Week 14:  Cognitive Impairment and Elder Abuse

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Miss the class?  Listen to instructor Dr. Minoo as she provides a short introduction to cognitive impairment and elder abuse.  

Additional resources on Elder Abuse

Cognitive Impairment and Elder Abuse

Did you know that World Elder Abuse Awareness Day (WEAAD) is June 15th? The purpose of World Elder Abuse Awareness Day is to provide an opportunity for communities around the world to promote a better understanding of abuse and neglect of older persons by raising awareness of the cultural, social, economic and demographic processes affecting elder abuse and neglect.  

Globally, the number of cases of elder abuse is projected to increase as the older population worldwide is increasing. We need to prevent violation of older human rights by building a strong support for older adults. (National Institute on Aging, 2024) Every person, no matter how old, deserves to be safe from harm by those who live with them, care for them, or have daily contact with them. (APA's Committee on Aging, 2022)  

Each year, hundreds of thousands of adults over the age of 60 are abused, neglected, or financially exploited. Learn more about this topic so you can help identify elder abuse and protect older adults who may be vulnerable. (Elder Abuse | National Institute on Aging, 2024) 

This week, we will look at the prevalence and complications of elder abuse, types of elder abuse, signs and risk factors, who mostly abuses older people, how cognitive impairment correlates with elder abuse, and most importantly, how to prevent and report elder abuse. 

WEAAD-Factsheet-FAQs.pdf

Learn more about Elder abuse, neglect and exploitation in this guide.

What is Elder Abuse?

The World Health Organization (WHO) 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. This type of violence constitutes a violation of human rights and includes physical, sexual, psychological or emotional abuse, financial abuse, neglect, and serious loss of dignity and respect. 

Globally, the number of cases of elder abuse is projected to increase as many countries have rapidly aging populations. (World Health Organization, 2022)


Elder Abuse is Common 

Even if the proportion of victims of abuse of older people remains constant, the global number of victims will increase rapidly due to the aging population growing to some 320 million victims by 2050, as the global population of people aged 60 years and more increases to 2 billion by 2050. (World Health Organization, 2022)

A 2017 systematic review of the 38 544 studies initially, identified fifty-two studies in twenty-eight countries from diverse regions were eligible for inclusion. Results showed that over the past year, 1 in 6 people (15.7%) aged 60 years and older were subjected to some form of abuse, which is roughly 141 million people in community settings. (Yon et al., 2017, e147-e156)

The results of a 2019 systematic review of nine studies that met the inclusion criteria from an initial 55 studies showed that the prevalence of elder abuse in institutional settings was 64.2%. 2 in 3 staff reported that they had committed abuse in the past year. Researchers concluded that global action to improve surveillance and monitoring of institutional elder abuse is vital to inform policy action to prevent elder abuse. (Yon et al., 2019, 58-67)  

Emerging evidence indicates that the prevalence of abuse of older people in both the community and in institutions have increased during the COVID-19 pandemic. A US study, for instance, suggests that rates in the community may have increased by as much as 84%. (World Health Organization, 2022) 

In the United States, it is estimated that over 10% of those aged 65 and older experience some form of elder abuse in a given year.  (US. Department of Justice, 2024) 

elder-abuse-infographic-508.pdf

Spotting the signs of Elder Abuse

Elder Abuse is Serious 

Abuse of older people is an important public health problem. It is a serious problem in the United States. The available information is an underestimate of the problem because the number of nonfatal injuries is limited to older adults who are treated in emergency departments. The information doesn’t include those treated by other providers or those that do not need or do not seek treatment. Additionally, many cases are not reported because elders are afraid or unable to tell police, friends, or family about the violence. Victims have to decide whether to tell someone they are being hurt or continue being abused by someone they depend upon or care for deeply. (Fast Facts: Preventing Elder Abuse |Violence Prevention Injury Center CDC, 2024)

Some complications of elder abuse include worsening health problems, premature death, social isolation, depression, increased rate of hospitalization and institutionalization (World Health Organization, 2022), and financial devastation. For example, the annual loss by victims of financial abuse is estimated to be at least $36.5 billion in the United States. (Get the Facts on Elder Absence, 2021)  

Abuse can happen in any form to any older person. In the next session we learn about the different types of abuse. Infographic shows the types of signs of elder abuse.

Different Types of Elder Abuse

Common types of elder abuse include: 

·   Physical abuse means inflicting physical pain or injury upon an older adult. It can range from slapping or shoving to severe beatings and restraining with ropes or chains. When a caregiver or another person uses enough force to cause unnecessary pain or injury, even if the reason is to help the older person, the behavior can be considered abusive. Physical abuse also encompasses behaviors such as hitting, beating, pushing, shoving, kicking, pinching, burning, or biting. It also includes the inappropriate use of medications, physical restraints, and physical punishment of any kind.

·       Sexual abuse involves forced or unwanted sexual interaction of any kind with an older adult. It includes touching, fondling, intercourse, photographing the older adult in suggestive poses, forcing the person to look at pornography or any other sexual activity with an older adult, when the older adult is unable to understand, unwilling to consent, threatened, or physically forced. 

·       Verbal, emotional, and psychological abuse includes yelling, swearing, threatening, making insulting or disrespectful comments, or repeatedly ignoring the older adult. Psychological abuse involves any type of threatening behavior that sets up a power differential between the older adult and his or her family member or caregiver. It can also include treating the older person like a child and isolating the person from family, friends, and regular activities.

·       Financial Abuse means the misuse or withholding of an older adult’s resources by another. It can include forging checks, taking someone else's retirement or Social Security benefits, or using a person's credit cards and bank accounts without their permission. It also includes changing names on a will, bank account, life insurance policy, or title to a house without permission.

·       Passive/Caregiver neglect, which can be intentional or unintentional, involves intentionally failing to meet the physical, social, or emotional needs of the older person. Neglect can include failure to provide food, water, clothing, medications, assistance with activities of daily living, or help with personal hygiene. (APA's Committee on Aging, 2022)

What are the Warning Signs of Elder Abuse?

·       Physical abuse: Bruises, pressure marks, broken bones, abrasions, burns.

·       Sexual abuse: Unexplained vaginal or anal bleeding, Venereal diseases or vaginal infections.

·       Verbal, emotional, and psychological abuse: Unexplained withdrawal from normal activities, a sudden change in alertness, unusual depression, strained or tense relationships, and frequent arguments between the caregiver and older adult. Belittling, threats, or other uses of power and control by individuals are signs of verbal abuse.

·       Neglect: Bedsores, unattended medical needs, poor hygiene, unusual weight loss. (Get the Facts on Elder Abuse, 2021) 

What Makes an Older Adult Vulnerable to Abuse?

A combination of medical, psychological, functional, social, and economic factors may be associated with the occurrence of elder maltreatment. These risk factors may potentially expose older adults to a heightened risk of abuse. Examples include but are not limited to: 

·       Chronic medical and mental health conditions

·       Cognitive impairment

·       Physical, financial, and emotional dependence

·       History of poor family relationship between older adult and caregiver

·       Caregiver burden

·       Social isolation

·       Lack of access to support and resources (NCEA | Elder Abuse, 2023) 

Recent studies show that nearly half of those with dementia experienced abuse or neglect. (National Council on Aging, 2021) Many of them go unreported and uncounted because victims are sometimes unable to communicate or tell anyone about the abuse. In fact, cognitive impairment (such as dementia or Alzheimer’s disease) is an important risk factor for elder abuse. (Alzheimer's Abuse, 2024) 

How Does Dementia Increase the Risk of Elder Abuse?

Unfortunately, evidence suggests that people with dementia are more likely to be abused than those without dementia diseases.

Dementia can cause psychological or behavioral symptoms such as agitation and aggression in patients. This aggression can add tension and intensify conflicts between dementia patients and their caregivers, increasing the risk of verbal abuse, physical abuse, and neglect.

The Chicago Health and Aging Project (CHAP) study found that every one-point decline in cognitive function scores was associated with an increased risk for elder mistreatment. The risk of elder abuse or neglect increases due to increasing cognitive decline. The same study identified a sharp increase in the severity of self-neglect, and the ability to care for one’s health and hygiene, with declining cognitive function scores.

Video:  10 forms of elder financial abuse

Research suggests the risk of mortality associated with abuse and self-neglect may be higher in adults who are suffering from Alzheimer’s or other dementia diseases. One study of older adults with the most severe cognitive impairments who had self-neglected or abused had significantly higher rates of mortality compared to those who did not report self-neglect or abuse. Self-neglect particularly, was associated with higher rates of neuropsychiatric-related mortality. (Does Dementia Increase the Risk of Elder Abuse?, 2023)

The qualitative study aimed to identify risk factors for abuse and neglect among older people with dementia or cognitive impairment, and to develop strategies to prevent abuse and neglect from integrated perspectives of patients, family caregivers, and helping professionals. Results showed risk factors associated with older people included reduced cognitive capability, limited physical health, social restriction, and the lack of participation in decision-making. Risk factors associated with caregivers included caregiver burden and poor coping skills. Community factors consisted of the lack of a dementia-friendly communities that responded to elder abuse and neglect in a preventive manner. Researchers concluded that a dementia-friendly community should be developed by providing more opportunities regarding education and training for older people as care recipients, caregivers, and service professionals and changing policies. (Lee et al., 2018,(Suppl 1):960) 

Studies showed that older adults with financial exploitation had poorer cognitive function than those without financial exploitation. (DeLiema, 2018, 706–718) (Wood et al., 2014, 414-23)

Functional connections between brain regions involved in decision-making and social cognition contribute to increased financial exploitation risk in older adults. A growing body of research has implicated a network of brain regions important for economic decision-making and social cognition, including the medial prefrontal cortex (mPFC), medial temporal lobes, and the insular cortex. Picture below shows the brain regions associated with economic decision making .

In a neuroimaging study of two groups of older adults with and without a history of Financial Exploitation (FE), results showed that the FE group showed greater functional connectivity between the medial frontal cortex and the right lateral temporal gyrus and orbitofrontal cortex and less functional connectivity with the right pre- and postcentral gyri. Researchers believed that altered neural functional connectivity between brain regions important for decision-making and social cognition may result in a vulnerability to FE in older adulthood ahead of any noticeable cognitive decline or impairment. (Weissberger et al., 2020) 

Brain areas related to financial decision making

Where Should I Go for Help in Case of Elder Abuse?

If you feel you are being abused or neglected, help is available. If you can safely talk to someone about the abuse, such as your physician, a trusted friend, or a member of the clergy, who can remove you from the situation or find help for the abuser, do so at once. Your physician has a legal obligation to report the abuser and help you find safety.

If you suspect someone you know is being abused or neglected, don't let your fear of meddling in someone else's business stop you from reporting your suspicions. Your first step should be to try and talk with the older adult when the two of you are alone. You could tell them that you think something might be wrong and that you're worried and offer to take them to get help.

Therefore, if you suspect an older person is being abused, report what you see to an authority. Many older adults are too ashamed to report mistreatment. Or they’re afraid if they make a report, it will get back to the abuser and make the situation worse. Thus, family and friends must step in to address any problems. Most states also require that doctors and lawyers report elder mistreatment.

Some types of elder abuse may be criminal. You do not personally need to prove that abuse is occurring; professionals will investigate. Many local, state, and national social service agencies can help. These include:

·       Adult Protective Services programs help protect vulnerable adults from abuse, neglect, and exploitation. The National Adult Protective Services Association provides phone numbers for programs in each state on its website or by calling 202-370-6292.  

·       The National Center on Elder Abuse provides guidance on how to report abuse, where to get help, and state laws that deal with abuse and neglect. Visit the Center online or call 855-500-3537 for more information.

·       Long-term care ombudsman advocates for the needs of people who live in assisted living facilities, board and care homes, and nursing homes. They are trained to help resolve problems. Find a long-term care ombudsman in your state online or by calling 202-332-2275.

If you think someone is in immediate danger, call 911.

If you feel you have been abusive or are in danger of abusing an older person in your care, one solution may be to find ways of giving yourself a break and relieving the tension of having total responsibility for an older person who is dependent on you.  San Diego Aging and Independence services are a local resource for services that might help family caregivers find respite and in-home help with difficult care tasks such as bathing, dressing, and cooking. (APA's Committee on Aging, 2022) Also, Visit the ARCH National Respite Network and Resource Center’s National Respite Locator Service to find respite services in your area. (National Institute on Aging, 2024)

How Can I Prevent Elder Abuse?

·       Listen to older adults and their caregivers to understand their challenges and provide support.

·       Educate oneself and others about how to recognize and report elder abuse.

·       Learn how the signs of elder abuse differ from the normal aging process.

·       Check-in on older adults who may have few friends and family members.

·       Provide over-burdened caregivers with support such as help from friends, family, or local relief care groups; adult day care programs; counseling; outlets intended to promote emotional well-being.

·       Encourage and assist people (either caregivers or older adults) having problems with drug or alcohol abuse in getting help.

·       Report abuse or suspected abuse to local adult protective services, long-term care ombudsman, or the police. Use the National Center on Elder Abuse Listing of State Elder Abuse Hotlines

·       Find your state’s reporting numbers, government agencies, state laws, and other resources. (Fast Facts: Preventing Elder Abuse |Violence prevention Injury center CDC, 2024)

References

Alzheimer's Abuse. (2024). Nursing Home Abuse Guide. Retrieved April 30, 2024, from https://www.nursinghomeabuseguide.org/elder-abuse/alzheimers-abuse/

APA's Committee on Aging. (2022, November 10). Elder abuse: How to spot warning signs, get help, and report mistreatment. American Psychological Association. Retrieved April 30, 2024, from https://www.apa.org/topics/aging-older-adults/elder-abuse

DeLiema, M. (2018). Elder Fraud and Financial Exploitation: Application of Routine Activity Theory. Gerontologist, 58(4), 706–718. 10.1093/geront/gnw258

Does Dementia Increase the Risk of Elder Abuse? (2023, October 27). Mandated Reporter Training. Retrieved April 30, 2024, from https://mandatedreportertraining.com/resources/blog/does-dementia-increase-the-risk-of-elder-abuse/

Elder abuse | National Institute on Aging. (2024). National Institute on Aging. Retrieved April 30, 2024, from https://www.nia.nih.gov/health/elder-abuse

Fast Facts: Preventing Elder Abuse |Violence Prevention|Injury Center|CDC. (2024). Centers for Disease Control and Prevention. Retrieved April 30, 2024, from https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html

Get the Facts on Elder Abuse. (2021, February 23). National Council on Aging. Retrieved April 30, 2024, from https://www.ncoa.org/article/get-the-facts-on-elder-abuse

Hall, J. (2016). Elder Abuse Surveillance: Uniform Definitions and Recommended Data Elements. Centers for Disease Control and Prevention. Retrieved April 30, 2024, from https://www.cdc.gov/violenceprevention/pdf/EA_Book_Revised_2016.pdf

Lee, J., Sun, F., & Chima, E. (2018). RISKS FOR ABUSE AND NEGLECT OF ELDERS WITH COGNITIVE IMPAIRMENT OR DEMENTIA: INSIGHTS FROM THREE GROUPS. Innov Aging, 16(2), (Suppl 1):960. 10.1093/geroni/igy031.3558

National Council on Aging. (2021, February 23). Get the Facts on Elder Abuse. National Council on Aging. Retrieved April 30, 2024, from https://www.ncoa.org/article/get-the-facts-on-elder-abuse

National Institute on Aging. (2024). Elder abuse | National Institute on Aging. National Institute on Aging. Retrieved April 30, 2024, from https://www.nia.nih.gov/health/elder-abuse

NCEA | Elder Abuse. (2023, December 26). National Center on Elder Abuse. Retrieved April 30, 2024, from https://ncea.acl.gov/elder-abuse#gsc.tab=0

US.Department of Justice. (2024). Elder Justice Initiative (EJI) | About Elder Abuse | United States Department of Justice. Department of Justice. Retrieved April 30, 2024, from https://www.justice.gov/elderjustice/about-elder-abuse

Weissberger, G., Mosqueda, L., Nguyen, A. L., Axelrod, J., Nguyen, C. P., Boyle, P., Spreng, N., & Han, D. S. (2020, November). Functional Connectivity Correlates of Perceived Financial Exploitation in Older Adults. Front. Aging Neurosci, 12. https://doi.org/10.3389/fnagi.2020.583433

Wood, S., Rakela, B., Liu, P.-J., Navarro, A. E., Bernatz, S., Wilber, K. H., Allen, R., & Homeier, D. (2014). Neuropsychological profiles of victims of financial elder exploitation at the Los Angeles county elder abuse forensic center. J Elder Abuse Negl, 26(4), 414-23. 10.1080/08946566.2014.881270

World Health Organization. (2022, June 13). Abuse of older people. World Health Organization (WHO). Retrieved April 30, 2024, from https://www.who.int/news-room/fact-sheets/detail/abuse-of-older-people

Yon, Y., Gonzalez, M. R., Mikton, C. R., Huber, M., & Sethi, D. (2019, February). The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis. European Journal of Public Health, 29(1), 58-67. https://doi.org/10.1093/eurpub/cky093

Yon, Y., Mikton, C. R., Gassoumis, Z. D., & Wilber, K. H. (2017, February). Elder abuse prevalence in community settings: a systematic review and meta-analysis. Lancet Glob Health, 5(2), e147-e156. 10.1016/S2214-109X(17)30006-2