Clinical and Forensic Markers Indicating Abuse or Neglect

Cognitive and mental health disorders affect a large number of aging persons and can lead to impairment of thinking, memory, functional ability, and ultimately decision-making capacity. They can prevent persons from seeking help, advocating on their own behalf, or extricating themselves from abusive situations, and they make elders more prone to exploitation by others. Dementia itself and its management can be a stimulus for abusive action when the family feels or is unprepared or unsupported in the care of an affected dependent. Ability to serve as a witness or provide testimony is diminished. Ultimately, the mental states of demented elders can progress to a point at which they are unable to meet even their most basic needs.

Most statistics on this topic are derived from adult protective services (APS) databases. The definition of mental disorders varies from state to state, as do the training requirements of APS workers, many of whom are not health care professionals. Some elders with impairments have otherwise well-developed social skills and, without formal testing, can escape notice by physicians and other professionals who care for them. The National Elder Abuse Incidence Study asked nonmedical volunteers to comment on depression and dementia based on their opinions. They found 59.5 percent incidence of dementia and 43.6 percent incidence of depression. Because the reporters were not health professionals nor did they have any mental health training, the data are estimates and not representative of actual diagnoses (National Center on Elder Abuse, 1998).

Self-neglect usually but not always is associated with either dementia or some type of mental health problem. Individually, and particularly in combination, these conditions may constitute risk factors for, as well as signs of, abuse and neglect. In a preliminary analysis by the Texas Department of Protective and Regulatory Services, self-neglect and medical neglect (failure to obtain or have obtained appropriate medical care) cases were more likely to be associated with other types of elder mistreatment than were cases of physical or sexual abuse (Dyer et al., 2000a). Self-neglect may very well represent a part of the continuum where older persons who are initially declining either functionally, mentally, or both try to care for themselves. If they can no longer meet their needs themselves, then they need help from others. Progressive functional decline may result in physical decline and in some instances institutionalization.

Dementia. Dementia is related to elder abuse and neglect (Benton and Marshall, 1991; Aravanis et al., 1993; Coyne et al., 1993; Lachs and Pillemer, 1995). Two primary data studies demonstrated that dementia



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