Behind Closed Doors: How Providers Can Help Stop the Cycle of Emotional Abuse in Older Adults

Abuse of any kind can do irreparable harm to a patient's physical and psychological health, destroy social and family ties and lead to devastating financial loss. Older victims, in particular, have been shown to die earlier than those who have not been abused. The following article is the first in a series of stories designed to shed light on the escalating and often-overlooked global issue of elder abuse and neglect — physical, sexual, emotional and financial. Our aim is to increase provider awareness and improve the detection and management of at-risk geriatric patients.

An estimated 1 in 6 older adults regularly experience some type of maltreatment, most commonly at the hands of someone they trust. Although physical injuries may raise suspicion in astute healthcare providers, emotional or psychological wounds can be more difficult to recognize in geriatric patients — and trickier to address.

Emotional abuse is defined by coercive or threatening behavior – often verbal – that undermines a person’s sense of dignity or self-worth and threatens their psychological well-being. Although it seldom poses an immediate threat to life or limb, emotional abuse can have a profoundly negative effect on a patient’s quality of life, explains Cleveland Clinic geriatrician Ronan Factora, MD. Particularly in older adults, continued maltreatment can also increase the risk of serious mental health issues like anxiety and depression – which, in turn, can lead to deleterious downstream risks, including cardiovascular disease.

“Domestic violence isn’t always physical,” Dr. Factora says. “Simply put, repeated attempts to demoralize, dehumanize, intimidate or isolate another person qualify as abuse. Any provider who manages older adults should understand that continued psychological injury can do irreparable harm to geriatric patients, many of whom rely on family members and other caregivers for aid and protection.”

It takes many forms

Dr. Factora notes that emotional abuse can manifest in a number of ways. In some cases, the patient may be subjected to overt mistreatment, including name calling or verbal threats of harm or abandonment. In other cases, the telltale signs may be as subtle as muttered criticisms or passive-aggressive remarks. Ignoring the patient or treating them coldly, isolating them from friends or family, violating their privacy, blaming them for things they can’t control, and placing assistive devices out of reach can also signify emotional abuse.

Although emotional injuries can be challenging to pinpoint, Dr. Factora discourages providers from shrugging off any signs of psychological abuse.

“Abusers often use psychological games to manipulate the patient into believing they have no value, are unworthy of love, or are trapped in the relationship,” he says. “No one should be subjected to those patterns of behavior, so it’s important for providers to trust their own instincts. If you sense there may be a problem, probe deeper.”

Spotting red flags

Dr. Factora notes that victims of emotional abuse frequently show signs of self-neglect – a subtle but important indicator of maltreatment. At-risk patients may attempt to limit contact with their abuser by avoiding meals or baths, or they may miss medical appointments for fear of asking an abusive caregiver for transportation.

He also urges providers to observe their older patients for signs of agitation or extreme emotionality, odd behavior (e.g., sucking, biting or rocking), unusual sleep patterns or eating habits, personality changes (e.g., apologizing excessively, depression or anxiety) and marked withdrawal. All are potentially troubling signs that warrant closer inspection.

When emotional maltreatment is suspected, Dr. Factora suggests providers start by screening the patient for anxiety and depression. However, he cautions that it can be unproductive and potentially dangerous to ask the patient or their companion accusatory questions about potential abuse. He notes that victims may be reluctant to complain or too afraid to implicate a caregiver. In some cases, patients may accept the abuse as a “compromise” – viewing their maltreatment as a trade-off for the physical or financial care provided by their abuser.

Mitigating risk

When possible, providers should speak to the patient alone, says Dr. Factora; however, he cautions that victims may deny their abuse for a variety of reasons, even when carefully screened.

“It’s important to approach these patients with sensitivity, reminding them that many people care and are there to help,” he adds. “Simple questions about their living situation, daily stressors and close relationships can often provide valuable insights about their emotional health.”

Dr. Factora also suggests taking time to ask the patient’s primary caregivers about their own stressors and coping strategies, noting that emotional abuse often occurs when a perpetrator is overwhelmed or feels unable to handle the older patient’s physical or cognitive needs.

“These conversations can give caregivers the opportunity to self-reflect, acknowledge their stressors and come to terms with their own behavior,” he explains. “Getting at the root cause of the conflict is more likely to improve the situation than simple admonishments like ‘Hey, stop talking to your mom like that!'"

Stopping the cycle

Even in the unlikely event that emotional abuse can be reliably confirmed, the options for medical intervention are limited, Dr. Factora says. In such situations, thorough documentation and continued follow up may be the patient's best defense.

He adds that any statements by the victim or their companion should be registered in the medical record in as much detail as possible (ideally, using direct quotes). Providers are also encouraged to seek additional support from hospital social workers or the local adult services office.

Because psychological abuse often overlaps with other forms of maltreatment, he also urges providers to monitor their at-risk geriatric patients for additional warning signs. By regularly evaluating for physical injuries and signs of neglect, including weight loss, clinicians can help reduce the risk of escalating abuse, he says.

"After all, the quality of care we provide geriatric patients rests on our ability to respect their autonomy while addressing their vulnerabilities."