About 12 years ago, my Aunt Patsy had a severe stroke that forced her to retire. She was not able to live alone or handle her finances, so her adult daughter and son-in-law moved into Patsy’s beautiful five-bedroom, three-bathroom home on a multiacre lot. Her daughter promised to take care of Patsy, manage her finances, and ensure all her needs were met.
Fast-forward five years. All of Patsy’s retirement and investment monies were gone, and her home was in foreclosure. Where did the money go?
Fast-forward another two years. Patsy was secluded to sleeping on the couch in her own home. She had been without antihypertensives for several months and hadn’t seen her physician in over a year. To quiet the anger from other family members, Patsy’s daughter took her to see the doctor, but the only prescription that got filled was for opioid pain medication.
Within another year, under the threat of physical harm from her son-in-law, Patsy was forced from her own home, which was in foreclosure with the bank again; the county had repossessed it for failure to pay property taxes.
The entire situation made me sick. I knew it wasn’t morally right, and I hated how my aunt was treated, but I didn’t know what to do, where to report, how to report, or even if you could report something so horrible. I started researching elder mistreatment because of Aunt Patsy. Not enough health-care providers are aware of what elder mistreatment looks like or our ethical and legal obligations.
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Statistics on elder mistreatment
Elder mistreatment is not uncommon. It’s a broader term that includes abuse, exploitation, and neglect; however, the term elder abuse is still used to describe abuse (physical, sexual, or emotional) and includes elder neglect and exploitation/financial abuse.1
Elder mistreatment is estimated to impact one in 10 older adults who live independently or in senior living communities, and one in six elder adults living in assisted-living facilities or nursing homes. Despite this frequency, research suggests that only one in 24 cases of elder abuse is identified and reported to the proper authorities.2
Victims of elder mistreatment have a significantly higher mortality rate and poorer health outcomes, such as depression, dementia, and worsening (or uncontrolled) chronic conditions. The increase in morbidity and mortality is directly related to undetected and unreported cases of mistreatment.3
What is elder abuse and how often does it occur?
The National Center on Elder Abuse (NCEA) defines elder abuse as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.”2 There are five types of elder abuse: physical, emotional, sexual, financial/exploitation, and neglect. Emotional abuse, exploitation, and neglect are significantly more common, while sexual and physical elder abuse occur less frequently.4 Table 1 outlines explanations of the various types of mistreatment and examples of what they entail.
Table 1: Types of elder mistreatment 2,4,6
Emotional abuse: intentional use of verbal or nonverbal acts to inflict pain, distress, or fear
- Name-calling, intimidation, insults, threats, verbal berating
- Threats of punishment or deprivation, manipulation, harassment
- Treating the adult like a child/infant
- Isolation from family, friends, social contacts
Exploitation: illegal or improper use of another individual’s money, property, or assets
- Taking money or belongings under false pretenses, fraud, or forgery
- Cashing checks or making expensive purchases without consent
- Denying access to finances or home
- Coerced change of will, power of attorney, property ownership
- Abuse of position in power of attorney or conservatorship
- Scams
Neglect: intentional or unintentional refusal or failure to provide any part of one’s duties in caring for another which may result in harm
- Withholding food/water, clothing, shelter, attention
- Failure to assist with activities of daily living (ADL), provide glasses, dentures, walker/cane, hearing aids
- Failure to ensure personal safety, health, finances
- Denying medications, medical or dental treatment
Physical abuse: intentional use of physical force that may result in bodily injury, pain, or impairment
- Hitting, beating, pushing, kicking, punching, pinching, biting
- Overmedicating or undermedicating
- Use of restraints
- Exposure to extreme weather
Sexual abuse: any type of sexual contact that is nonconsensual or sexual contact with any person incapable of giving consent
- Rape, sodomy, forced sexual contact, forced nudity/participation in nude photography
- Inappropriate touching, unwanted sexual advances
- Forced sex with a third party
- Forced watching of pornography
Risk factors and signs of elder abuse
Multiple factors can contribute to an elder adult’s risk for mistreatment.3 Table 2 lists potential risk factors.
Table 2: Potential risk factors for elder mistreatment 2,3,5
- Physical limitations (needing assistance with ADL)
- Poor physical health (dependence on others, uncontrolled medical conditions)
- Poor mental health
- Cognitive impairments (dementia)
- History of substance abuse
- History of previous trauma or other abuse
- Lower socioeconomic status
- Little social interaction (isolation)
Elder adults who are military veterans, have been diagnosed with post-traumatic stress disorder (PTSD), or are LGBTQ+ may be at additional risk for experiencing elder mistreatment.6 Depending on care from family members, older adults are at a higher risk for abuse than those living in assisted-living or long-term-care facilities. The risk of abuse also significantly increases as the level of dependence on the caregiver increases.1
What can dental professionals do?
Dental professionals should fully assess a patient’s medical and dental history, emotional status, physical characteristics, and extra- and intraoral manifestations. Concerns should be raised when patients are unusually anxious or aggressive, overly eager to please, or state they are not in control of their finances.1 Patients experiencing mistreatment will often provide illogical explanations to questions, quickly change topics of discussion, dodge questions, or physically jump in reaction to movement from another individual.7 Table 3 outlines signs of elder mistreatment that the dental team may see.
Table 3: Dental professionals may notice these signs of elder mistreatment 2,8,9
Emotional abuse
- Uncommunicative attitude
- Unreasonably fearful behavior
- Evasiveness or lack of social contact
- Overly eager to please
Exploitation
- Patient reports not handling personal finances or not having any money
- Sudden change in financial status
- Unwillingness to discuss financial aspects of dental treatment
Neglect
- Delay between onset of illness and seeking medical/dental treatment, untreated medical conditions
- Noncompliance with medication, appointments, or instructions
- Dehydration or malnutrition, sunken eyes, unexplained weight loss
- Poor personal or oral hygiene
- Inappropriate clothing for the season, dirty clothing
- Rampant decay or untreated periodontitis
- Ill-fitting dentures or lack of dentures
- Epulis fissuratum, candidiasis
Physical abuse
- Unexplained injuries or history of frequent injuries
- Bruises at varied stages of healing
- Patterned bruises resembling a belt, burns, bite marks, restraints
- Traumatic alopecia
- Facial fractures, avulsed teeth, or broken dentures
Sexual abuse
- Medical report of sexually transmitted infection (STI) or medication to treat STI
- Report of recurrent urinary tract infections
- Herpetic gingivostomatitis, syphilis chancre, HPV-related lesions
- Palatal petechiae or bruised edentulous ridges
Interactions with caregivers that may raise concerns with dental professionals:
- Caregiver and patient provide different explanations of injuries/oral conditions
- Caregiver doesn’t allow the patient to answer questions or seems hostile toward the patient
- Caregiver appears inattentive or has a lack of knowledge of the patient’s needs
- Caregiver appears overwhelmed, angry, or frustrated with the older adult
- Evidence or suspicion that the caregiver is abusing alcohol or drugs is also a red flag for elder mistreatment.9
Screening for elder abuse
Currently, there is no standard tool or test to identify or screen for elder mistreatment. There are more than 15 screening tools to identify patients at high risk for mistreatment or detect specific types of elder abuse. All assessments vary in methods, implementation, length, reliability, and validity, making it even more difficult and confusing for health-care professionals to detect elder mistreatment.7
In the dental setting, the general abuse screening from the American Psychological Association (APA) is most applicable.
General abuse screening: 4 basic questions to ask the patient1,8
- Do you feel safe in your 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?
If suspicion of elder mistreatment is suspected: 4 additional questions to ask the patient1,8
- Has anyone ever touched you without consent?
- Has anyone made you do things you did not want to do?
- Has anyone ever taken something from you without asking your permission?
- Have you ever signed any documents that you did not understand or did not want to sign?
Documentation and reporting
Dental professionals are not responsible for investigating or proving that elder mistreatment has occurred; however, they are responsible for documenting and referring to the proper authorities. Permission does not need to be obtained from the elder adult; it’s the dental professional’s ethical duty to proceed with the referral.1,6 Law enforcement or social services will take appropriate actions and interventions to determine next steps and act in the best interest of the older adult.6,7
What should be included in the documentation:
- Answers to screening questions
- Patient’s physical/emotional state and appearance
- Observations from health and dental assessments
- Photos, descriptions, and measurements of lesions, bruises, or other signs of mistreatment
The more specific and descriptive the documentation, the more helpful it will be to the proper authorities.7 Intraoral cameras are not limited to use in the oral cavity; they can be utilized to document injuries or lesions anywhere on the patient’s body.1
According to the US Department of Justice,10 “licensed health care providers, health care practitioners, or practitioners providing professional services” include dental providers as mandatory reporters of elder mistreatment in all 50 states, plus Guam, Puerto Rico, and the Virgin Islands.
Nineteen states specifically name “dentists” or “dental hygienists” as mandatory elder abuse reporters: Arkansas, Colorado, Connecticut, Hawaii, Idaho, Illinois, Indiana, Kansas, Maine, Massachusetts, Montana, Missouri, Nevada, North Dakota, Oregon, Rhode Island, South Dakota, Vermont, and West Virginia.10 Reporting methods are not standard between states/territories. Mandatory reporters are to report suspicions of elder abuse through a toll-free hotline or online reporting system immediately, although some states allow as long as 48 hours for reporting.10
The American Bar Association’s Commission on Law and Aging has a state-by-state resource that summarizes state/territory laws, reporting timelines, and where to report suspicions of elder abuse.11 Dental hygienists can also look up specific reporting instructions and directions by state or territory from the National Adult Protective Services Association.12
Editor’s note: This article first appeared in Through the Loupes newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe to Through the Loupes.
References
- Erdman KA. Note the signs of elder abuse. Dimensions of Dental Hygiene. June 5, 2018. https://dimensionsofdentalhygiene.com/article/note-the-signs-of-elder-abuse/
- Red flags of abuse fact sheet. National Center on Elder Abuse. https://www.pacourts.us/Storage/media/pdfs/20210516/225550-ncea_redflagsea.pdf
- Storey JE. Risk factors for elder abuse and neglect: a review of the literature. Aggression and Violent Behavior. 2020;50(1):101339. doi:10.1016/j.avb.2019.101339
- Elder abuse. National Institute on Aging. National Institutes of Health. 2020. Reviewed July 21, 2023. https://www.nia.nih.gov/health/elder-abuse#-types
- Get the facts on elder abuse. National Council on Aging. February 23, 2021. www.ncoa.org/article/get-the-facts-on-elder-abuse
- Weissberger GH, Goodman MC, Mosqueda L, et al. Elder abuse characteristics based on calls to the National Center on Elder Abuse Resource Line. J Appl Gerontol. 2020;39(10):1078-1087. doi:10.1177/0733464819865685
- Van Royen K, Van Royen P, De Donder L, Gobbens RJ. Elder abuse assessment tools and interventions for use in the home environment: a scoping review. Clin Interv Aging. 2020;15(1):1793-1807. doi:10.2147/CIA.S261877
- Elder abuse: how to spot warning signs, get help, and report mistreatment. American Psychological Association. November 10, 2022. https://www.apa.org/topics/aging-older-adults/elder-abuse
- Rosen T, Stern ME, Elman A, Mulcare MR. Identifying and initiating intervention for elder abuse and neglect in the emergency department. Clin Geriatr Med. 2018;34(3):435-451. doi:10.1016/j.cger.2018.04.007
- Victims’ rights and reporting obligations. United States Department of Justice. Updated April 3, 2023. https://www.justice.gov/elderjustice/victims-rights-and-reporting-obligations
- Adult protective services reporting laws. American Bar Association Commission on Law and Aging. April 2022. https://www.americanbar.org/content/dam/aba/administrative/law_aging/2020-elder-abuse-reporting-chart.pdf
- Get help in your area. National Adult Protective Services Association. 2023. https://www.napsa-now.org/help-in-your-area/
