.................... ESSAY PAPER


Jay E. Jorgensen

A dentist's social responsibility to diagnose elder abuse* Because of the high prevalence of dental disease and consequent need for dental care in the elderly, dentists are in frequent contact with the elderly, thus providing an opportunity for realizing their social obligation t o become more involved in diagnoslng and reduclngelderabuse. Current estimates of the incidence of elder abuse in the US indicate that nearly 10%of the elderlypopulatlon is affected, and this Incidence rate is steadily increasing. Problems of vague definitions regarding abuse, elusiveness of the problem, and limited interest on the part of health care professionals may have deterred dentists from more involvement In the past. Apathy, tunnel vision, and vested interests of dental professionals may also contribute to the poor oral health of the elderly and consequently decrease the elders ' quality of life. However, bydevelopinga clear understanding of possible etiologies and by knowingphysical and behavioral indicators of abuse, dentists can better fulflll their moral and social obligations and greatly reduce the incidence of elder abuse.

This paper won Second Prize in the Eleventh Annual Arthur Elfenbaum Essay Award Contest, conducted by the American Society for Geriatric Dentistry. Mr. Jorgensen is a junior dental student at the UCLA School of Dentistry.

n many cultures, there has been an unwritten respect for the "wisdom of age". Even Biblical scripture commands us to "Honor thy father and thy mother."' However, while most Americans have great respect and loyalty for their elders, social and economic pressures have made this group of citizens a target of abuse and neglect. Professional concern has focused increasingly on the problem of elder a b u ~ e . ~This , ~ ,problem ~ has grown in the US to such a degree that current estimates of its incidence put the number at roughly 1.5 million cases reported annually5,which involves approximately 10% of our current elderly (over 65) population6. The number of cases reported per year has increased nearly 100,000 per year since 1980.2 If this incidence rate continues and if the elderly population increases as expected due to the aging baby boom generation, clearly the potential exists for the reported number of elder abuse cases to rise to several million a year. Therefore, it is imperative for all allied health professionals to be prepared to intervene now in order to decrease this incidence in the future. To date, many disciplines have attempted to reduce this type of abuse. Medicine and nursing have developed protocols for research on elder abuse with the identical goals of successful detection and prevention. Psychology has played a role through research and as part of the multidisciplinary intervention team. Through persistent demands for legal measures, health care professionals have persuaded law-makers to become engaged in the fight against elder abuse. These officials have sought to

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establish unified definitions of elder abuse and mandatory reporting guidelines.',*Social workers have also become involved as an integral part of both reporting and intervention. Most recently, a few dentists have come to realize their role in research, detection, and intervention. Although each discipline plays a role in reducing the abuse of the elderly, dentistry must become more involved because of the high prevalence of dental disease and consequent need for dental care in the elderly. As health care providers, dentists should realize that their moral and professional obligation to care comprehensively for patient health needs must include the diagnosis and report of elder abuse. This type of intervention can also improve patient attitude, self-esteem, and social functioning.' This will lead to a more manageable patient. Dentists may also have a greater opportunity than other health care providers to diagnose the more subtle types of abuse, such as inadequate nutrition or obscure physical abuse or neglect ke., signs which present in the oral cavity), whether self-abuse or abuse caused by the caregiver. Additionally, this involvement will further build trust in dentist/ patient relationships and can improve the co-operation and respect between dentist and physician. General dentists, as well as dental specialists, see elderly patients during routine dental treatment. To the astute dentist, these visits provide the opportunity to examine these patients thoroughly for signs of abuse or neglect. The opportunity to have frequent contact with the elderly places dentists in the position to be

able to intervene early and prevent elder abuse. By increasing their ability to diagnose this problem, dentists can contribute significantly to its resolution.

Problems of the past In the past, dentists have confronted three major problems which may have deterred their involvement. First is the problem that all involved disciplines face: how to define elder abuse. Research has produced little agreement about what actually constitutes elder abuse. Definitions vary from state to state, which makes exact incidence difficult to determine.5 However, most definitions will include the following types of abuse':

Physical abuse, according to the Select Committee on Aging, is defined as active violence (assault) or passive violence (negligence) that results in bodily harm or mental distress to the elder. The Committee defines negligence as an act of carelessness, a violation of rights, or a breach of duty resulting in injury.R Financial abuse includes illegal or unethical exploitation of an elder's money or property. Psychological abuse includes name-calling and other verbal intimidation or threats which cause mental anguish and aim to dehumanize the elder. Sexual abuse generally involves the aggressive act of a grandson or son-in-law, and may be kept secret by other family members who realize it is happening. Self-abuselneglect can range from simple physical neglect to suicide and is often precipitated by actions and attitudes of caregivers which make the elderly feel lonely and worthless. A second problem confronting dentists is that elder abuse is easy to hide. In many cases, elders are embarrassed to admit that a loved one would inflict injury (mental or physical) upon them? Burns and bruises, for example, are easily concealed by clothing. Verbal assaults and intimidation are more difficult to observe or

diagnose. Financial abuse may also go undetected unless one is closely involved with the older person. In addition to the problems of definition and elusiveness, a third problem in recognition and prevention of elder abuse involves the limited interest shown by the dental profession. To date, there has been little published on this problem in dental literature. Martin and Brownlo,"described elder abuse and the professional responsibility of the dentist under Arkansas law. McDowellI2published a paper on the presenting signs and symptoms of elder abuse as might be observed in the dental office. Holtzman and Bomberg4reported the results of a survey on dentists' awareness of elder abuse and neglect. Finally, Axelband' reported on the prevention of elder abuse. While these represent an excellent beginning, dental contributions to the literature of abuse diagnosis and prevention need to expand greatly. Moreover, dentists have also shown little interest in the problem of abuse on the patient level. This raises an important question: How much apathy, tunnel-vision, and vested interests on the part of health care providers contributes to the problem of neglect? Due to their age, elderly people tend to receive inadequate health care.I3 Providers, including dentists, tend to have a hopeless perspective as to the longevity of the elders' lives.5 These negative attitudes may contribute significantly to extreme dental neglect and the relatively poor dental health found in the elderly.13*14J5 Reports indicate that clinicians may be "disinclined to attempt to persuade elderly patients to retain their natural teeth."I4 This, in effect, reduces the quality of life an elder might enjoy. Dental health, on the other hand, can improve the elder's quality of life by reducing infections and allowing proper mastication and, consequently, proper no~rishment.'~ Therefore, dentists have a great social responsibility to increase their involvement in reducing the problem of abuse. But how should dentists increase their involvement? The first step is

for them to acknowledge and recognize the problem. In the Holtzman and Bomberg studyJ, 9.1% of the dentists surveyed had never heard of elder abuse or neglect as a social or medical problem; 81 % were aware of elder abuse as a social problem, but only 10% had personal suspicion or knowledge of abuse to one of their patients. These figures raise some interesting questions: (1)Do dentists truly know what elder abuse is? (2) Do they look for it? (3) Do they know what to look for? (4)Do legal ramifications or fear of personal consequences deter dentists' involvement? A more thorough education on the causes of, and subtle clues to, elder abuse will ultimately help the dentist to become more actively involved and possibly prevent litigation.

Causes of abuse Basic to preventing elder abuse is the ability to recognize its potential causes. Even though scientific investigation provides minimal knowledge about possible causes of abuse5,it is believed that the greatest precipitating factor of elder abuse is ~ t r e s s .The ~,~ AMA Council on Scientific Affairs' report on elder abuse suggests at least five situations which can lead to increased stress?

Dependency: An abusive situation which arises due to increased need for home care (due to illness or early discharge from the hospital). This situation adds immense stress to the lives of the caregivers, and if they are unable to adapt to the new situation, the potential for abuse increases. Lack of close family ties: Failure of parents to develop close bonds of love and friendship during childhood can lead to abuse when the adult child must undertake care-giving responsibilities. In situations where a parent has been distant from the adult child for long periods and now needs to be cared for by the child, the parent is commonly viewed as an intruder. Lack of financial resources: In today's economic climate, caring for an elder can become a major

Special Care in Dentistry, Vol12 No 3 1992 113

financial concern. Either the adult child or spouse must stop working to care for the parent, or expensive in-home help must be obtained. If neither of these options is possible, the elder may suffer from neglect. Psychopathology in the abuser: In some cases, aggression may be due to impaired social or psychological development. Elder abuse may also be associated with alcoholism, drug abuse, or other psychosocial stress.' Family violence: Violence patterns can be a cyclic phenomenon due to a parent-child role reversal. This situation may occur in families where violence is a normal reaction to stress, the abusive child was abused as a child by the parent, or where the caregiver is exhausted by the demands of the elder and feels hopeless. In addition to the causes stated above, Rathbone-McCuan and HashimiI6also suggest:

Functional incompetence: In this case, mentally impaired or physically impaired children or spouses are responsible for the care of the elderly and may not be competent. Absence of community resources: Poor housing, fixed incomes, unemployed adult care-givers, a lack of respite care, and similar problems increase the potential for abuse.

By understanding these and other possible causes of stress, dentists can increase their sensitivity to situations with the potential for abuse. This realization can also serve to guide the dentist in the type of intervention to p~rsue.~ Diagnosingelder abuse While "no simple way"3 exists to diagnose such an elusive phenomenon, protocols have been developed to aid the practitioner in detecting elder abuse. Both qualitative and quantitative means of measurement have been developed. While quantitative questionnaires may be filled out by the health care provider, they necessarily involve personal bias.s To

help compensate for this, dentists may use a Likert-type scale for qualitative evaluation of specific areas that need special consideration. Used separately or together, these instruments provide a more accurate picture to the diagnostician as to whether elder abuse is taking place or can be pre~ e n t e d However, .~ the time involved in preparing additional records may deter dentists from routine use of these protocols in the dental office. A more practical approach to diagnosing elder abuse may be simple observation of both physical and behavioral signs6 Physical signs can be distinguished in two major areas: (1)Physical neglect, which would include dehydration, lack of medical care, malnutrition, improper medications, decubitus ulcers, and the elder presenting with poor oral and physical hygiene are all potential indicators that something is wrongSF6;and (2) physical injury, including such things as lacerations, abrasions, unexplained fractures, head injuries, bruises, and sprains or dislocations.6 In addition, McDowell'2has indicated that orbital fractures, eye injuries, bite marks, lip trauma, and fractured teeth or jaws are also reliable physical injury signs that should alert the dentist to a possibly abusive situation. Behavioral signs can also provide valuable information on the elder's relationship with the care-givers. Elderly people who present with confusion, excessive fear in the presence of adult children, or who complain excessively should cause the dentist to be suspicious of possible abuse or neglect.s,6A thorough review of the patient's medical history should also accompany observation of these signs.5 While these are not exhaustive, they give the clinician assistance in screening for the possibility of elder abuse or neglect. After diagnosing elder abuse, it is important for the dentist to report the abusive situation immediately. By understanding the role of social services in abuse cases and using this resource wisely, the dentist can effectively initiate the intervention process. Respite care facilities and other social services to decrease the burden on the caregiver, though

ti4 Special Cam in Dentisty, Vol12 No 3 1992

sometimes limited, do exist. However, they can help only if the abuse has been identified and the family is referred properly.

Future research To date, dental research in the area of elder abuse has been limited. There are many opportunities for research by interested dentists. The development of a clinically practical assessment tool which would reveal both serious and more subtle cases of elder abuse or neglect is needed. Case reports about elder abuse detected by the dental practitioner need to be published in local dental journals. Information on the psychological implications of elder abuse and its impact on dental treatment could be valuable. Continuing education courses could be offered to practicing dentists in order to increase dentists' awareness of elder abuse and possible signs of abusive situations that can be detected clinically. These are just a few of many possible areas of study with potential to help dentists understand and lessen the abuse of the elderly. Conclusion Elder abuse needs to be recognized and prevented, and as dentists we have moral obligations to our patients to do everything in our power to aid in this effort. In order to be effective, dentists need to acquire a fuller understanding of elder abuse and neglect and their etiologies. We must also increase our ability to detect this elusive problem. When confronted with cases of potential abuse or neglect, dentists must be able to report and refer these cases properly. By confronting the problem, dentists can improve the oral health and integrity of the oral functions of older people. This would contribute significantly to the quality of life in the elderly, and would aid dentists in fulfilling their moral and social responsibility to help in the reduction of elder abuse. Special appreciation to Dr. Diane McLain, Director of Advanced Education in the General Dentistry Department at UCLA Dental School, for assistance as Faculty Mentor.

1. Janz M. Clues to elder abuse. Geriatric

Nursing 5:220-22,1990. 2. AMA Council on Scientific Affairs. Elder abuse and neglect. J Am Med Assoc 257966-71,1987. 3. Ashley J, Fulmer TT. No simple way to determine elder abuse. Geriatric Nursing 5:286-88,1988. 4. Holtzman JM, Bomberg T. A national survey of dentists' awareness of elder abuse and neglect. Spec Care Dentist 11:711,1991. 5. Fulmer TT.Mistreatment of elders: assessment, diagnosis, and intervention. Nurs Clin North Am 24:707-16,1989. 6. Jones J,Dougherty J, Schelble D, Cunningham W. Emergency department protocol for the diagnosis and evaluation of geriatric abuse. Ann Emerg Med 171006-15,1988,

7. Joint Hearings Before the Special Committee on Aging, US Senate, and the Select Committee on Aging, US House of Representatives. 96th Congress, June 11, 1980. 8. United States House of Representatives, 97th Congress, First Session, Select Committee on Aging. Elder abuse: an examination of a hidden problem. A report (Comm. Publ. No. 97-277). Washington (DC): United States Government Printing Office, 1981. 9. Axelband AA. Putting an end to elder abuse. NY State Dent J 1034-6,1991. 10. Martin WE, Brown CA. Elder abuse, Arkansas law, and dental professional responsibility-Part 1. AR Dent J 59(4):178,1988. 11. Martin WE, Brown CA. Elder abuse,






Arkansas law, and dental professional responsibility-Part 2. AR Dent J 60(1):246,1989. McDowell, JD. Elder abuse: the presenting signs and symptoms. TX Dent J 229-32, 7990. Manderson RD, Ettinger RL. Dental status of the institutionalized elderly population of Edinburgh. Community Dent Oral Epidemiol3:lOO-7,1975. Sanders RH Jr, Solomon ES, Handelman SL. Relationship of age to tooth loss in a chronic care facility. Spec Care Dentist 2(1):25-30,1982. Empey G,Kiyak HA, Milgrom. ' I Oral health in nursing homes. Spec Care Dentist 3(2):65-7,1983. Rathbone-McCuan E, Hashimi J. Isolated elders. Rockville (MD): Aspen, 1982.

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A dentist's social responsibility to diagnose elder abuse.

Because of the high prevalence of dental disease and consequent need for dental care in the elderly, dentists are in frequent contact with the elderly...
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