AGING, ALONE, OVERLOOKED AND IN DANGER
Agencies find 235,000 elderly victims of abuse
Across the USA, solitude has become a threat for hundreds of thousands of senior citizens living at home. ❚ Last year, state Adult Protective Services (APS) intervened in more than 142,000 cases to protect seniors at risk from what is termed “self-neglect” – seniors who have become too physically or mentally incapacitated to care for themselves and have no other care providers.
Overall, according to new federal data obtained exclusively by the New England Center for Investigative Reporting (NECIR), state-based APS agencies completed more than
713,000 investigations in fiscal year
2017. The agencies identified nearly
235,000 victims of abuse, including the self-neglect cases. About 10 percent of the total abuse victims counted were under age 50, because some states include abuse or neglect of younger adults with disabilities.
These numbers, part of an initial attempt by the federal government to track maltreatment of seniors nationwide, understate the scope of the problem, probably dramatically, according to the agencies compiling the data.
“The elder abuse data is not com-
plete. It’s correct in terms of what’s reported, but there are so many cases that aren’t reported,” said Alice Page, an Adult Protective Services and systems developer with the Wisconsin Department of Health Services. “We’re way behind in elder abuse reporting than, for example, in child abuse reporting. It’s just a different system. There’s much more emphasis and resources that have been put into Child Protective Services than there have been into elder abuse or abuse of adults. And so we’re sort of playing catch-up.”
Elder abuse can range from physical or sexual assault against vulnerable seniors to financial scams to abandonment or neglect by caregivers. A common threat is self-neglect: an elderly person unable to provide for his or her own clothing, shelter, food, medication or other basic needs and having no one to provide care. The problem is growing as the population ages.
States have operated under a federal mandate to collect data on child abuse for decades. There is no federal mandate to do the same for elder abuse and neglect.
“We have often referred to elder abuse as a silent issue. For decades, people just didn’t want to address it at all,” said Edwin Walker, deputy assistant secretary for aging at the Department of Health and Human Services, which leads the effort to build the national database.
The Administration for Community Living embarked on a voluntary effort with the cooperation of state APS agencies to compile a national database of abuse of seniors living at home. For the most part, abuse in nursing homes or other settings is managed by other agencies and counted separately.
A state-by-state breakdown reveals holes in the data. The totals do not include reports from six states – New Mexico, Oregon, Nevada, South Dakota, West Virginia and Wisconsin – for a variety of reasons.
West Virginia does not collect statewide data on maltreatment of seniors, leaving it to each county to keep its own tally. Wisconsin counts its data on a calendar year, not a fiscal year, thus has not been able to produce reports for the time period the federal data system uses.
Oregon sent its data in late and was not included in this year’s report. Officials in Nevada and South Dakota have been gearing up to provide data for the new federal reporting system called the National Adult Maltreatment Reporting System (NAMRS) and expect to be included in next year’s report.
States all have different standards for determining when abuse or neglect has occurred, meaning the same set of evidence may qualify as a “substantiated” abuse or neglect case in one state, but not in another.
Self-neglect challenges
Self-neglect dominates the work of Adult Protective Services units across the country.
“Self-neglect appears to be a very serious problem in our society, not a new problem. But it is, as you’ve been picking up, approximately two thirds of the cases reported by APS nationwide,” said Holly Ramsey-Klawsnik, director of research for the National Adult Protective Services Association.
Ramsey-Klawsnik cautioned that the prevalence of self-neglect in state case files does not mean this is the most common form of adult maltreatment – only that it is the one most readily identified. “Self-neglect cases are so much more visible,” she said. Neighbors, friends or social workers can tell when a senior’s house has fallen into disrepair or an older person is unwashed or unkempt. It may be harder to tell if a senior had money stolen by a caregiver or was denied access to appropriate medical treatment.
Adults are generally assumed to have autonomy and control of their decisionmaking, so it is hard for a government agency to know when to intervene, particularly if the elderly person rejects assistance. Some people “just refuse to accept help for whatever reason,” said Cynthia Lien, assistant professor of medicine at New York’s Cornell Medical Center. She said there is “a large population who just are incapable of giving up coping mechanisms or repeat behaviors that they’ve developed over years,” even when those behaviors no longer work.
“That manifests in things like an unsafe home environment or hoarding disorders or refusing to see a doctor because maybe they had a bad interaction in the past with a physician and they just don’t trust the health system,” she said.
Self-neglect is not simply an issue of risk for the senior individual making the poor decisions.
“We do know that self-neglect increases illness, increases emergency room use, increases hospitalization, increases nursing home use, increases hospice use and hastens mortality,” Ramsey-Klawsnik said. “Self-neglect is costing society a lot of money when they have to go to the E.R. and have no money to pay for insurance.”
Beyond that, a senior in an apartment who hoards or fails to take out the trash may create an unhealthy environment or a vermin problem for everyone else in the building.
States struggle with how to intervene. “We can’t force somebody who’s just making poor choices to do something,” said Kathy Morgan of Washington state’s Aging and Long-Term Support Administration. “Although our investigators do a really great job of talking with people and trying to assist them with services or supports that may be able to put in place if they’re willing to do that.”
State assistance in self-neglect cases can range from referrals to Meals on Wheels or in-home care services to cognitive assessments that could lead to assignment of a guardian if the senior no longer has the capacity to make decisions.
Soaring cases
Though the data in NAMRS are full of gaps and aberrations, what is clear is that the number of abuse and neglect cases is soaring nationwide.
❚ Washington state had about 19,000 elder abuse reports in 2012 and 49,000 reports in 2017, Morgan said.
❚ Massachusetts confirmed 7,100 abuse and neglect cases in 2015 and
9,800 in 2017.
❚ Ohio reported about 16,200 reports of abuse, neglect and exploitation of seniors in 2017, up from about 13,150 in
2014.
❚ Pennsylvania officials investigated
13,000 abuse reports in fiscal year 2014 and nearly 18,000 in fiscal year 2016.
Part of this increase is simply a function of better reporting systems in the states and more public awareness that elder abuse is a problem that should be reported to authorities.
Part is also because there are more seniors in communities around the country as Americans live longer, remain in their homes longer and survive ailments that would have been fatal in prior decades.
“I think elder abuse is more prevalent,” Morgan said. “As our population continues to grow and is getting older – our 60-and-older population, we’re going to continue to see these types of numbers.”
“We have often referred to elder abuse as a silent issue. For decades, people just didn’t want to address it at all.” Edwin Walker Department of Health and Human Services