May 1, 2013
by Joseph P. Graskemper, DDS, JD, DABMM, FAGD, FAES, FICOI, FASO, FACLM
Abuse and neglect are not limited by age. Child abuse awareness has been well documented in the dental literature. All states have mandatory reporting statutes for child abuse. This is not the case for elder abuse. It was not until 2009 with the passage of the Elder Abuse Victims Act that elder abuse received national attention. Elder abuse should be brought to the attention of all dental healthcare providers because of the maturing population. As healthcare professionals, we have an ethical duty to protect those under our care from abuse and neglect. The National Center of Health Statistics points out: “During 1950 to 2000, the U.S. population grew older. From 1950 to 2000, the percent of the population under 18 years fell from 31 percent to 26 percent while the 65 to 74 years increased from 6 to 7 percent and the 75 years and over increased from 3 percent to 6 percent (doubled). From 2000 to 2050 it is anticipated that the percent of the population 65 years and over will increase substantially. Between 2000 and 2050, the percent of the population 65 to 74 years of age will increase 7 to 9 percent. By 2040, the population 75 years and over will exceed the population 65 to 74 years of age.1
Current statistics on elder abuse are difficult to gather due to the non-uniform reporting of elder abuse among the various states. However, the elder population growth has been followed closely. The population 65 and over has increased from 35 million in 2000 to 40 million in 2010 (a 15% increase) and is projected to increase to 2020 (a 36% increase for that decade). The 85+ population is projected to increase from 5.5 million in 2010 and then to 6.6 million in 2020 (19%) for that decade. Those reaching age 65 in 2009 has an average life expectancy of an additional 17.3 years. There were over 53,000 persons over 100 or more in 2010, which is a 53% increase from 1990.2
With this high elder population growth occurring, dentists, as healthcare providers, must be made aware of the elder abuse and neglect. The National Center on Elder Abuse defines seven types of elder abuse used to describe harmful acts toward an elderly adult, such as physical abuse, sexual abuse, emotional or psychological abuse, financial exploitation, and neglect, including self-neglect.3 The actual definition of elder abuse varies due to the many differing state statutes on elder abuse. The National Research Council describes elder mistreatment as: (a) intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended) to a vulnerable elder by a caregiver or other person who stands in a trusted relationship to the elder or (b) failure of a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.4
To clarify abuse and neglect: Abuse is act of commission that harms or creates a risk of harm and neglect is an act of omission that harms or creates a risk of harm by non-action of the caregiver. Abuse and neglect are of equal importance. One should not be viewed as a lesser mistreatment since both may cause equal harm to an elder person. Hence, for the purpose of the article when abuse is stated it is equally applied to neglect unless otherwise pointed out.
Elder abuse history begins much more recently than child abuse, which found its beginnings with the Mary Ellen case of 1874 and then the founding of the National Children’s Bureau in 1912. Interest in elder abuse began to surface in the 1950s with Congress passing legislation, as part of the Social Security Act, to provide funds to the states on a three-to-one matching basis for setting up these protective service units.5 It wasn’t until 1974 that Congress amended the Social Security Act to mandate protective services for adults over the age of 18.6 This was aimed to protect those with impairments or disabilities over the age of 18. Finally in 1987, with amendments to the Older Americans Act the National Center for Elder Abuse was formed. This was followed by the Elder Abuse Victims Act of 2009 and the Elder Justice Act of 2010. With explosive growth of the elder population, elder abuse has now become a concern for all healthcare professionals.
The types of elder abuse are many and diverse.
Physical abuse has been described as any injury, impairment or physical pain that was a result of physical force upon a elder. Included in physical abuse is force feeding, unreasonable or excessive physical restraints, and improper or excessive drugging. This may be seen in the dental office on a patient that has rub marks on wrists, acts abnormally for age and mental status, or broken glasses or dentures on a patient who previously was well cared for.
Emotional/psychological abuse has been described as any verbal or non-verbal act that causes emotional distress or pain. Verbal abuse may be seen in the manner the caregiver talks to the elder person. Talking abusively is shown by intimidation, anger, humiliation, threats and insults. Isolation, the act of non-inclusive or ignoring the elder are also taken as non-verbal emotional abuse. This can be seen in the dental office as a previously talkative patient quickly becomes silent or acts afraid to talk when approached. An elder patient may even say they are being abused emotionally. However, be aware that some elders afflicted with Alzheimer, senility, or other ailments of the aging may not have a clear view of their situation. Nevertheless, the dentist should follow-up the elder’s concerns by assessing the elder’s situation with an understanding of the signs of elder abuse/neglect.
Sexual abuse is any non-consensual sexual contact with an elder, including unwanted touching and sexually explicit photography.
Neglect is the failure of a caregiver to properly provide care for the elder under their care. There is active and passive neglect. Active neglect would include the intentionally withholding needed care; while, passive neglect would include the inability of the caregiver to provide the needed care. When a patient who previously was properly groomed, clothed and cared for, now presented him/herself un-groomed, disheveled, and unwashed, with broken glasses, dentists, being professional healthcare providers must inquire as to the kind of care being provided to that elder. Questions must be asked to ethically protect the elder with the understanding that the caregiver, sometimes a comparably aged spouse, may not be able to provide proper care any longer though the caregiver may be attempting it in good faith. Professional guidance must be given.
Self-neglect is also a concern even though there is no perpetrator. When an elder can no longer care for them selves for a variety of reasons, self-neglect may become an issue. Poor hygiene, not following medicinal regimen, malnutrition are signs of self-neglect that a dentist should be aware. A patient, who lives alone, and has always had great oral home care and now is unable to properly clean their teeth should prompt the dentist to question if and how care is being provided.
Financial or material exploitation are also evident in the event of a perpetrator taking advantage of an elder in the manner of fraud, theft, or “con” jobs. Often elders, being patients for many years, will discuss their personal problems with the dentist, hygienist, dental assistant or others on the dental staff. A patient who has always paid properly in the dental office all of a sudden becomes a payment problem, should raise some awareness that this elder patient may be in trouble. Not only the dentist but the entire dental staff should be made aware of the signs of elder abuse that may be seen in the dental office.
Abandonment occurs when a caregiver leaves a elder to care for themselves either at home or in a public place such as a shopping mall and it can be reasonably foreseen that the elder is not capable.
Reporting elder abuse has been considerably less reported than child abuse. In a survey of 407 dentists, only
7% reported having suspected a case of elder abuse and only 1% had filled a report.7 In another survey of 321 dentists, 87% reported they never screen for any domestic violence.8 All states have mandatory reporting for child abuse; however, this is not the case for elder abuse. In those states with required/mandatory reporting of elder abuse, 22.5% of all domestic elder abuse reporting came from healthcare providers.9 Of those cases, 64.2% were substantiated and 31.7% were self-neglect.10 All but 5 states (Colorado, New Jersey, New York, North Dakota, South Dakota) require certain types of caregivers or professionals to report domestic elder abuse.11 By certain types of caregivers/professionals, the states vary greatly as to who is included as a caregiver/professional. From mandatory reporting for any person who has assumed full or intermittent responsibility for the care or custody of an elder or dependent adult, whether or not he or she receives compensation, including administrators, supervisors, and any licensed staff of a public or private facility that provides care or services for elder or dependent adults (any person) to limited mandatory reporting by certain professions listed or persons with certain qualifications/circumstances professionals. It must be pointed out that this area of legislation is currently under often review by the various jurisdictions; hence, check with local authorities as to your specific situation and/or requirements.
When the situation arises that requires an assessment of your elder patient’s care, a general physical and behavioral assessment should be made. Does the patient present him/herself adequately for their age group (hygiene and causal interaction)? Patient history is important as to whether the elder patient is being cared for or is self-reliant. Any finding that causes an elder abuse awareness or suspicion to be raised must be addressed. Document your finding on a separate piece of paper if not dentally oriented. Signs that raise suspicion for the dentist and staff of abuse or neglect are: lip trauma, ill-fitting denture, lack of dental care, poor dental and/or personal hygiene, fractured or unexplained missing teeth, broken eyeglasses or frames, signs of being restrained (restraint marks on wrists), unpaid dental bills, and the actual elder’s reporting of being physically abused.
The American Dental Association (ADA) adopted a policy in 1996 regarding abuse and neglect: ADA supports educating dental professionals to recognize abuse and neglect, not only in children, but also women, elders, people with developmental disabilities, the physically challenged and any other person who might be the object of abuse or neglect, and encourage training programs on how to report such abuse and neglect to the proper authorities as required by state law.”12
The ADA Principles of Ethics and Code of Professional Conduct—Section 3: Principle of Beneficence (“do good”) states: The dentist has a duty to promote the patient’s welfare. Subsection 3.E. Abuse and Neglect states: Dentists shall be obliged to become familiar with the signs of abuse and neglect and to report suspected cases to the proper authorities, consistent with state laws.13
The ADA Principles of Ethics and Code of Professional Conduct – Section 1: Principle of Patient Autonomy (“self-governance”) states: The dentist has a duty to respect the patient’s rights to self-determination and confidentiality.14 Dentists have a concurrent ethical obligation to respect an adult patient’s right to self-determination and confidentiality and to promote the welfare of all patients. Care should be taken to respect the wishes of an adult patient who asks that a suspected case of abuse and/or neglect not be reported, where the reporting is not mandated by law. If the dentist is not a mandated reported of a particular type of abuse, and is not immunized from liability for making such good-faith reports, the dentist could be legally liable for making the report. Failure to respect the adult patient’s wishes would not only violate the principle of patient autonomy, but could also subject the dentist to legal liability for violating the confidentiality of the dentist-patient relationship.15
Therefore, the dentist’s ethical responsibility is at least to the minimum of his or her jurisdiction’s legal requirements for reporting abuse and/or neglect.
If the dentist is mandated by their jurisdiction to report abuse and/or neglect and the dentist fails to report, the dentist could be liable for any of the follow depending on that jurisdiction’s statutes: a misdemeanor, fines and imprisonment, loss of license, loss of malpractice insurance, proximate damages, and/or professional misconduct. Usually, the dentist is usually held liable for a misdemeanor and/or professional misconduct, which may open the door for that jurisdiction’s professional licensing agency to investigate, leading to possible action against the dentist’s licensure.
In a recent study, the majority of dental students surveyed were unsure of their responsibilities of reporting elder abuse. The demographic shift in American society towards an older public brings with it the need to undertake institutional change in the culture of dental education.16 With greater awareness of elder abuse and/or neglect being taught in dental schools, future dentists will have a better understanding of elder care and the professional being ethically and legally responsible to care for their aging patient population as a true healthcare provider.OH
Dr. Graskemper practices full-time in Bellport, New York and is an Associate Clinical Professor at Stonybrook School of Dental Medicine, teaching professionalism ethics, and risk management. He has been awarded 5 Fellowships and is a Diplomat in the American Board of Medical Malpractice. He is a Board member of the International Dental Ethics and Law Society and the American Board of Medical Malpractice. Dr. Graskemper has authored many peer-reviewed articles, lectured and published nationally and internationally and recently published a book: “Professional Responsibility in Dentistry: A Guide to Law and Ethics”. He may be reached at email@example.com for comments or consultations.
Oral Health welcomes this original article.
1. United States Department of Health and Human Services, National Center for Health Statistics, Health, United States, 2004, DHHS Pub. No.2004-1232 (DHHS, Washington, DC 2004), p.21.
2. http://www.aoa.gov/aoaroot/aging_statistics/Profile/2011/2.aspx —accessed 3-1-13.
3. Tatara PhD.,Toshio, Kusmeskus M.A., Lisa, National Center on Elder Abuse, Elder Abuse Information Series No. 1, Washington DC 1996, p. 1.
4. National Research Council, Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging American, National Academies Press, Washington DC 2003.
5. Bonnie, Richard J., Wallace, Robert B., Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America, National Research Council, The National Academies Press, Washington DC 2002, p. 239.
6. ibid. p. 239.
7. McDowell J, Kassebaum D, Fryer G. Recognizing and Reporting Domestic Violence: A Survey of Dental Practitioners. Special Care Denttistry 1994; Vol. p. 49.
8. Love C, Gerbert B, Casper N, Brontstone A, Perry D, Bird W. Dentists’ Attitudes and Behaviours Regarding Domestic Violence. Journal of the American Dental Association 2001; Vol. 132, p 86.
9. Tatara PhD.,Toshio, Kusmeskus M.A., Lisa, National Center on Elder Abuse, Elder Abuse Information Series No. 1, Washington DC 1996, p. 1.
10. ibid. p. 2.
11. ibid. p. 3-5.
12. Current Policies Adopted 1954 – 2011, ADA Efforts to Educate Dental Professionals in Recognizing and Reporting Abuse and Neglect (Trans.1996:683) p. 21.
13. ADA Principles of Ethics and Code of Professional Conduct—S
ection 3: Principle of Beneficence (“do good”).
14. ADA Principles of Ethics and Code of Professional Conduct – Section 1: Principle of Patient Autonomy (“self-governance”).
15. ADA Council on Ethics, Bylaws, and Judicial Affairs on Advisory Opinion 3.E.1, Reporting Abuse and Neglect. 2000. P.1.
16. Gironda M, Lefever K, Anderson E., Dental Students’ Knowledge About Elder Abuse and Neglect and the Reporting Responsibilities of Dentists, Journal of Dental Education. Vol 74, No. 8, p. 829.