of dress. vestigation of this type of maltreat-
Skin and mucous mem- Skin turgor, other signs of dehydration. ment.47
branes Multiple skin lesions in various stages of evolution.
Bruises, decubitus ulcers. MANAGEMENT
Evaluate how skin lesions have been cared for.
Head and neck Traumatic alopecia (distinguishable from male-pattern alopecia on the ba- Whenever mistreatment is con-
sis of distribution).
Scalp hematomas.
firmed, the clinician’s highest prior-
Lacerations, abrasions. ity is to ensure the safety of the eld-
Trunk Bruises, welts. The shape may suggest an implement (e.g., iron or belt). erly person while respecting the
Genitourinary tract Rectal bleeding.
Vaginal bleeding. patient’s autonomy. The answers to
Decubitus ulcers, infestations. two pivotal questions dictate how to
Extremities Wrist or ankle lesions suggesting the use of restraints, or immersion burn achieve this (Fig. 1). First, does the
(stocking–glove distribution).
Musculoskeletal system Examine for occult fracture, pain. Observe gait. patient accept or refuse interven-
Neurologic–psychiatric Conduct a thorough evaluation to assess focality. tion? Second, does he or she retain
status Depressive symptoms, anxiety.
Other psychiatric symptoms including delusions and hallucinations.
decision-making capacity? The eld-
Formal mental-status testing (e.g., Mini–Mental State Examination or erly person who is in immediate
Mental Status Questionnaire). danger should be separated from
Cognitive impairment suggesting delirium or dementia has a role in assess-
ing decision-making capacity. the abuser whenever possible. Hos-
Imaging and laboratory As indicated from the clinical evaluation. pitalization can be justified on this
tests Albumin, blood urea nitrogen, and creatinine levels, toxicologic screening basis, or on the basis of injuries
(assess care giver’s compliance with medical regimen).
Social and financial re- Inquire about other members of the social network available to assist the or neglected medical problems, al-
sources elderly person and about financial resources. though third-party payers may not
This information is crucial in considering interventions that include alter-
native living arrangements and home services.
approve hospital admission solely
because the elderly patient has been

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Vol. 332 No. 7 CURRENT CONCEPTS 441

Does the patient accept intervention?

Yes No

Implement a safety plan (e.g., Does the patient have the capacity to accept or
safe-house placement, a protective refuse intervention?
order from the court, hospital
admission).

No Yes
Educate the patient about the
incidence of mistreatment of the
elderly and the tendency for it to
increase in frequency and severity
over time. Educate the patient about the
Discuss with Adult Protective
Services the following options: incidence of mistreatment of
the elderly and the tendency
Provide assistance that will alleviate for it to increase in frequency
the causes of mistreatment (e.g., and severity over time.
Assistance with financial
referral to drug or alcohol rehabilita-
management
tion for addicted abusers; education,
home health, or homemaker services Provide written information
for overburdened care givers). about emergency-assistance
Conservatorship
numbers and appropriate
referrals.
Refer patient or family members
Guardianship
to appropriate services (e.g., social
work, counseling, legal assistance Develop and review a safety
and advocacy). plan.
Court proceedings (e.g.,
orders of protection).

Develop a follow-up plan.

Figure 1. Response to Abuse or Neglect of an Elderly Person.

All efforts should be coordinated with Adult Protective Services programs as required by individual states; the staffs of these programs
have specific expertise in dealing with abuse and neglect of the elderly and are likely to be familiar with resources within the community
that can be tailored to individual circumstances. Modified from the American Medical Association guidelines37 and Elder Mistreatment
Guidelines for Health Care Professionals.40

abused. In less urgent cases, clinicians’ interventions and not cognitively impaired, his or her wishes must be
should be tailored to the specific situation. When a high respected. The clinician can only emphasize that the
burden of chronic disease is causing stress for the care patient need not remain in the current situation, offer
giver, a variety of home care or respite services may im- whatever interventions the victimized patient will ac-
prove matters. Disease-specific support groups (for ex- cept, and set in motion a follow-up plan. For patients
ample, the Alzheimer’s Disease and Related Disorders who no longer retain decision-making capacity, the
Association) may provide a useful outlet for care givers. court may need to appoint a guardian or conservator to
When psychopathologic factors in the abuser are re- make decisions about living arrangements, finances,
sponsible for the situation, such interventions are less and care. Typically, the state Adult Protective Services
likely to be effective, and alternative living environ- agency participates prominently in this process. In such
ments for both parties should be considered. In all cas- cases the physician’s role is not only to document the
es, victims should be counseled that violence may esca- objective physical findings that suggest mistreatment,
late and that the physician is a source of help. The but also to provide concrete examples of impaired (or
efficacy of the intervention plan should be monitored by intact) decision-making capacity.
the physician with the help of Adult Protective Services Maintaining patients’ independence is a primary
personnel. goal of modern geriatrics. Unfortunately, independ-
Particularly vexing for clinicians is the case of a com- ence may not be possible in the all too common situa-
petent elderly person who insists on remaining in an tion in which the abuser is also the patient’s primary
abusive environment. When the patient is competent care giver. If interventions do not stop the abuse and

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442 THE NEW ENGLAND JOURNAL OF MEDICINE Feb. 16, 1995

there are no alternative living arrangements that are home employees, hospital staff were the most likely to
safe and acceptable to the patient, long-term care may report abuse to an ombudsman program.49
be the best option. Although the fear of placement in Few data are available on institutional abuse, and no
a nursing home often prevents patients from revealing national survey has documented its prevalence. A ran-
abuse or neglect, we have been involved in several dif- dom-sample survey of nursing home staff members in
ficult cases in which placing abused elderly patients in one state found that 10 percent of nurses’ aides report-
long-term care facilities dramatically improved their ed that they had committed at least one act of physical
quality of life. abuse in the preceding year, and 40 percent reported
committing at least one act of psychological abuse.50
REPORTING REQUIREMENTS Abuse may also be perpetrated by other residents or
Forty-two states have mandatory-reporting laws that visitors. In addition to the types of abuse already de-
require health care workers to report suspected abuse scribed, the failure to devise or implement a goal-ori-
of elderly persons to an official state agency, usually ented care plan for each resident may be considered
Adult Protective Services.48 Such a report usually re- abusive or neglectful in some contexts. Examples in-
sults in an unannounced visit to the home of the elderly clude unreasonable restraint (either physical or with
person. Although these legislative requirements are the injudicious use of psychotropic medications), isola-
well intentioned, a recent report from the Government tion from other residents, or failure to respect the wish-
Accounting Office concluded that increasing public es of a competent elderly person with regard to medical
awareness is a more important factor in uncovering care or other interventions.
cases of abuse of elderly persons than reporting re- The Older Americans Act of 1976 established Nurs-
quirements and that states with mandatory-reporting ing Home Ombudsman programs to respond to the
laws could not be meaningfully compared with states abuse and neglect of residents of long-term care facil-
without such requirements, because of differing defini- ities; according to its provisions, every resident must
tions of abuse.48 have access to the nursing home’s ombudsman. Phy-
The term “mandatory reporting” is perhaps unfor- sicians should report their suspicions of abuse to the
tunate, because it implies that the physician needs ir- state ombudsman. Federal requirements concerning
refutable proof of mistreatment and that the subse- the quality of care in nursing homes were legislated as
quent home visit is a punitive investigation. Neither part of the Omnibus Budget Reconciliation Act of
need be true. In many states, the suspicion of abuse 1987.51
alone is grounds for reporting, and the physician does Most states have resource hotlines that both physi-
not have to prove anything. Many mandatory-report- cians and patients can call with questions about abuse
ing statutes grant immunity to physicians who report and neglect of the elderly in the community or in long-
their suspicions in good faith, and often the reporter term care settings. Clinicians should consult state gov-
remains anonymous.37 The home visit that results ernment directories under the listing “Adult Protective
from a report of suspected abuse can be viewed not as Services” or “Department on Aging” or contact the Na-
an investigation, but as part of the process that gath- tional Center on Elder Abuse (c/o American Public
ers information about the patient in his or her environ- Welfare Association, 810 First St. NE, Suite 500, Wash-
ment that would be otherwise unattainable. Physicians ington, DC 20002) or telephone (202) 682-2470 for a
should also be aware of their potential liability when referral to their state agency.
cases of domestic violence are not correctly diagnosed
We are indebted to Dr. Leo Cooney for reviewing an earlier draft
or reported.37 of the manuscript, and to Nedra Yopp and Geraldine Hawthorne for
Mandatory reporting may also create a difficult their assistance in the preparation of the manuscript.
problem when a patient insists that the physician not
report the abuse. Again, the problem can be avoided by REFERENCES
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Steinmetz SK, eds. Handbook of marriage and the family. New York: Ple-
Adult Protective Services personnel are also experi- num Press, 1987:725-65.
enced in the evaluation of older adults who are alone 3. Stark E, Flitcraft A. Violence among intimates: an epidemiological review.
and failing in the community for a variety of reasons. In: Van Hasselt VB, Morrison RL, Bellach AS, Hersen M, eds. Handbook of
family violence. New York: Plenum Press, 1988:293-317.
4. U.S. Congress, House Select Committee on Aging. Elder abuse: what can
INSTITUTIONAL ABUSE be done? Washington, D.C.: Government Printing Office, 1991.
Abuse that occurs in medical, long-term care, or 5. Wolf RS. Elder abuse: ten years later. J Am Geriatr Soc 1988;36:758-62.
6. Blakely BE, Dolon R. The relative contributions of occupation groups in the
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