Veterans Experiencing Elder Abuse: Improving Care for a High-Risk Population About Which Little is Known

Abstract

At least 10 percent of older adults may experience abuse, neglect or exploitation annually in the United States, and this problem is expected to grow as our population ages. Little is known about the prevalence and characteristics of elder abuse among Veterans, but this population is likely at high-risk based on established elder abuse risk factors. Compared to the general population, Veterans who receive their care through the Veterans Health Administration (VHA) have higher prevalence of poor psychological health, poor physical health, functional impairment, cognitive impairment and social isolation. As the largest integrated healthcare system in the United States, the VHA has long been a leader in the development of innovative, integrated care programs for populations of geriatric patients. Now, the VHA again has an opportunity to lead by promoting research, clinical care and education in the area of elder abuse, furthering their mission of serving those who served. This article outlines the rationale for developing a research agenda for elder abuse within the VHA as well as potential first steps towards understanding more about this complex problem impacting Veterans.

The Veterans Health Administration (VHA) has long been tasked with providing care to our Nation’s Veterans, including those who are most vulnerable or at risk. As the healthcare system specifically dedicated to meeting the needs of those who served our country, the VHA has often been at the forefront of developing innovative, integrated care programs. Nowhere has this been more evident than in their pioneering research on geriatric syndromes and models of clinical care for Veterans in later life. From the development of long-term care programs within the VA in 1964 to the advent of Geriatric Research, Education, and Clinical Centers (GRECCs) in the early 1970s to pioneering comprehensive home-based primary care programs (HBPC) and more recently the innovation of Medical Foster Home, the VA has always been a leader in using research and education to improve care for vulnerable older adults.¹ Given the recent and anticipated future growth of the population of older Veterans,^2,3 particularly those who receive care through the VHA,⁴ this focus on innovative, integrated care is of increasing importance. The VHA now has another opportunity for leadership in the care of Veterans facing the challenges of aging, disability, or serious illness: improving identification, intervention, and prevention of abuse, neglect and exploitation.

Abuse, neglect and exploitation occur commonly and can dramatically impact the health and well-being of older adults. Elder abuse is defined as harm of an older adult by another person or entity, that occurs in any setting either in a relationship where there is an expectation of trust, and/or when an older person is targeted based on age or disability.⁵ Mistreatment can include physical abuse, sexual abuse, psychological abuse, neglect, and financial exploitation, with many individuals suffering from multiple types. Studies have shown as many as 10 percent of community-dwelling older adults suffer from mistreatment each year,^6–9 and rates may be much higher among those with dementia¹⁰ and residents in skilled nursing facilities.¹¹ Abuse has been linked to adverse health outcomes in older adults including depression¹² and dramatically increased mortality.^13–15 Older adults experiencing mistreatment are also at increased risk of emergency room visits,¹⁶ hospitalization¹⁷ and nursing home placement.¹⁸ Though challenging to quantify, abuse of older adults is estimated to cost many billions of dollars in direct medical costs each year.⁵ Currently, most cases go undetected, with as few as 1 in 24 cases identified and reported to authorities.⁸ Much of the morbidity and mortality may be related to this poor detection.¹⁹

Veterans: A population potentially at risk

Limited research exists examining elder abuse in sub-populations of older adults, and despite calls for further investigation in this area,²⁰ we know of little published research focusing on U.S. Military Veterans. In the only study we are aware of examining elder abuse among Veterans,²¹ Moon et al uncovered that reports to Adult Protective Services for elder abuse were made for 5.4 percent of older adults receiving care through the VHA in Los Angeles. As it is widely accepted that most cases of elder abuse go unreported, this figure suggests that a much higher percentage of Veterans may be experiencing abuse or neglect. Existing literature on risk factors for abuse also strongly suggests that Veterans, and particularly those who receive care within the VHA, may be at high risk for experiencing abuse, neglect, or exploitation.

Poor Mental and Physical Health

Poor mental health, prior trauma, and depression increase risk of elder abuse victimization.^22–25 Through combat as well as other military experiences, exposure to trauma is near ubiquitous for Veterans. One prior survey of older male Veterans found that 85 percent reported prior exposure to a traumatic event.²⁶ While prevalence estimates of post-traumatic stress disorder (PTSD) among Veterans tend to vary greatly depending on the population being studied,²⁷ rates of PTSD are much higher than in the non-veteran population. Furthermore, though Veterans may have similar rates of anxiety and depression as non-veterans,²⁸ for those who receive care within the VHA the prevalence of depression is higher than the general population.²⁶

Poor physical health has also been linked to increased risk of elder abuse.^6,29 Veterans over age 55 are more likely to have two or more chronic medical conditions compared to similarly aged non-veterans and are also more likely to report their health as poor or fair.³⁰

Functional and Cognitive Impairment

Functional dependence and physical disability have repeatedly been shown to increase abuse risk,^6,29,31–33 which is concerning given that more than half of older Veterans report difficulties in physical functioning.³⁴ Cognitive impairment may dramatically increase the risk of elder abuse,^35,36 and projections by the VA estimate that 18–28% of Veterans over the age of 80 had dementia in 2014, with the prevalence by age and gender expected to increase by 2019.³⁷

Social Isolation

Various components of social isolation have been linked to increased risk of elder abuse. Being divorced or separated is a risk factor for experiencing abuse,³² and the presence of a spouse or other romantic partner appears protective.^29,33 Loneliness in an older adult has been shown to increase risk for mistreatment in China³⁸ and the U.K.²⁵ Due to a range of factors, older Veterans experience a high burden of social isolation and loneliness. When compared to similar non-veteran patients, VHA patients have a higher prevalence of loneliness,³⁹ with some studies reporting a prevalence as high as 44 percent in older Veterans.⁴⁰ More than 50 percent of older Veterans may experience social isolation.⁴¹ And, while Veterans overall are more likely to be married than non-veterans,⁴² older Veterans who receive care through the VHA are less likely to be married than those who do not.⁴

Low Socioeconomic Status

Low socioeconomic status, which may make elders more dependent on others and provide fewer options for living and caregiving arrangements, is a risk factor for elder abuse victimization.^6,32,33 Due to the financial and relational benefits that are afforded to those who served in the military, Veterans on the whole experience less poverty than the general population. However, as the VHA serves as a safety-net healthcare system for Veterans who may not be able to access healthcare in the private system, the socioeconomic status of Veterans who receive VHA care is much lower than those who predominantly receive care in the community.⁴

A Growing Older Veteran Population

Veterans are older than the overall U.S. population.² In addition, while the proportion of the population over age 65 is growing across the U.S., the pace of this growth is accelerated among Veterans. In 2015, adults over age 60 represented 55% of all Veterans³ compared to about 15% in the general population.⁴³ Furthermore, Veterans who receive their care within the VHA tend to be older than those who do not.⁴

Call to action: Expand knowledge and improve care for Veterans affected by elder abuse

While Vognar et al have raised awareness about the potential scope of the problem of elder abuse among Veterans,²⁰ a coordinated research agenda has not yet materialized. Here we propose a call to action. Many older Veterans are likely experiencing abuse, neglect, or exploitation with this mistreatment having a profound effect on their health and quality of life. The VHA has an opportunity to take a leadership role in response to this important and challenging issue, which will grow as the Veteran population ages. In recognizing the urgency of this threat to the well being of older Veterans, the VA is well positioned to further elucidate the problem, develop effective interventions, and disseminate this knowledge. Failing to do so may result in continued undetected abuse among older Veterans, leading to downstream poor health outcomes, increased healthcare utilization, and higher costs.

A senior leader from the VA sits on the Elder Justice Coordinating Council, which was formed under the Elder Justice Act passed in 2010⁴⁴ and is tasked with implementing recommendations for increased federal involvement in elder abuse. One of the 8 recommendations is to develop a federal elder justice research agenda.⁴⁴ As the largest integrated health system in the country, the VA is poised to lead this charge. Furthermore, pursuing elder abuse work aligns with related VHA clinical priorities. Secretary Shulkin has called suicide prevention the “top clinical priority” for the VHA. Older Veterans are at high risk for this tragic outcome. It is known that the suicide completion rate among older adults is much higher than for any other age group.⁴⁵ Active research efforts are underway in the VHA to identify modifiable risk factors that predispose older Veterans to suicide. While rigorous studies are lacking, some hypothesize that experiencing abuse may be a risk factor for suicide among older adults,⁴⁶ and calls for further work studying this potential connection have been made.⁴⁷

Broadening Understanding of a Unique Population

Research is a critical next step, and many strategies may be used to understand Veterans’ experiences of elder abuse as well as the unique challenges of identifying, intervening, and preventing mistreatment in this population. For example, Veterans may be uniquely less likely to disclose abuse or neglect to providers due to stigma around vulnerability and victimhood.⁴⁸ In addition, with an over 100-page patient privacy policy⁴⁹ and a privacy officer at every VHA facility dedicated to investigating incidents of potential privacy violations, the culture of privacy protection at the VA may lead providers to be hesitant to report suspected elder abuse, or to believe that proof, rather than suspicion alone, is needed prior to reporting.

Initial studies may include focus groups and qualitative interviews with Veterans and VHA providers to understand their experiences and current practices surrounding suspected elder abuse. Findings of these may inform larger-scale national surveys to quantify prevalence as well as existing approaches for identification, intervention, and prevention. Creative approaches such as linking local or national VHA databases to Adult Protective Services or law enforcement data sets of known victims may be useful to identify cases of elder abuse in Veterans to study in more detail. Research should describe characteristics of Veterans who experience elder abuse and generate potential Veteran specific risk factors. Risk factors unique to the Veteran population that may aid in detection would be valuable to assist in identifying vulnerable individuals. For example, one might hypothesize that Veterans receiving VA pensions or other VA monetary benefits might be at elevated risk of financial exploitation.

Building Programs to Help Veterans and Others

Data supporting specific elder abuse intervention models are currently lacking and more studies need to be done prior to widespread adoption and implementation within the VHA, community healthcare systems, and social service agencies. Every VA Medical Center is required by policy to establish a local training on abuse and neglect for staff and to outline policy on reporting cases of abuse and neglect. However, additional study is needed to determine types and efficacy of interventions provided. The VHA is the largest healthcare system in the U.S., presenting immense opportunity for developing, testing and disseminating innovative programs for elder abuse interventions. In many settings, successful elder abuse programs have been multi-disciplinary.^50,51 The VHA is a potentially ideal environment for integrated, multi-disciplinary approaches. Furthermore, the VHA national health record facilitates longitudinal follow-up for Veterans who have experienced abuse previously, who often continue to be at risk.

Focusing on elder abuse represents an important opportunity for an organization that historically has both collected high quality national data and used these data to design and scale innovative models of clinical care for older adults. For example, VA’s home-based primary care (HBPC) program started in 1972 with a pilot of six locations. Currently, HBPC teams are caring for Veterans with some of the most complex problems at over 130 VHA medical centers. The VHA’s current development of the Intimate Partner Violence (IPV) Assistance Program may be a model way forward for elder abuse program development. Recognizing IPV as a significant problem, the VA convened a task force that developed 14 recommendations for high quality IPV care. These recommendations are being piloted in six VA facilities nationally in two phases and are being evaluated using a Modified Delphi instrument. Concurrently, this assessment tool has been administered to all VA facilities nationally to gather information on the current state of IPV programming. The eventual goal will be to disseminate a successful IPV Assistance Program nationally.

While this describes an effective top down approach, local VHA medical facilities may also have developed effective programs for elder abuse and neglect. These programs need to be studied, and those that are effective should be disseminated so that Veterans throughout the country may benefit from best practices that address the unique needs of the Veteran population. There are multiple avenues for doing this within the VA including annual calls from the Secretary for best practices for the diffusion of excellence and already-established national monthly calls for different service lines. Furthermore, as the VHA has historically done in the care of older adults, programs generated within the VHA would push the field of elder abuse forward in community health systems as well.

Challenges and a Way Forward

Variability in state laws regarding reporting of suspected cases of abuse is one obstacle limiting cohesive national efforts. Furthermore, as a federal organization, a state cannot ordinarily compel a VHA facility or its employees, while acting within the scope of their employment, to comply with state law. VA has provided national policy guidance on this issue. In 2012, VA released a directive on “Reporting Cases of Abuse and Neglect” that stipulated that all VHA facilities must comply with their own state laws for reporting abuse and neglect.⁵² This directive also mandated documentation of the report, examination and subsequent treatment offered in the Veteran’s medical record. One way for the VA to continue this path of leadership would be to call for an inter-agency federal task force on elder abuse. This might include members from the VA, the Department of Justice, the Department of Health and Human Services, and other departments that have a stake in this complex problem affecting us all as we age. VA leadership could also call for congressional funding for the Elder Justice Act, which has not yet been fully funded. The VA can stimulate research in elder abuse by allocating research dollars or issuing Requests for Applications in this area. They could spearhead efforts at collaboration between state and federal agencies, as well as with private-sector innovators as laid out in the 2015 White House Conference on Aging.⁵³

Conclusion

The Veterans Health Administration has a mandate to provide high quality care for the country’s Veterans. It has a long history of embracing this mission by pioneering leadership in program development, education and research. Now, as the aging of the Veteran population accelerates, the VHA has a new opportunity to lead. The VHA should seize opportunities to partner with the Department of Justice, law enforcement, community service agencies, and social and medical science researchers to leverage their expertise in abuse and neglect. Educational programs for Veterans should be developed and existing trainings for providers enhanced. New, innovative interventions should be nurtured with metrics for evaluation established. By focusing on clinical care, education and research for elder abuse and neglect, the VHA will dramatically improve care for older Veterans who are most at-risk, while also furthering the mission of serving those who served.