Abstract

The prevalence of elder abuse and neglect increases in the modern societies as a result of global and population aging. It may take different forms such as physical, verbal, emotional, sexual abuse, exploitation, neglect and abandonment. We present two cases of elder abuse. The first case is a male patient with dementia presenting periorbital and facial ecchymoses resulting from interfamilial violence. The second case is a female with facial injuries, bone fractures and severe brain injuries. Elder mistreatment remains even in the 21st century a well hidden issue. There are many factors that are featured as risk factors for elder abuse. Poverty and ageism are the two main risk factors according to the United Nations Report in 2002. In addition, risk factors are interdependent, rendering the problem of elder abuse complex. Its management requires its handling as a social problem. In this manner, dental and medical education should provide skills for the diagnosis of elder abuse as well as for the understanding of the complex interaction between injuries and illness in the elderly. These approaches need a cooperation of many professionals from different faculties that will be alert in order to detect cases of mistreatment that usually remain undetected. Conclusively, regardless of the strategies being chosen for the management of elder abuse and neglect, the aim should be the protection of the dignity and the rights of the elderly in order to provide healthy and active aging.

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INTRODUCTION

According to the National Center on Elder Abuse, an institution of the U.S. Administration on Aging, Elder abuse refers to any knowing, intentional or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable adult. The abuse may be physical, emotional, sexual, exploitation, neglect or abandonment (National Center on Elder Abuse Administration on Aging, 2010a). Another definition for elder abuse comes from the International Network for the Prevention of Elder Abuse that says that elder abuse is 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. In fact, elder abuse is the mistreatment of an older person over 65 years of age from a perpetrator, a person that has a trust relationship to the victim who causes harm or increases the risk of harm (Bonnie and Wallace, 2003). It is noteworthy that elder abuse it is not only the act of doing harm to an older person but also the indifference to help and care about them. Today, the interest about the growing problem of elder abuse raises as many aspects of this social problem remain unclear or even hidden.

The major reasons for this shift of interest is the global aging of the population (Kinsella, 2004) and the problem of secondary aging i.e., the increase in older disabled people. In fact, it is expected that the older population will be doubled during the period from 1995-2025 (Krug et al., 2002). These phenomena are related to an increase in vulnerable older people, being dependent from family members or generally caregivers. Thus elder abuse is a consequence of global and population aging (Lowenstein, 2009).

Concepts on elder abuse: Different models were suggested as a framework in order to understand the phenomenon of elder abuse. One model is the child-abuse model. This model fails in explaining the complexity of elder abuse as it presupposes that the victim is dependent from the caregiver that is usually a daughter. A second concept is that of spouse abuse that involves older people, completely independent and suggests that abuse is rather related to personality problems of the perpetrator (Pillemer and Finkelhor, 1989; Stone et al., 1987).

 

Table 1:	Taxonomy of elder abuse

 

Other investigators advocate that the family violence concept is inadequate for explaining the complexity of elder abuse (Phillips, 1988).

Types of abuse: A more descriptive presentation of the various forms of elder abuse was done by Hudson (1991). This taxonomy is made up of five levels (Table 1). The types of abuse mentioned above may occur together. In fact verbal abuse, financial exploitation and neglect may happen together (Lowenstein et al., 2009). Global and population ageing contribute not only to the increase of abuse but also to an alteration of the pattern of elder abuse. It seems that physical abuse co-occurs with other types of mistreatment as these types of violence ages (Lowenstein et al., 2009).

Prevalence: There are many prevalence figures regarding elder abuse. In particular, elder abuse as it was assessed by Pillemer and Finkelhor (1988) for the Boston area was 32 older persons per 1000 with equal numbers for men and women (Pillemer and Finkelhor, 1989).

The prevalence seems to be even higher as it is postulated that one of four vulnerable persons is at risk of abuse (Cooper et al., 2008). The prevalence of mistreatment among demented older persons is higher than that of non-demented (Wiglesworth et al., 2010; Cooney et al., 2006) with the most prominent types of abuse being verbal abuse (51%), verbal abuse alone (33%) and physical abuse (20%) (Cooney et al., 2006).

Signs and assessment of elder abuse: The role of the dentist in detecting victims of abuse is significant as over 75% of the victims of physical abuse, show easily detectable signs on the head, neck and perioral region (Tilden et al., 1994). According to the US Administration on Aging, signs of abuse may range from slight changes in people’s psychology to National Center on Elder Abuse Administration on Aging (2010b):

•	Bruises, pressure marks, bone fractures, abrasions, burns may be results of physical abuse, mistreatment or neglect

•	Unusual depression and withdrawal from work as a result of emotional abuse

•	Bruises in the genital region and the breast resulting from sexual abuse

•	Poor hygiene, weight loss as a result of neglect

•	Sudden changes in financial situations as a result of exploitation

•	Inappropriate behaviour of a spouse or caregiver such as belittling, threats and a bad relationship between the older person and the caregiver, indicate verbal or emotional abuse

There are also signs that should make the health care professional suspicious (Quinn and Tomita, 1997):

•	The chronological age of the injuries i.e., the interval between the injury and the consultation of the doctor

•	The way in which the older person was found in particular whether he/she came to the department with someone other than the caregiver or he/she was found at home alone

•	The presentation of the history of the injuries by the patient that may hide the real cause

•	The non-compliance with the prescribed medications

The assessment requires proper recording of the injuries that includes the description: of the size, location, shape and color of the injury (Quinn and Tomita, 1997). The color of the injury conceals its age. In the first 2 days the injury is tender, until the 5th day after the injury its color is red-blue then it changes to green after the 7th day to yellow after the 10th day to brown and after 2 weeks there is no sign of injury (Quinn and Tomita, 1997). Bruises as a result of physical abuse are >5 cm and occur mainly on the head, neck, lateral right arm and posterior part of the body (Wiglesworth et al., 2009). The examination of the patient requires X-rays, computer tomography examinations in order to rule out bone fractures, gynecological examination to search for signs of sexual abuse, toxicology and metabolic screening for under or over medication and endocrinological or nutritional dysfunction, respectively (Quinn and Tomita, 1997). The number of older persons attending the emergency department of the hospitals is increasing thus there is a need to make a proper physical examination taking into account the multitude of pathologies from which this social group may suffer from, including abuse.

In fact fall injuries could be the result of medication toxicity and myocardial infarctions but also elder abuse that should be taken into account (Sanders, 1999). This interaction of injury and disease in the elderly must be known to health care professionals in order to identify cases of abuse and violence (Paranitharan and Pollanen, 2009). Elder mistreatment is related to a higher rate of mortality (three-fold increase) (Lachs et al., 1988). Recent findings point out that victims of elder abuse show polymorph nuclear infiltrations of the lung and the liver due to the multiple injuries as in traumatic or hemorrhagic shock (Hayashi et al., 2010). This leads to Multiple Organ Failure (MOF). Thus when a chronic disease in older patients is excluded, the MOF may be a result of physical abuse.

CASE REPORTS

First case: A 72 years old male presented to the hospital with periorbital ecchymoses and ecchymoses of the right side of the face as a result of fisticuffs from his son (Fig. 1). The patient suffered from dementia.

 

Fig. 1:	Ecchymoses of the face and the periorbital region

 

 

Fig. 2:	Elder abuse victim shows signs of trauma with multiple significant facial injuries and fractures of facial bones. Injuries of the head often lead to dead of elder abused individuals as a result of intrafamiliar violence

 

Second case: A 80 year old female conducted the hospital after brutal intrafamiliar violence (Fig. 2). The clinical investigation reveals injuries of the face, fractures of bones of the facial skeleton and brain injuries.

DISCUSSION

Elder mistreatment is not a phenomenon of a particular area or state. Although, the numbers of male and female victims of elder abuse are equal, women undergo more violent and serious abuse (Pillemer and Finkelhor, 1988). Additionally, it is mostly related to urban living and social exclusion (Litwin and Zoabi, 2003).

Lowenstein (2009) advocates in her study on elder abuse, in order to recognize an issue as a real problem it must be dealed with as a social problem. This provides the adequate severity in order to make the public and the authorities aware of this issue. United Nations (2002) reported that the two main determinants for elder abuse are poverty and ageism. In particular, social and economic difficulties, a lack of knowledge of the law and the services provided by authorities and poverty are some of the factors that contribute to elder abuse according to the world view environmental scan on elder abuse (Podnieks et al., 2010). These factors are characterized as risk factors and not causes for many reasons, including the different techniques utilized to analyse them (Schiamberg and Gans, 1999). The psychopathology of the abuser as well as of the victim is another important issue.

The perpetrator mostly has a history of psychological illness (Wiglesworth et al., 2010; Wolf, 1992). On the other hand older persons with signs of depression are more likely to become abused than none depressed ones (Dong et al., 2010). Thus the clinicians should also focus on the caregivers because signs of anxiety and depression as well as their perception about the behaviour of the care receiver may manifest abuse (Wiglesworth et al., 2010). It is of particular interest to understand how elder abuse is being faced by the elderly. In fact, older people perceive abuse as neglect, violation of rights and deprivation of decisions, finances, choices (WHO/INPEA, 2002). Elder abuse in turn causes injury, illness, loss of productivity, isolation an despair (WHO, 2002).

Difficulties in managing the problem of elder mistreatment and abuse arise as cultural, economical, educational, political and social factors raise barriers (Podnieks et al., 2010). Different aspects have been given to this multifaceted problem. Recent concerns raise the hypothesis that is not only a governmental issue but also a judicial, intergenerational, intrafamiliar and a health problem (Lowenstein, 2009). According to the WHO it involves many specialties, in particular justice officials, law enforcement officers, health and social service workers, labour leaders, spiritual leaders, faith institutions, advocacy organizations and older people themselves (WHO, 2002). There are now many concepts on which the management of this problem should be based each one addressing different aspects of this phenomenon. The situational model suggests that supporting the families with nurse assistance and other measurements that lower the stress of the caregiver reduce the possibility of elder abuse (Phillips, 1986). The environmental model states that the environment induces stress to the caregiver that is unable to keep up with the expectations (lack of resilience), resulting into a maladaptation.

Thus the increase of the competence of the caregiver lowers the possibility of abuse (Ansello et al., 1986). Without taking into account one specific theoretical framework, it is obvious that the risk factors for elder abuse are interdependent thus multiple strategies are more successful than tryings that address one factor separately (Schiamberg and Gans, 1999). In fact it is difficult to assess the efficacy of the strategies implemented for the management of elder abuse as there aren’t enough high-quality studies that address this issue (Ploeg et al., 2009).

According to the WHO, the main goal of the health care providers is to promote healthy and active aging (WHO, 2002). In this manner, future investigations should focus on the problem of elder mistreatment and protection of the elderly as a social problem in order to protect their dignity. In order to address this multidimensional issue, the contribution of professionals from many faculties is essential. It is important to underline that the problem of elder abuse is present in all societies and is independent of the financial status of the societies (WHO, 2002). Thus a cross-cultural and cross-national approach for the management of and awareness about elder abuse (Kosberg et al., 2002) as well as a common nomenclature and language used by professionals are needed. Another important strategy in order to make professionals aware of the sociocultural problem of elder abuse is the early education of dental and medical students in items addressing the phenomenon of ageing, the problems of the elderly and the increasing prevalence of elder abuse in the days.

Unfortunately, new doctors are unaware of elder abuse and are unable to detect it so they cannot keep in pace with the changes occurring in the population (Gironda et al., 2010).

CONCLUSION

The prevalence of elder abuse in the society increases as a result of global and population ageing. Each type of elder abuse is harmful, starting from the more psychologistic ones to the physical violence. This implies that the problem of abuse must be addressed starting from the more hidden form of verbal abuse. This approach should focus on elder mistreatment as a social problem and should aim at protecting older person’s dignity and rights by developing effective approaches for protection and management.

How to cite this article:

A. Kokkas, L. Zouloumis, C. Stavrianos and E.M. Dietrich. Elder Abuse: Two Cases.
DOI: https://doi.org/10.36478/rjmsci.2010.357.361
URL: https://www.makhillpublications.co/view-article/1815-9346/rjmsci.2010.357.361