Correspondence
Abuse and Neglect of Elderly Persons
N Engl J Med 1995; 333:70July 6, 1995
- Article
To the Editor:
The review of abuse of elderly persons by Lachs and Pillemer (Feb. 16 issue)1 was timely, accurate, and comprehensive. We think, however, that it runs the risk of excessively portraying elderly patients as victims of malign outside influences and thus distracting readers from realizing that mentally competent older people may share responsibility for their own circumstances and must consequently be directly involved in their management and resolution.
For example, we recently encountered a patient who has lived in great pain for nine years because of a neglected invasive basal-cell carcinoma that has metastasized to lung and bone. She is frail and can no longer walk because of the pain. She has been cared for by two family members over the nine years. We initially suspected willful neglect and abuse and proceeded to interview the patient and her care givers both separately and together. We discovered that the patient had adequate decision-making capacity but had allowed the carcinoma to progress because of fear of the medical system and ignorance of the natural history of the condition. Perhaps this is an example of self-abuse. We have been able to progress with treatment only after convincing her to take ownership of the problem and share responsibility for its further management.
Furthermore, instances in which marginally competent elders behave violently toward their care givers are not uncommon. There is a delicate balance between responsibility and victimization. For example, an 82-year-old man, disabled and immobilized because of untreated Parkinson's disease, was cared for by his 80-year-old wife. When levodopa therapy was instituted, he immediately resumed his former pattern of physical abuse directed against his wife, who therefore refused to administer the medication. We suggest that this is not reciprocal abuse, but rather a solution that is the lesser of two evils.
1 ReferencesKieran G. O'Connor, M.B.
Thomas E. Finucane, M.D.
Johns Hopkins University, Baltimore, MD 212241
Lachs MS ,Pillemer K . Abuse and neglect of elderly persons. N Engl J Med 1995;332:437-443
Full Text | Web of Science | Medline
To the Editor:
As a geriatrics consultant to an Adult Protective Services program, I thank you for the excellent review by Lachs and Pillemer of the mistreatment of elderly persons. Such abuse is a growing phenomenon, at least in part because larger numbers of people are living past their eighth decade, the age at which the prevalence of dementia reaches 50 percent,1,2 making them more vulnerable to neglect and abuse by themselves and others.
In my experience, the signs of physical and emotional abuse listed in 3 of the article are not as common as signs of malnutrition, neglect, and immobilization, such as atrophic glossitis, temporalis wasting, generalized cachexia, lymphopenia, elongated toenails, contractures, and deconditioning. The latter findings may serve as the only objective grounds on which a court will grant orders of protection to Adult Protective Services, and thus they are important for physicians to record when mistreatment is suspected.
2 ReferencesDuncan S. MacLean, M.D.
Polyclinic Medical Center, Harrisburg, PA 171101
Evans DA ,Funkenstein HH ,Albert MS , et al. Prevalence of Alzheimer's disease in a community population of older persons -- higher than previously reported. JAMA 1989;262:2551-2556
CrossRef | Web of Science | Medline2
Wernicke TF ,Reischies FM . Prevalence of dementia in old age: clinical diagnoses in subjects aged 95 years and older. Neurology 1994;44:250-253
Web of Science | Medline
Author/Editor Response
Dr. Lachs replies:
To the Editor: We appreciate Dr. MacLean's clinical observations regarding additional clinical stigmata of mistreatment of elderly persons. The field still relies primarily on description; ultimately, pathognomonic findings for mistreatment may be identified, as has been the case with child abuse. The contributions of astute clinicians are invaluable in this regard.
The clinical examples provided by O'Connor and Finucane give an impetus to view the diagnosis and management of mistreatment of elderly persons in terms of the ``geriatric syndrome,'' which includes the dynamics of the relationship between the patient and the care giver as well as the environment in which they both function. In the second case they describe, it appears that chronic disease became superimposed on a lifelong propensity toward family violence, rendering the patient untreatable. This is a compelling argument for the role of the primary care physician in the early recognition and management of all forms of domestic abuse. It also makes one wonder which chronic illness -- Parkinson's disease or family violence -- was ultimately more devastating to the patient's functional independence and quality of life.
Mark Lachs, M.D., M.P.H.
New York Hospital-Cornell University Medical Center, New York, NY 10021
