When Simple Interventions Can Save Lives
Brooke Astor’s son was recently sentenced to prison for stealing from and defrauding his mother, capping off one of history’s highest-profile cases of elder mistreatment. In her later years, Ms. Astor appeared increasingly terrified, her hygiene declined, and her prescriptions went unfilled: a few of the many red flags overlooked or ignored by those around her. Elder mistreatment is a growing and underreported issue projected to affect 3 million older adults by 2030. Social isolation, cognitive impairment, and physical frailty put many older adults at high risk of becoming victims of abuse and neglect, often perpetrated by an adult child or other family member.
Image: Karin-Elizabeth Ouchida, MD
The Doctor as Detective
Physicians, particularly those in primary care and emergency departments, are critically poised to detect and intervene in cases of elder mistreatment, according to Karin-Elizabeth Ouchida, assistant professor (Geriatrics), co-director of the Montefiore Geriatrics Home Visiting Program, and founder of the Elder Abuse and Neglect Consultation Service. “While doctors are not mandated in New York state to report elder mistreatment, we are ethically responsible for promoting the health and rights of vulnerable populations,” Ouchida said. “Our intervention can improve the morbidity and mortality of older adults.”
The stories of Dr. Ouchida’s patients are sobering: an 89-year-old woman with dementia, thought to be physically, psychologically, financially, and sexually abused by a male neighbor. An 88-year-old woman with multiple health problems, feeding the mice in her squalid third-floor walk-up. An 85-year-old woman hospitalized eight times in a year for diabetes and heart failure because her developmentally delayed son and sole caregiver couldn’t appropriately manage her diet and medications.
Seeing Through the Gray
Elder mistreatment spans a broad spectrum. Self neglect, such as failing hygiene or dangerously cluttered living conditions, and caregiver neglect account for nearly half of all cases. Neglect often goes unreported because it is unintentional due to inexperience, ignorance, or inability of the individual or caregiver (in its most severe forms, neglect can extend to withholding meals, eyeglasses, or hearing aides). Financial abuse, including outright stealing or coercion into reassigning power of attorney or changing a will, is the second most common form. Psychological, physical, and sexual abuse also prevail.
In New York state, clinicians need only document a reasonable cause to suspect that elder mistreatment has occurred. Reporting it can be as simple as stating that the patient seems to have health or personal problems that require assistance, especially if the kinds of abuse or neglect are difficult to quantify (a caregiver providing food unfit for a diabetic diet, for example, or a son reluctant to force his mother to exterminate her home against her wishes).
Working to "Age" Awareness
While the number of elder mistreatment cases will undoubtedly increase as the population ages, little is known about its characteristics, causes, or consequences, or about effective means of prevention or management. Through funding from the United Jewish Appeal's Caring Commission, Ouchida helped to develop Montefiore’s novel Elder Mistreatment Consultation Service, a geriatrician-social worker-geriatric psychiatrist team who evaluate potential victims and link them and their caregivers to appropriate community-based social and legal services. The team also alerts primary care physicians to follow up. "In many cases there are two victims," Ouchida said. "We want to take the guilt away from the caregiver and help both parties. There's no criminal activity, but these cases need to be tracked to make sure their situations improve."
Ouchida has also created an elder mistreatment workshop for all Einstein medical students in which they learn to interview patients and caregivers and become familiar with appropriate intervention measures and available resources. Empathic interviewing and careful documentation are key measures, according to Ouchida. “Healthcare providers, especially those in emergency departments and clinics, need to be well equipped to do assessments,” she said. “We train them to make their records as complete as possible for successful transitions of care.”
In Later Years, Better Living
When Ms. Astor was hospitalized for a hip fracture in 2003, her physicians and nurses may have missed a critical opportunity to help. As a result of intensive, ongoing interventions involving nonjudgmental assessment, extensive teamwork and communication, the octogenarians seen by Ouchida and her team now lead safer lives. One is supported by home care, another is in assisted living, a third has capable legal guardianship. “Interacting with this underserved, vulnerable population has been a great opportunity for us,” said Ouchida. “With very simple interventions we can make a huge difference in their lives.”
- Montefiore Elder Abuse and Neglect Consultation Service
The Elder Abuse and Neglect Consultation Service was started by the Einstein/Montefiore Division of Geriatrics with funding from the UJA Federation Caring Commission.
The service’s consultation team is comprised of geriatricians, a social worker, and a geriatric psychiatrist who give comprehensive evaluations of patients aged 65 and older who are victims of suspected abuse or neglect, and assist in linking them and their caregivers to appropriate community-based services for social and legal assistance.
Assessments can be performed in the Moses Division of Montefiore Hospital or at the Geriatrics Ambulatory Practice in the Green Medical Arts Pavilion.
- Jewish Association for Services to the Aged (JASA)
- Bronx Adult Protective Services
Call 311 or APS Central Intake (212-630-1853)
- Bronx District Attorney’s Office
- Bronx Elder Abuse Task Force
- Weinberg Center, Hebrew Home for the Aged