• Prevention Quarter: IPV and Elderly

    Dr. D'Andrea Joseph

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    IPV and Elderly

     It is said that in British common law in the late 18th century a husband was allowed to “physically chastise” his wife, provided the stick used was “no thicker than his thumb.” While the validity of this statement has been called into question, it is clear that intimate partner violence (IPV) and domestic violence (DV) is not new concept. What is new, however, is the recognition of the prevalence of IPV. The World Health Organization (WHO) reports IPV as one of the most common forms of violence against women. All socioeconomic, religious, and cultural groups experience IPV and it occurs in both sexes. However, according to the WHO, IPV suffered by men is the usual defense and the overwhelming global burden of IPV is borne by women.

    In the US, Alabama and Massachusetts were among the first states to make wife beating illegal in 1871. It was not until 1975, however, that Nebraska became the first state to outlaw marital rape. Several states followed over time including as recently as 1984 when in the People vs. Liberta, New York State finally deemed that marital rape was indeed a crime. Sexual violence is simply one aspect of IPV.

    The terms IPV and DV are often used interchangeably. It is the “willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. It includes physical violence, sexual violence, psychological violence, and emotional abuse”. It is important to note that IPV does not require sexual intimacy or a sexual relationship. At the core of IPV is the exertion of control and power of one individual over another where the victim is subjected to various forms of abuse. In a World Health Organization (WHO) multi-country study, 23–56% of women who reported ever experiencing physical or sexual IPV had experienced both. A comparative analysis of data from 12 Latin American and Caribbean countries found that the majority (61–93%) of women who reported physical IPV in the past 12 months also reported experiencing emotional abuse. Of note, IPV is not unique to women. In the US, 1 in 4 women and 1 in 7 men have experienced severe physical abuse from an intimate partner and 1 in 6 women and 1 in 14 men have experienced sexual violence. Consistent with the disease that is IPV, physicians are not immune. A national study performed in 2017 found that surgeons experienced IPV similar to the general population. That study found that from a sample of more than 800 practicing surgeons and trainees, 61% had suffered some form of abuse. While emotional abuse was the most common at 57.3%, physical abuse (13.1%) and sexual abuse (9.6%) were also reported.  In 2017 in direct response to the tragic killing of a well-known transplant surgeon, the American College of Surgeons Clinical Congress had a special session to address IPV in the community. The statement on IPV was updated and a call to action resulted in the creation of an IPV task force.

    The clinician has a unique opportunity to assist victims of IPV, but it can often go unrecognized. Trauma is often the sentinel event and Kothari et al found that 5% of patients who presented with injury had this because of IPV. More concerning is a study by Campbell et al, that showed that 42 – 66% of women killed by intimate partners had seen a health care professional in the year prior. In patients 65 years and older, there is even less of a focus on the possibility of IPV as a cause for the patient’s presentation. While IPV abuse of the elderly and vulnerable adults is common in the United States, it often remains undetected. Nearly 31% of women and 26% of men report having some form of IPV in their lifetime with the elder population affected at a rate of 700,000 to 1.2 million. The last of the baby boomer population is expected to reach retirement age by 2029 with this group currently accounting for 25% of the population.  There are more than 46 million adults > 65 years old in the U.S. Between 2020 and 2030 the number of older adults is projected to increase by almost 18 million and by 2050, that number is expected to grow to nearly 90 million.

    The definition of elder abuse as formulated by the WHO (2017) is “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person”. It has been shown that elderly patients who are victims of abuse are 3.1 times more likely to die in 3 years as compared to like patients.  The estimated prevalence of elder abuse ranges from 2 to 10% depending on the definitions and methods. While one in 10 elderly adults may experience abuse, only one in five will have the case reported. Intimate partner violence in the abuse of elderly and vulnerable adults is common in the United States but often remains undetected. Nearly 31% of women and 26% of men report having some form of IPV in their lifetime with the elder population affected at a rate of 700,000 to 1.2 million. The last of the baby boomer population is expected to reach age retirement age by 2029 with this group currently accounting for 25% of the population.

    Elder abuse can present as neglect and emotional. In addition, it can be difficult to distinguish intentional from non-intentional injury due to the increased likelihood of certain types of injury in that population. Factors contributing to the risk of abuse in that population include poor physical health and mental illness, as well as being completely or partially dependent on caretakers for activities of daily living (ADL). Moreover, certain cultures are less likely to report abuse for fear of caretaker admonishment or being removed from the home and leaving the vulnerable person alone.

    Health care settings can serve as key points of entry into services for both victims and perpetrators and provide an important opportunity for intervention. However, barriers to screening, including lack of IPV awareness, lack of understanding from health care workers, and lack of resources to commit to universal screening result in underreporting of the true incidence of IPV in any population and in particular, the elderly. Understanding the incidence and prevalence of IPV in the older population is tantamount to patient care.

    Further compounding the issue of IPV is the ongoing pandemic. The COVID-19 pandemic is the result of the SARS-COV2 virus, first identified in late 2019. Measures to control the inevitable spread included mask-wearing and limiting physical contact in the form of lockdowns. The necessary measures of quarantine had an expected side effect of a distinct increase in the incidence of IPV across countries. With the lockdowns, victims were no longer able to seek their usual resources and were confined to continuous contact with the abuser. As expected, there was stress induced by the pandemic itself and the unknowns, but also by the loss of finances, decreased family contact, and the need for ongoing childcare and homeschooling. These issues were exponentially increased in marginalized populations.

    Multiple studies have shown a marked increase in the incidence of IPV with the onset of the pandemic, specifically correlating with the initiation of quarantine. The WHO accounts reported a marked increase in calls concerning domestic violence across the UK, USA, and China. In a city in Hubei, the number of reports tripled in February 2020 as compared to the same period the previous year.  In the US, major cities like New York, Philadelphia, Boston, and Chicago experienced increased reports that ranged from 7% to almost 30%. Resources previously available to the IPV victim such as the courts, safe-havens, and even hairdressers were absent making the situation even direr. No studies have been done to date delineating what the impact of this increase has been on the elderly population, but it is logical that they too were similarly impacted.  

    While IPV is a known cause of injury and harm to our patient population, ongoing research has led to a better understanding of the phenomenon. Given that IPV is prevalent in society and that the elderly patient is at increased risk as described above, it follows that the trauma surgeon and provider lead the way in trying to understand how to effect change. Ongoing research is needed in that population and in particular on whether the onset of the pandemic has exacerbated the incidence, as it has in other populations. Trauma care is tasked with a goal of zero preventable deaths that involves investigation into IPV in our growing elderly population.


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