The American Medical Assn. recently issued its first guidelines on elder abuse, urging physicians and other health-care professionals to be more alert to signs of mistreatment or neglect of older patients by their families or care givers.
The guidelines, part of a new AMA campaign against family violence, come amid growing national concern about a long-hidden problem in which as many as 2 million elderly Americans are believed to be victims of abuse or neglect.
The problem was highlighted by a widely publicized "granny dumping" case in which a 42-year-old Oregon woman went on trial last week on charges that she abandoned her 82-year-old father, who has Alzheimer's disease, at a race track in Idaho so she could steal his pension checks.
But most elder abuse goes unreported, with the victims embarrassed, intimidated or unaware of how to get help, according to experts. "So many people suffer in silence," said Ronald Adelman, chief of geriatrics at Winthrop-University Hospital in Mineola, N.Y., and a member of the eight-member panel that drew up the new guidelines. "A whole process of education has to occur for both physicians and older patients."
"A physician may be the only person outside the family who sees the older adult regularly. It's critical that we have guidelines to help us recognize, treat and prevent abuse and neglect in older patients," said Palma E. Formica, a member of the AMA's board of trustees and a family practitioner in Old Bridge, N.J.
Mistreatment resulting in harm or threatened harm to the health or welfare of an older adult may include physical or sexual abuse, psychological or verbal abuse, financial exploitation or neglect.
The AMA noted that the abuse, which may not be intentional, cuts across all racial, ethnic and socioeconomic groups and may be caused by any family member or care giver. The risk may be greater in families in which the care giver is afflicted by mental illness, alcoholism or drug abuse, where there is a history of family violence or where there is heightened family stress from care giving or economic pressures.
The AMA's 42-page guidelines recommend that physicians incorporate standard questions to screen for possible mistreatment into routine care of the elderly. The best means of detecting it, they said, is to examine and interview patients in private, away from family members or other care givers.
"It's not something people are going to offer immediately," said Adelman. "If a third person is always present, either because of fear of retaliation, you're going to miss the problem."
He said health-care providers should watch for patterns and not attribute problems to age by assuming, for example, that falls or injuries are necessarily caused by frailty or that failure to take medication is caused by forgetfulness.
Adelman described a 76-year-old New York woman with chronic heart problems who had been admitted to the hospital six or seven times over eight months.
"I assumed she forgot to take her medicine," he recalled. "Whenever I saw her, she was always accompanied by her daughter, with whom she lived." Finally, the patient asked to talk with him alone and revealed that her daughter's two teen-age sons had been stealing her money, so she was unable to buy her heart medicine. The patient moved in with a sister and underwent counseling with her daughter's family. "If I had talked to the patient alone earlier, I could have intervened," he said.
The AMA suggested that physicians inquire into the general well-being of the patient and ask a series of direct questions to elicit signs of abuse or neglect. Such questions include whether anyone has hurt the patient, touched him without consent, made him do things he didn't want to do, taken anything that belonged to the patient, threatened him, left him alone a lot or failed to help him when needed.
The guidelines stress that "clinicians do not have to prove that elder mistreatment has occurred, they need only document a reasonable cause to suspect that it has."