Abstract

Seniors can be vulnerable to abuse for many reasons in many different aspects of life. Elder abuse refers to any action or inaction that threatens the well-being of a senior. Abuse can occur at home or in a residential facility at the hands of a family member or another caregiver. But abuse is not only about broken bones and bruises and marks seen on the body of the victim. There can be different types of elder abuse. The senior may be subjected to more than one type. Most common types are: physical abuse, sexual abuse, inactive abuse, active abuse, self-neglect or abandonment, financial exploitation and psychological abuse. Signs and symptoms can be noticed by neighbors and be reported. It is of major importance that the dentist/doctor is qualified and informed of the protocol on handling cases of elder abuse. Usually elder abuse is the well-kept secret of a family and it is a problem within families. Unfortunately elder abuse can happen to any family. The topic of elder abuse is difficult because all practitioners wish that it did not happen. Cases of family violence are hard to deal with because we know that they are not the result of some disease or accident. Instead, they are done deliberately. Although, victims are often reluctant to report their abuse, the fact that about 75% of physical injuries are inflicted to the region of the head, face, mouth and neck places dentists in a very good position to recognize the signs of abuse and take steps to intervene.

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INTRODUCTION

It is a fact now a days that the structure of the society has been transformed by the demographic, financial and health alterations that occurred. As a result of the higher age limit and the decreased rates of fatality that advanced medicine and the anthropocentric character of western societies have achieved, we observe a substantial anode of the elder population. Although, it seems ideal and optimistic as a phenomenon, nevertheless it has some severely unpleasant parameters. These consequences refer to the quality of life and the amount of love and attention these old people receive when they depend on others. Beyond the concomitants of old age, related to the person’s health and are expected to appear, the situation is exacerbated by violent episodes, neglect and maltreatment that all together compose the wound of elder abuse. As elders become more physically frail, they are less able to stand up and defend themselves against abusers of any kind (Fig. 1).

Fig. 1:	Facial trauma significant facial injuries and ecchymoses caused by his son

They are unable to see or hear as well or think as clearly as they used to, leaving openings for unscrupulous people to take advantage of them. Many times elder people are being abused in substantial ways by people who are responsible for their care and their well-being. That’s why unfortunately, a large number of these cases go unreported (Podnieks et al., 1990; Douglass and AARP, 1995; Herschaft et al., 2006).

Elder abuse usually takes place where the senior lives. Sometimes, institutional settings can also be sources of elder abuse. It is believed that the problem of elder abuse emerges from the inability of the youngest members in a family to coexist with those that are less active and disabled due to their advanced age. Medical institutions and public services have the responsibility to investigate any suspicious cases that they are dealing with so, they can determine the true causes of injuries, signs of neglect and peculiar/disoriented behaviour from the old patient. Some factors that promote this phenomenon are:

•	The elderly depend entirely on the family
•	Alzheimer’s disease
•	Financial awkwardness of the family that supports the elder person
•	Stress that is very common

So although, the society has progressed and the improved strata offers a comfortable way of living, still the tragic wound of elder abuse is not yet known to many as a term and as a reality and only few actions are taken for its extinguishment. The most sensitive groups are those over the age of 75 as statistics show but these facts do not exclude every elder person from becoming a victim, regardless to his/hers financial and social status, health condition and sex. Those who leave by themselves either because they’re widowed or single, experience social exclusion are suppressed, manipulated and sentimentally affected by their care givers. Violators/aggressors are usually members of the family (adult children, son/daughter in law), spouses that have been mistreated throughout the years of marriage and want revenge and hired care givers. They can also be high positioned officers that can influence and exploit an old and ignorant person (Podnieks et al., 1990; Mouden, 1996; Fulmer, 2003; Stavrianos et al., 2007; Herschaft et al., 2006). Although, typically when one hears the term domestic abuse thinks about child or spousal abuse, elder abuse is another hidden form of abuse that has more recently come to the public’s attention (Quinn, 1986).

HISTORICAL TRENDS

Elder abuse first was defined by two reports published in 1975 (Baker, 1975; Burston, 1975). A 1997 study by Kleinschmidt found that reported elder abuse had increased 94% compared to 1996 (Kleinschmidt, 1997). Many studies demonstrate that elder abuse is widely unreported and that is because the victims are afraid or unable to report their problems (Capezuti, 2000; Swagerty, 2003). Some seniors may be even feeling ashamed or embarrassed about their situation and may not confide in others concerning abuse. It is quite difficult for them to trust a total stranger because sometimes the maltreatment is seen by them as normality (Swagerty, 2003). Also the first references were made to granny bashing in the British literature in 1975. Since then, it has become painfully clear that mistreatment of seniors is a problem in the whole world. Elder abuse may be as prevalent or perhaps even more prevalent than child abuse (Frazier and Hayes, 1991; Moran, 1998). That is why it is not until recent years that we have developed organizations where anyone can report elder abuse so as it can be fought in a certain effective way. Some of them are: Adult Protective Services, National Center of Elder Abuse in the USA and Law Enforcement when physical abuse is happening.

CATEGORIES OF ELDER ABUSE

Numerous cases of abuse have been recorded and it is obvious that elder abuse has many faces and can be expressed in many ways. Some forms of elder abuse are:

Physical abuse: It presents similarities to child abuse. Traumas are usually tracked on the head and the neck and all inexplicable injuries are justified as accidents by the victim’s environment (Le et al., 2001). It is the most immediately recognized form of abuse. It constitutes any type of injury sustained from hitting, biting, slapping or striking with objects the poor victim. Unfortunately physical abuse is the least validated form statistically and rarely come to the attention of the medical or criminal justice systems. This happens because social stereotypes of frail or feeble or generally weak seniors are often used to explain cuts, burns or bruises which are actually caused by physical abuse. Because society’s consciousness of mistreatment of the elderly is very low, abusers are protected by ignorance. People are improbable of suspecting their criminal behaviour (Douglass and AARP, 1995; Moran, 1998; Swagerty, 2003).

Signs of abuse and orofacial injuries (Le et al., 2001; Herren and Byron, 2005):

•	Injuries that have not healed properly
•	Injury not consistent with cause
•	Unusual injuries
•	Loose teeth, cuts, fractures, burns and welts
•	Malnutrition
•	Pallor
•	Lip trauma
•	Bruising of the edentulous ridges or facial tissues
•	Fractured teeth
•	Subluxated teeth
•	Avulsed teeth
•	Fractures of maxilla and mandible

Sexual abuse: It is unbelievable and monstrous as it sounds, yet is quite common. Sexual abuse is contact without the elder’s consent. Such contact can involve physical sex acts but also activities such as showing an elderly person pornographic material, forcing the person to get undressed or to watch sex acts unwillingly. Although, all these might seem hypes, unfortunately they do occur in modern societies as sad as it might be. It is something that most dentists would not consider at all. Most of the signs of sexual abuse including vaginal bleeding, bruises on breasts and venereal diseases are out of the realm of general dentistry. However, many sexually transmitted diseases may show in the oral cavity (Swagerty, 2003; Herschaft et al., 2006) as following:

Oral signs of sexual abuse (Herren and Byron, 2005):

•	Gonorrhea
•	Chlamydia
•	Syphilis
•	Type 2 herpes
•	Lacerations of frenum
•	Palatal petechia

Passive neglect: The absence of proper care but it is considered not to be intentional. The inability of the care giver to provide sufficient care to the elderly arouses when the person suffers it self by illness or is not trained sufficiently and even when the care giver does not realise the importance of the tasks he/she undertook. It is the most commonly form of mistreatment. In most situations, passive neglect is the result of well-meaning family members who assume the care of a frail and dependent senior but who are incapable of meeting that person’s needs. Some causes of passive neglect are the following:

•	Bad physical, emotional or financial status of the caregiver
•	The senior’s inability to contribute in any way in the household
•	The fragility of human relationships in general
•	The fact that home care requires important skills such as the ability to clean an adult with limited or no mobility and the ability to turn and bathe a bed-bound person without causing bruises and without hurting one’s self
•	The major changes that occur in the functioning of the home and the relationships between all the members of the family
•	Unexpected unemployment, marital conflicts or other problems such as inadequate financial resources and emotional instabilities can absolutely destroy a family’s capacity for providing home care
•	The isolation of a family which can result in passive neglect because the members of the family are incapable of taking care of their own needs (Douglass and AARP, 1995; Moran, 1998)

Active neglect: It is the intentional deprivation of services to the elder person by the care giver causing them discomfort and exalts any health and psychological issues. This is done by constrictions and lack of food, medicines, hearing aids, dentures and other helpful equipment necessary for the person’s well being. This type of behaviour leads to deliberate abandonment. It is often linked to a desire to cause pain or suffering. The reasons can include all the elements that may cause passive neglect but the difference in this kind of abuse is the fact that the person decides not to provide for the dependable senior. Usually this form of elder abuse is associated with victims who are socially or physically isolated from the witnesses who could prevent this kind of mistreatment (Douglass and AARP, 1995; Moran, 1998).

Self-neglect: It happens when the person it self does not look for his/hers vital needs like food, medication, personal hygiene, clothing and medical treatment. This may occur either because the senior is disabled or because he refuses to provide for him/her self. This category may be a part of the upper forms of abuse because it usually occurs due to caregiver’s issues as listed above (Herschaft et al., 2006).

Financial exploitation: It usually involves unauthorized use of an elderly person’s funds or property. It can be caused either by a caregiver or by an outside scam artist, either way, this type of abuse is usually perpetrated by someone close to the senior. Unfortunately many times a caregiver might misuse an elderly person’s personal checks, credit cards or accounts, steal cash or even household goods from him/her, forge the elder’s signature or engage in identity theft. The outsiders usually try to fool the elder by creating phony charities or by using investment fraud. Sometimes they even announce a non-existing prize that can be won by the elder only if he/she gives a certain amount of money in cash. Financial abuse is all about taking money, performing scams and using the senior’s property or possessions without permission. Greed is the principal cause for this type of abuse. Financial abuse and exploitation are considered to be forms of theft. Although, they are rarely reported to the police, they are observed in all around the globe (Douglass and AARP, 1995; Swagerty, 2003).

Healthcare fraud and abuse: As sad as it might sound, it is carried out by unethical doctors or hospital personnel, or even other professional care providers. It includes:

•	Not providing healthcare but charging for it
•	Overcharging medical services
•	Recommending fraudulent remedies for illnesses
•	Medicaid fraud (Herschaft et al., 2006)

Psychological abuse: When the elderly is deprived of socialization is handled like a burden and feels useless and unworthy because of the way his environment treats him. This leads to depression and lack of self confidence making the person feel lonely and in constant anxiety and distress. The elderly can be humiliated and intimidated by their care givers or even suffer from extortion, threats and abandonment, absence of tenderness and loving emotions that are necessary to any human being. These reflect on the behaviour of the pensioner as the person feels awkward around people, appears incompetent of expressing opinion, fear and agony is obvious in his/her look and does not show any interest in life and what happens around. Emotional abuse is about emotional pain or distress caused by reckless behavior of the people who surround seniors. There are two forms of emotional abuse:

Verbal forms:

•	Intimidation through yelling or threats
•	Humiliation and ridicule
•	Habitual blaming

Nonverbal psychological forms:

•	Ignoring the elderly person
•	Isolating him/her of friends and activities
•	Terrorizing or menacing him/her (Douglass and AARP, 1995)

The interesting fact about psychological abuse is that it is not necessarily associated with a dependent-caregiver relationship, thing that happens in other forms of abuse. Some abusers may even be dependent upon their victims. Psychological abuse of course is associated with a poor relationship between the victim and the abuser. It is intentional although, there are a lot of reasons which are known to be the causes in such situations. Such reasons are alcohol abuse or unemployment. Psychological abuse in general includes the infliction of emotional distress through verbal threats, intimidation, humiliation and social isolation (Moran, 1998; Wedding, 2001; Herschaft et al., 2006).

Signs and symptoms: Unfortunately, signs and symptoms of elder abuse are hard to notice especially at first because most of the times they can be mistaken as results of dementia or frailty. Especially when caregivers deny elder’s problems.

General signs of elder abuse:

•	Frequent arguments or tension between the caregiver and the elder person
•	Changes in the personality of the elder person
•	Changes in his/her general behavior especially when these changes occur rapidly (Douglass and AARP, 1995; Herschaft et al., 2006).

When it comes to emotional abuse, one could witness a threatening caregiver and weird behavior on behalf of the elder person by signs of rocking and mumbling to him/herself. When it comes to physical abuse, one may notice broken bones or dislocations, broken eyeglasses or frames, unexplained signs of injury such as bruises, welts or scars which in these cases usually appear symmetrically on the body. Also, one may experience caregiver’s denial to allow him/her to see the elder person alone. One can observe cuts, lacerations and generally injuries which are not compatible with the history of the patient. When it comes to sexual abuse there are bruises around breasts or genitals, torn, stained or blooded underclothing, unexplained vaginal or anal bleeding and unexplained venereal disease or genital infections. When it comes to financial exploitation, there can be sudden changes of the elder’s financial condition, items or cash missing from his/her household, unpaid bills, unnecessary services, goods or subscriptions or in general financial activities that the elder couldn’t possibly have done by him/her self. Finally, when it comes to healthcare frauds, one may find evidence of overmedication or under medication or inadequate care when bills are paid in full (Douglass and AARP, 1995; Moran, 1998). Diagnostic tools for the medical/dental team examining the victim are firstly an accurate interview of the victim concerning his/her health, conditions, previews injuries and generally a social/academic and financial status as well as his/her environment situation. All these reveal significant aspects. Then a full examination is done to record all indications, symptoms and injuries and if decided necessary further investigation is held. Also X-rays can be used for diagnosis as well as cat scans, photographs, radiograph exams and anything that might shed some light on the case. Every patient that is under investigation for possible abuse has to be treated by a certain protocol and the doctor is obliged to collect all evidence and inform the authorities. The medical examiner has to be experienced enough in cases of elder abuse so, he/she can determine the true cause of his findings on the patient. He has to be in place to recognize old bruises from new from their appearance and that is a clue of previous assaults and continuous abuse of this person by a third party. If the deformities and the injuries are on both sides of the face, there is a bruised eye and ecchymosis in the area then all these make us presume of their intentional causing. Also fraction of the maxillofacial bones is noticed in cases of elder abuse as well as fractions of the nasal area and the zygomatic arc (Le et al., 2001).

What is not usually found in elder abuse are biting marks that are more common in sexual abuse. Some times the clinical examiner needs to give a differential diagnose for symptoms or indications that either come from abuse or pathological conditions that appear along with old age. Some conditions with indications that might seem tricky for the doctor to determine their causes are (Herschaft et al., 2006):

•	Vascular denaturation and deformation, clots and varicose veins that give ecchymosis and discolouration of the skin living it looking bruised
•	Lupus
•	Erythema (bad form)
•	Diabetes
•	Peripheral vascular ulcers
•	Ulcers due to immobility

An extra difficulty in detecting cases of elder abuse is the lack of collaboration with the victim. The reasons are recapitulated below (Douglass and AARP, 1995; Herschaft et al., 2006):

•	The elder victim is in denial or can not realise the situation
•	They are afraid of abandonment, isolation and revenge by the care giver or the prospect of being held in an institution
•	They are under the absolute control of their torturer and completely depend on him/her to receive food, clothing, medication and housing
•	They have the fear of loneliness if the care giver is removed or imprisoned
•	Some of them are really proud and dignified people and feel ashamed to declare what they are suffering
•	Others are unaware of the organizations created to protect them and are there for help
•	There are some cases of old people who they ignore their civil rights and find it hard to comprehend the functions of the legal system
•	In some cases matters of religious believes, cultural factors and language difficulties interfere
•	There is also a general disbelieve for the integrity of law enforcement officers and lack of trust towards them due to past unpleasant experiences
•	Finally most of them don’t want to be exposed and their anonymity revealed

DISCUSSION

Doctors and dentists are a crucial link in discovering and identifying potential elder abuse because during examinations are required to search for signs and symptoms of potential abuse and if they find any, they are required to report them to the police. Visual examinations are only the first step in diagnosing abuse. Communication with the potential victim plays a really important part. Some general screening questions for elderly patients are (Kahan and Paris, 2003):

•	Have you been hurt by a loved one or care provider?
•	Have you ever felt pressured or forced to do things against your will?
•	Are you afraid of anyone at your home or care facility?
•	Do you ever need help when alone and cannot get in touch with anyone?
•	Do people assist you with caring for your teeth?
•	Do people assist you with your meals? Are you ever hungry and unable to get food or water?
•	Do people assist you when you are sick or don’t feel well?
•	Do you feel your medications are available when you need them?

A doctor or a dentist plays an important role in senior’s life. That’s why they are in a position to be trusted by seniors and some questions they can ask to reveal physical or sexual abuse:

•	Have you been kicked or shoved?
•	Have you ever been tied down or locked in a room?
•	Have you ever been force-fed?
•	Has anyone touched you in a sexual way without permission?

Psychological abuse questions:

•	Have you received the silent treatment?
•	Do you get routine news and information?
•	What happens when you and your caregivers disagree?
•	Have you been threatened with punishment or institutionalization?
•	Do you ever feel alone?

Financial exploitation (Fig. 2) questions:

•	Is money being stolen from you or used inappropriately?
•	Are you given inadequate information about your finances?
•	Have you been forced to sign a power of attorney or any other document against your will?
•	Does your caregiver spend your money on themselves?

Neglect (Fig. 2), questions:

•	Do you lack items that you need such as false teeth, eyeglasses, medication, etc.?
•	Is your home safe?
•	Have you been left alone for long periods of time?

The following questions are to be asked when abuse is identified:

•	How many times has it happened?
•	Why do you think it happens?
•	When do you think it will happen again?
•	How long has this been occurring?
•	Do you feel it is safe to return home?
•	What would you like to see happen from this?
•	Is the abuser present? Do you know their names?

Intervention strategies for dental practitioners: A dentist should keep in mind that abuse is not confined within socioeconomic boundaries, it occurs in all racial, cultural and economic backgrounds. As a dentist, one should be on the lookout for the injuries of abuse in all of his/her patients.

Fig. 2:	Exploitation neglect abandonment, Where you are, I have been and where I am, you may be (An old Greek saying)

At first try to look for reasonable explanations but if suspicions develop as a result of unusual behaviour or unexplained trauma, they should be reported to the proper authorities. Also, dentists should never make assumptions or underestimate the signs of trauma because abuse rarely is an isolated incident. Abuse is not a family matter that must stay within the privacy of a home because without outside intervention violent episodes tend to recur and escalate in intensity. We must all keep in mind that violence is not caused by alcohol or drugs so, the abusers themselves must take responsibility of their actions and not blame anything else (Salber and Taliaferro, 1995). It is fact though that many abusers grew up in abusive homes and that is why breaking this intergenerational cycle of domestic violence is everyone’s responsibility. Dentists can and should be proactive in recognizing abuse and reaching out to help the victims (Denham et al., 1994). The first step in helping the victims is to consciously empathize with them and their needs. Because it is really difficult for them to trust someone and admit the fact that they have been abused. Secondly when a dentist suspects such a problem, he/she must proceed carefully in the interview. Some guidelines are:

•	Listen to what the victim is trying to convey verbally and nonverbally
•	Respect silence. Do not rush the victim or put words in the victim’s mouth
•	Keep any questions short. Use words that are part of the victim’s vocabulary. Avoid asking leading questions
•	Give immediate reassurance and support, indicating that you believe the victim and that you don’t think that he or she provoked the abuser

When a victim discloses information about being abused, limit any further interview (Jorgensen, 1992; Denham et al., 1994; Sweet, 1996). Report it right away to the local social services personnel who are in position to handle such cases. Intervention is not dentist’s duty but must be done by trained professional counsellors with experience in support and guidance techniques. Third, a dentist must be prepared to recognize and deal with abused patients. The staff should be informed in this subject as well. He/she musts assemble a resource list of phone numbers and contact persons who could assist in such situations. The dentist must be aware of the fact that victims are most vulnerable psychologically and physically at the time when they first come forward with stories of abuse and be ready to handle the situation properly. The responsibilities of a dentist to educate patients and be proactive in matters of abuse do not stop outside the office setting. The dentist must consider ordering and displaying pamphlets, brochures and educational materials from local crisis centres that will assist members of the public in becoming familiar with the abuse. Providing information for people in society and helping them understand this issues many times is equally important as identifying individual victims. Generally dentists play a significant part in dealing with such cases. That is why they must recognize and try to break the cycle of abuse (McDowell et al., 1992; Jorgensen, 1992; Denham et al., 1994; Douglass and AARP, 1995; Sweet, 1996).

CONCLUSION

Elder care giving can be extremely stressful for some people. Thus it brings problems not only to the elder person but also to the caregiver who usually suffers from depression. This along with other parameters can lead to elder abuse. The medical examiner should be aware of the foundations and organisations that interfere in such cases and he must approach and rely on. He must also know all the laws concerning matters of abuse and let his patient know of his rights and consult him what his next moves should be and what proceedings should be followed. Elderly people wearing full or partial dentures are obliged to be treated as any other individual in the society as they should have a high quality of life exactly as anyone else. Nevertheless, elder abuse is an existing phenomenon. This is why dentists should always be aware and pay extreme caution in cases that elder abuse is suspected. Denture wearers that report malfunction of prosthetic appliances due to broken dentures, broken clasps and broken teeth especially in the anterior area should carefully be treated as potentially abused victims. Orofacial injuries should be examined thoroughly. Dentists, according to concurrent guidelines have to take a detailed medical and dental history in order to reveal a possible abuse. Severe attacks always consist of several different signs and symptoms as mentioned above. Dentists should be aware that abuse may result in oral or dental injuries so, they must be knowledgeable about such findings. Identification and reporting of potential abuse by doctors and caregivers is not only crucial for the victim’s life but also is required by law. Elder abuse unfortunately happens more frequently in society than many people realize. Everyone must help in safeguarding the elderly population.

How to cite this article:

C. Stavrianos, L. Vasiliadis, J. Emmanouil, O. Pantelidou, A. Pantazis and C. Papadopoulos. Elder Abuse and its Forms of Expression.
DOI: https://doi.org/10.36478/rjmsci.2011.133.140
URL: https://www.makhillpublications.co/view-article/1815-9346/rjmsci.2011.133.140