Elder abuse and neglect: social problems revealed from 15 autopsy cases

1. Introduction 

Elder abuse is the most recent violence issue to gain the attention of the public and the medical community. Child abuse received significant attention in the 1960s and domestic violence in the 1970s [1], but elder abuse was not described in medical literature until, 1975, when two reports of ‘granny battering’ appeared [2], [3]. Since then, the medical profession has gradually come to recognize this problem, and many reports of this recently recognized form of violence have appeared in the United States [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], Canada [16], [17], [18] and Europe [19], [20], [21], [22]. The authors of the United States studies have estimated that between 700,000 and 2,500,000 older Americans are abused each year [12]. The National Elder Abuse Incidence Study (NEAIS) conducted by the National Center on Elder Abuse at the American Public Human Services Association suggested that as many as 688,948 or as few as 210,900 older persons aged 60 years and over may have been the victims of abuse and/or neglect in domestic settings in 1996 [15]. By contrast, reports on elder abuse in Japan are rare, and little is known about the actual situation [23]. In Japan, the social concept that older persons should be treated with great care by family and medical staff is widely held, and elder abuse has been thought to occur only on rare occasions. Nevertheless, elder abuse has occurred in Japan and is a major hidden social problem. In this report, we describe 15 cases of elder abuse that occurred in Gifu Prefecture, Japan.

2. Materials and methods 

We conducted a retrospective review of autopsy cases examined at the Department of Legal Medicine, Gifu University School of Medicine, between 1990 and 2000 in which the subjects were 65 years old or older. We found 125 cases (63 males and 62 females) in our search. The investigative reports, autopsy findings, and toxicological analysis of all 125 cases were reviewed, and 15 cases were classified as elder abuse or neglect, according to the definition of elder abuse by the National Aging Resource Center on Elder Abuse (NARCEA) of the United States [24]. The cases of elder abuse were subclassified into seven categories, according to the NARCEA definitions: physical abuse, emotional abuse, financial abuse, sexual abuse, neglect, self-neglect, and miscellaneous.

In principle, obvious homicides were excluded from the study; however, two homicidal cases were included because the autopsies revealed evidence of physical abuse.

3. Results 

Our research revealed 15 victims of elder abuse who died in Gifu Prefecture, Japan, between 1990 and 2000. During this period, all medico-legal autopsies in Gifu Prefecture were performed at the Department of Legal Medicine, Gifu University School of Medicine. The ages of the victims ranged from 66 to 87 years, with a mean age of 74.5 years. The male to female ratio was 1:2. Five victims had difficulty performing activities of daily living (ADLs) because of dementia and/or physical disturbances, but the other victims had no difficulty with their ADLs.

Physical abuse was the most common type of elder abuse, followed by emotional abuse, neglect, and financial abuse (Table 1). No cases of sexual abuse occurred in this study. In eight cases, the victims were subjected to two or more types of abuse.

Table 1. Elder abuse victims in Gifu Prefecture from 1990 to 2000a

	Case	Age (years)	Sex	Cause of death	Dementia of victim	Perpetrator(s)	Income of perpetrator	Psychological abnormality of perpetrator	Physical abuse	Neglect	Emotional abuse	Financial abuse
	1	76	F	Starvation	−	Daughter-in-law and son	+	−		+	+
	2	81	F	Hypothermia	−	Son	−	Alcoholism	+	+		+
	3	67	F	SDH	−	Son	−	−	+			+
	4	73	M	Suffocation1	+	Sons	+	−		+
	5	84	F	Suffocation1	+	Son-in-law	+	−	+	+	+
	6	72	F	SDH	−	Son	−	Alcoholism	+			+
	7	74	F	SDH	+	Daughter-in-law	+	Amentia	+		+
	8	80	F	Drowning	−	Unknown			+		+
	9	71	F	SDH	−	Grandson	−	−	+
	10	73	F	Suffocation2	−	Son	−	Schizophrenia	+
	11	76	F	Fire (homicidal)	−	Grandson	−	Schizophrenia	+
	12	87	M	Strangulation	−	Son	−	Schizophrenia	+
	13	71	M	SDH	−	Son	−	−	+
	14	67	M	TICH	−	Neighbor	+	−	+		+
	15	66	M	TP	−	Others	+	−	+

a SDH, subdural hemorrhage; Suffocation1, aspiration of gastric content; Suffocation2, aspiration of blood from laryngeal injury; TICH, traumatic intracranial hemorrhage; TP, traumatic pneumothorax.

The cause of death in the elder abuse victims varied with the type of abuse (Table 1). Among the victims of physical abuse, subdural hemorrhage was the most common cause of death (six out of 13 cases), followed by other violence-related deaths and hypothermia. An 80-year-old woman committed suicide by drowning after being subjected to physical and emotional abuse. Victims of neglect died of either starvation or suffocation after the aspiration of food into their airway.

Thirteen of the 15 elder abuse cases were domestic, and a son of the victim was the most common perpetrator, followed by a grandchild, daughter-in-law, or son-in-law. In one case, the perpetrator(s) was not identified, despite the fact that the female victim had obviously been subjected to domestic elder abuse. In the ten cases where the victim's son or grandchild was the perpetrator, eight of the perpetrators were unemployed and had little or no income. Four of the perpetrators in the domestic elder abuse cases had a mental illness, and two were chronic alcoholics.

Among the neglect cases, two victims had developed dementia and had some difficulty with their ADLs, with or without physical impairments. In the other neglect cases, the victims became unable to perform their ADLs because of trauma caused by repeated physical abuse.

4. Discussion 

The definitions and terminology related to elder abuse vary considerably among researchers and among the laws of different countries and states in the United States [12]. Even the minimum age for inclusion in the geriatric category is debated. In some studies, the category has been defined as 65 years of age or older [5], [7], [11], while in other studies it has been defined as 60 years of age or older [15], [16], [17], [18], [20]. Many authors have defined four types of elder abuse: physical, emotional, financial, and neglect. However, other types of abuse have also been described. NARCEA has proposed seven categories of elder abuse, consisting of the four noted above plus self-neglect, sexual abuse, and miscellaneous [24]. NEAIS has also proposed seven elder abuse categories, including the four noted above plus self-neglect, sexual abuse, and abandonment [15].

Physical abuse is defined as the use of physical force that may result in bodily injury, bodily pain or impairment and is a common type of elder abuse. In the present study, 13 of the 15 victims were subjected to physical abuse, and nine of these victims were female. Emotional abuse is defined as the infliction of anguish, emotional pain or distress, and is another common type of elder abuse. In our study, five victims were subjected to emotional abuse and four of them were female. Women have traditionally been thought to be the most common victims of abuse [5], [12], [16]. However, some large surveys have found no gender-related differences [4], [8], [11], [15]. The abuse of women is thought to be reported more often than that of men, because the severity of the injury is usually greater [4]. The high incidence of abuse in women based on the autopsy cases in the present study may also reflect the above idea. Neglect is defined as the refusal or failure to fulfill any part of a person's obligation or duties to an older person, and is also a common type of elder abuse. In some reports, neglect has been the most frequent type of abuse, and followed by physical and emotional abuse [13], [15]. Older persons who have difficulty performing ADLs have a higher risk of becoming victims of neglect, particularly if their problem involves eating [4], [8], [11]. The victims of neglect in the present study exhibited dementia and/or physical impairments.

Various risk factors for elder abuse, including psychological health, have been described with regard to both the victims and the perpetrators. Poverty [11] and high alcohol consumption by the perpetrator [19] are considered to be risk factors of elder abuse. The physical and mental health and the functional ability of the victims are also considered to be risk factors for physical abuse [4], [8], [11]. The classic image of elder abuse is described by the caregiver-stress hypothesis, in which the older person becomes increasingly dependent on the caregiver for physical, emotional and financial needs, and the caregiver slowly but steadily becomes overburdened and resentful of the elder's demands, eventually lashing out or withholding the basic needs from the older person. However, such relationships, which create more caregiver stress and anger, do not increase the incidence of elder abuse [6], [12]. Abuse is more strongly correlated with the financial and emotional dependence of the caregiver on the older victim [15]. Such dependence is often the result of an underlying problem of the caregiver, such as alcoholism, legal difficulties, psychiatric condition or deviant behavior [5], [12], [16], [19]. Neglect is also associated with socially dysfunctional caregivers [19]. Older persons who live in social isolation are more frequently abused [15]. Abuse sometimes occurs in families where the older person has a dominant personality and the activities of child(ren) are strictly controlled and decided by the parent [22]. Children or grandchildren who are unemployed, depend financially and mentally on an elder, and live in social isolation have a high risk of becoming perpetrators [6], [11], [19]. Among the present cases, four female victims who were subjected to physical abuse and/or neglect by an unemployed son had been taking daily care of the son and had supported him financially. They also lived in social isolation. In these cases, the victims probably tolerated and/or accepted abuse with resignation. In such situations, it may be difficult for the victims to break the cycle of abuse and the perpetrator's dependency on the victim without the help of others. The education level of the perpetrator does not seem to be risk factor [10], [22]. This idea is supported by our case 2, in which the perpetrator had graduated from university and been on the teaching staff of a high school for 20 years.

Large community-based trials have revealed certain patterns of abuse. Neglect was commonly experienced by those who had no one to ask for help [17], lived alone [17], or were in poor health [6]. Living with someone increased the risk of physical and emotional abuse [17]. Financial abuse was more common among those who had no one to turn to or who lived alone [17].

One of the difficulties with regard to elder abuse is that some abused elders do not disclose their abuse and remain silent. Their reasons for not speaking out may include fear for their personal safety or that of others, isolation from their family, threats of institutionalization, family break-up, or the withdrawal of the services by caregivers who abuse them. Shame over having raised an abusive child may be another reason for their silence, and older victims sometimes blame themselves for the abuse or deny that the behavior is abusive. However, abused elders frequently show indications of abuse: unexplained bruises, wounds and burns from physical abuse, unusual habits, neurotic or conduct disorders from psychological abuse, and dehydration or malnutrition, poor hygiene, inappropriate dressing, extensive bedsores, urine burns, or fecal impaction from neglect [9], [10], [13], [18]. If elder abuse is suspected, physicians and professional caregivers should examine the subjects carefully, including a cognitive evaluation, and should ask about their living arrangements, financial status, social support, and emotional stress [9], [10], [13], [18], [21]. This may be the first step in preventing elder abuse and abuse-related deaths.

Some old Japanese tales have described elder abuse, one of which concerns the abandonment of a grandmother on a mountain because of poverty. However, elder abuse has been ignored in Japan and has not been openly discussed either socially or medically. In the present paper, we have reported 15 autopsy cases of elder abuse victims that occurred between 1990 and 2000 in Gifu Prefecture, where approximately 2,050,000–2,100,000 individuals lived during that period. Today, child abuse and domestic violence are attracting attention and are discussed as major social problems in Japan. However, there were 35 autopsy cases of domestic violence and only ten autopsy cases of child abuse in Gifu Prefecture during the above period. The number of autopsy cases for child abuse was fewer than that for elder abuse. The iceberg theory should always be kept in mind whenever elder abuse, child abuse, or domestic violence are discussed. This theory states that the reporting sources only receive information on the most visible types of abuse and neglect, while a large number of other incidents remain unidentified and unreported [15]. The present cases represent the severest type of elder abuse and neglect, and a considerably larger number of unreported elder abuse cases are thought to occur in Gifu Prefecture. A nationwide survey of elder abuse and neglect is needed to reveal the presence of elder abuse in Japan, and the creation of laws to prevent elder abuse is considered to be one way of dealing with these abuse cases.