and delayed time to diagnosis. Chronic social isolation and loneliness trigger an increased inflammatory state, leading to increased risk of cardiovascular disease, exacerbations of chronic illnesses, and a suppressed immune system.
Figure 4.5 Risk factors, possible adverse events, and possible treatment options for loneliness in older adults.
Approximately one‐quarter of community‐dwelling older adults in the US were characterized as socially isolated. Lower income, lower educational attainment, unmarried relationship status, and Caucasian race were all correlated with a higher risk of social isolation.44 Loneliness is difficult to capture objectively, but various surveys have indicated that 20–45% of adults report feeling lonely some or all of the time. Living alone and dissatisfaction with one's social circle, family, or community increased the risk of loneliness.
Treatment of loneliness must be tailored to individual circumstances to be effective; there is no one‐size‐fits‐all approach. Factors increasing the risk of social isolation, such as impaired hearing, should be addressed, and co‐morbid psychiatric diseases such as anxiety or depression should be appropriately treated. Social workers may be able to help patients establish reliable transportation, join senior centres, or pair at‐risk seniors with volunteer organizations that provide companionship. Patients can engage in volunteer groups or community organizations based on shared language, culture, or interests. Cognitive‐behavioural therapy can be effective for select patients who exhibit maladaptive social cognition, characterized by persistent negative thoughts about themselves and how they are perceived by others.45
Elder abuse
Elder abuse is widely under‐recognized and under‐reported, making it challenging to understand the true scope of the problem. Studies of prevalence vary widely, but 5‐10% of older adults likely suffer from elder abuse. In the US, female gender, African American race, lower socioeconomic status, and physical disability increase the risk of abuse. Patients with dementia are at the highest risk of abuse, with some prevalence studies estimating that nearly half of patients with dementia suffer abuse.46
The US Centers for Disease Control and Prevention (CDC) defines elder abuse as ‘an intentional act, or failure to act, by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult’ (https://www.cdc.gov/violenceprevention/elderabuse). Elder abuse can take numerous forms, including physical and sexual violence, neglect, and financial exploitation.47 Scams and fraud are discussed in more detail in a separate section in this chapter.
Despite its high prevalence, elder abuse commonly goes undiagnosed. One study of US emergency departments reported an incidence of 0.013% of reported elder abuse; this is several orders of magnitude lower than the estimated true prevalence, suggesting that most cases are missed. There are a number of reasons why elder abuse is under‐reported. Victims may be financially, emotionally, or physically dependent on their abuser. They may fear the consequences of reporting, such as institutionalized or retaliation. Cognitive impairment or speech impediments may limit patients’ abilities to report. Physicians may attribute bruising and fractures to osteoporosis, use of anticoagulants, or other common medical conditions. Signs of neglect such as poor grooming, pressure ulcers, and intertrigo may be missed during routine physical exams. It may be difficult to distinguish between neglect and disease progression. Finally, unlike child abuse, there are not injury patterns and radiologic findings classically attributable to elder abuse.
Information on the forms of elder abuse, causes, screening, and management are discussed in more detail in the Chapter 103. Cases of suspected abuse should be referred to Adult Protective Services (APS) in the US. If abuse is experienced at a nursing home, providers should report to the affiliated ombudsman in addition to APS. Outside of the US, providers should familiarize themselves with local laws and available resources to address elder abuse. Many developing countries lack the infrastructure to provide aid to those experiencing elder abuse. The WHO adopted the Global Strategy and Action Plan on Aging and Health at the World Health Assembly in 2016 to prioritize increasing resources for vulnerable older adults.
Scams and fraud
Scammers preferentially target older adults for several reasons. Cognitive impairment and financial insecurity may make them vulnerable targets. Older adults are also perceived as less technologically savvy, and thus scammers often target older adults with telephone or online scams (https://www.aarp.org/money/scams‐fraud).
Table 4.3 describes some of the most common scams and measures older adults can take to protect themselves. As technology continues to evolve, new scams will develop, and it will be impossible to counsel patients against all possible scams. Additionally, while not truly ‘scams’, unscrupulous businesses may try to upsell older adults with unneeded products or sell questionable investment prod ucts. Following are some general safety practices that patients can take to protect themselves financially:
Table 4.3 Common scams targeting older adults.
| Scam | Description | Protection measures |
|---|---|---|
| Health insurance (Medicare) fraud | Patient's insurance number is either stolen or willingly given under false pretences Patients may owe copays for products received, lose ineligibility for future claims, or pay higher premiums as a result of false claims | Never provide insurance information to unsolicited callers.Review healthcare and explanation of benefits documents; report unfamiliar services, equipment, or charges. |
| Fake check scam | Victim is provided with a check or wire transfer as payment under the pretence of employment, a prize, a law settlement, etc. Victim is asked to transfer a portion of that money to another account via wire transfer, payment app, or gift cards. Initial check will not clear, and victim will owe their financial institution the money transferred/spent. | Be wary of any offer of ‘free money’ or other offers that seems too good to be true.If given an unexpected check, call the issuer (via a reputable phone number from an official website) to ensure validity.Never wire money or send gift cards to strangers – this money is almost always unrecoverable. |
| Phishing | Victim receives an email, text message, phone call, or other solicitation requesting protected information, such as login details, credit card number, SSN, etc. The solicitation often mirrors reputable websites/companies but originates from an illegitimate source. | Confirm the domain name in emails and websites.Always visit websites directly rather than clicking links through emails.Be wary of emails with misspellings, grammatical errors, warnings of dire consequences, and/or a need for immediate action. |
| Imposter scam | Scammer impersonates a person the victim knows or pretends to be from a reputable company (such as a government agency). Cat‐fishing is a common variant in which the impostor attempts to lure the victim into a romantic relationship. Grandparent scam is a common variant in which the scammer pretends to be a grandchild in dire legal or medical trouble. |
Consider a family ‘code word’ that can be provided on request to positively identify oneself. If a call
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