Iowa family physician’s reporting of elder abuse: 20-year follow-up

ABSTRACT

The purpose of this project was to assess changes over 20 years, between family physicians perceived magnitude of elder mistreatment, physician knowledge of state laws, barriers to reporting suspected cases, and what is done in practice. Questionnaires were mailed to 1,080 physician members of the Iowa Academy of Family Physicians. Thirty-six percent of physicians returned the questionnaire. These respondents had a mean age of 51 years, were licensed for 19 years, and 51% were male. Twenty-nine percent of physicians ask their patients direct questions about elder abuse in 2022 compared to 14% in 2002. Identifying an elder abuse case was associated with asking direct questions about abuse and the belief that prompt action would be taken. Knowledge of elder abuse legislation was associated with reporting of all abuse cases, along with thinking there were clear definitions of abuse and that reporting benefits patients.

KEYWORDS:

• Elder abuse
• family physician
• reporting elder abuse

Introduction

Members of the Iowa Academy of Family Physicians (IAFP) were surveyed twenty years ago to ascertain their legislative knowledge, perceptions, and practices as mandatory reporters of elder abuse in Iowa. Survey results indicated that predictors of seeing elder abuse cases in the last year were; if the physician directly asked the patient about elder mistreatment, if the physician’s office had a protocol for reporting elder abuse, and if the physician had higher legislative knowledge about dependent adult abuse (Oswald et al., 2004). To discern if family physicians’ practices, perceptions and legislative knowledge about elder abuse had changed over time, an identical survey was repeated in 2022.

Since the time of the initial survey, changes in the Iowa dependent adult abuse Code Chapter §235B have been enacted. In 2014, the Iowa Code Chapter §235F Elder Abuse took effect, which provides protections for persons sixty years or older who are unable to protect themselves from elder abuse as a result of age or a mental or physical condition. This new law provided coverage for those individuals who were not dependent adults. A new category of abuse, personal degradation, was also added in 2019. “Personal degradation includes the taking, transmission, or display of an electronic image of a dependent adult by a caretaker, where the caretaker’s actions constitute a willful act or statement intended to shame, degrade, humiliate, or otherwise harm the personal dignity of the dependent adult, or where the caretaker knew or reasonably should have known the act would cause shame, degradation, humiliation, or harm to the personal dignity of a reasonable person” (Iowa Code Chapter 235B.2).

Physicians in Iowa are mandatory reporters for dependent adult abuse which includes elder abuse reporting (Iowa Code 235B.3[2]). As mandatory reporters, all Iowa family physicians must complete training in dependent adult abuse. Training requirements were in place for the years 2002 through 2022 and were revised in 2019 to consist of 2 hours of mandatory reporter training within six months of employment and one hour of additional training every three years to maintain a medical license (2019 Iowa Acts, House File 731). The frequency of retraining was increased from every five years to every three years and a more standardized curriculum was instituted since 2019.

In addition to state changes in legislation, there have been new findings regarding screening instruments for elder abuse and national recommendations about benefits of screening. In 2017 a systematic review identified 11 screening tools for the identification of elder abuse (Gallione et al., 2017). Of those tools, a physician specific abuse screening tool is available, the Elder Abuse Suspicion Index (Yaffe et al., 2008). This is a six-item screening questionnaire to raise a physician’s suspicion about elder abuse to the level that an evaluation by protective services is warranted. The instrument was tested for sensitivity and specificity in a practice setting with 663 subjects (Yaffe et al., 2008). Sensitivity and specificity were 0.47 and 0.75 when at least one question was positive. In 2018, the United States Preventive Services Task Force (USPSTF) recommended that the current evidence was insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older or vulnerable adults (Feltner et al., 2018).

Limited research has been conducted regarding family physicians and the reporting of elder abuse (Kennedy, 2005; O’Brien et al., 2014; Oswald et al., 2004; Rodríguez et al., 2006; Rosenblatt et al., 1996; Wagenaar et al., 2009; West et al., 2021). A survey similar to the IAFP survey (Oswald et al., 2004) was sent to 500 randomly selected family physicians and general internists in Ohio to assess their experience, knowledge, and attitudes toward elder mistreatment (Kennedy, 2005). With a 78% response rate, 31% of responding physicians stated that they had encountered a case of elder mistreatment in the last year, 63% reported never or almost never asked their elderly patients about mistreatment, and 80% felt they were not trained to diagnose elder mistreatment (Kennedy, 2005). A survey of 800 general practitioners in Ireland had a 24% response rate and found that 65% of the 192 respondents had encountered elder abuse cases. Most detected cases were discovered during home visits and many of these physicians were willing to be involved with these cases beyond medical treatments (O’Brien et al., 2014). In another study of physicians, semi-structured interviews were conducted with 20 primary care physicians practicing in the Los Angeles area (Rodríguez et al., 2006). Through a grounded theory approach, three paradoxes emerged from these interviews: 1) a physician-patient relationship which may impact the rapport and could increase or decrease reporting; 2) the patient’s quality of life which could be harmed if not reported or harmed if reported; and 3) the physician’s control over the ability to do what is best for the patient. These paradoxes may contribute to the underreporting of abuse (Rodríguez et al., 2006).

There is scant research from other parts of the world regarding healthcare providers and their knowledge, perceptions and practices involving elder abuse. In Malaysia, where there are no laws, guidelines, or protocols regarding elder abuse, 148 (93% respondence rate) of physicians and nurses responding to a survey revealed lack of understanding of signs of elder abuse and poor knowledge of reporting requirements, and not being trained on how to diagnose elder abuse (Ahmed et al., 2016). An Italian study surveyed 142 healthcare professionals (care assistants, nurses, and physicians). Of the 98 (69%) respondents, half were unsure of reporting procedures and there was a weak level of awareness and perceptions of elder abuse (Corbi et al., 2019).

A factor contributing to physician failure in elder abuse reporting is the physician’s education regarding elder abuse. A survey sent to Michigan residency directors in emergency, family, internal, preventive, and transitional medicine found that family medicine residencies include an approach of formal lectures and didactics along with exposure to elder abuse patients while emergency and internal medicine residencies demonstrated a lack of elder abuse education (Wagenaar et al., 2009). Another study found when medical students are provided elder abuse education training, their knowledge and awareness of elder abuse increases post education (West et al., 2021).

Family physicians perform a unique role in identifying and reporting elder abuse. Over 90% of Americans over the age of 60 years see their primary care physician every year (Levine et al., 2020). Family physicians apply a biopsychosocial model in understanding their patient’s subjective experience as an important contributor to accurate diagnosis, humane care and health outcomes (Borrell-Carrió et al., 2004; Engel, 1977). Forming strong therapeutic relationships is one of the pillars of a biopsychosocial-oriented clinical practice (Borrell-Carrió et al., 2004). Family physicians should be prepared with the resources, knowledge, and motivation to detect, report, and manage elder abuse. In a study conducted in Michigan of over 17,000 reported cases of possible elder abuse, physicians contributed 2% of the total reports (Rosenblatt et al., 1996). According to the “Iowa Dependent Adult Abuse Report from July 2021 – December 2021,” (https://hhs.iowa.gov/reports/dependent-adult-abuse) 1.9% of the total reports of dependent adult abuse in Iowa were submitted by physicians.

The present study was proposed because there have been changes in legislation and screening tools available for elder abuse detection, yet a small percent of total elder abuse cases have been reported by physicians. Further, there has been limited national and international research regarding physicians’ experiences with elder abuse patients and no follow-up studies have been reported. The purposes of this study were to 1) assess Iowa family physicians’ experiences with and perceptions about elder abuse seen in their practices in 2022 and compare this with 2002 physicians’ views, 2) compare physicians’ knowledge about elder abuse legislation between 2002 and 2022, 3) evaluate changes in physicians’ elder abuse perceptions and practices between 2002 and 2022 and finally, 4) investigate the variables associated with finding elder abuse cases in practice and the reporting of those cases seen in 2022.

Methods

Upon approval from the Institutional Review Board (ID# 202205406) for this study, 1,080 Family Medicine physicians practicing in Iowa, who are members of IAFP, were sent an Elder Abuse Questionnaire via mail. Each physician had been assigned a unique identification number for tracking responses. Physicians who did not respond to the first questionnaire within 3 weeks were mailed a duplicate questionnaire. A final duplicate questionnaire was sent to those who had not yet responded in the prior 6 weeks. Thirteen envelopes were returned due to incorrect addresses and two notifications for physicians who had retired, for a total of 1,065 potential participants.

Elder abuse questionnaire

The 36-item questionnaire was a duplicate of the questionnaire used in the earlier study and had been revised from studies prior to 2002 (Clark-Daniels et al., 1990; Daniels et al., 1989; Jones et al., 1997; Oswald et al., 2004). This questionnaire had been completed and reviewed by 23 physicians in the University of Iowa Family Medicine Department in 2002. Revisions were made based on their recommendations. Questionnaire was again reviewed for content validity and understandability by physicians in the departmental research group in 2022. Demographic characteristics, age, gender, date of first medical license, and zip code were obtained from the IAFP. The questionnaire asked for the number of elder abuse cases seen in the past 12 months, the most frequent type of elder abuse seen in their career, physician practices regarding elder abuse (ask patient direct questions regarding abuse, seen a case of abuse in the last month, reported cases to human services, have written protocol, etc.), reasons why they didn’t report a case of elder abuse, knowledge of elder abuse legislation, physician perception of the magnitude of elder abuse and familiarity with state services and mandates, and an open-ended question asking if they saw a case of elder abuse and didn’t report it, why they didn’t report it. The questions from the 2002 survey were used for the purpose of comparability. (Questionnaire available in supplementary file)

Rural-urban continuum codes

Rural-Urban Continuum Codes classification scheme of metropolitan/nonmetropolitan counties by the U.S. Department of Agriculture were used. The county Federal Information Processing System (FIPS) codes were matched to the physician zip codes to ascertain if the physician lived in a metropolitan or nonmetropolitan area. The zip codes obtained from IAFP may have been physicians’ home or practice location zip code. The assumption was that family physicians typically live close to their practice location. A number (1–9) was assigned to each zip code based on the following population information: 1) Counties in metro areas of 1 million population or more; 2) Counties in metro areas of 250,000 to 1 million population; 3) Counties in metro areas of fewer than 250,000 population; 4) Urban population of 20,000 or more, adjacent to a metro area; 5) Urban population of 20,000 or more, not adjacent to a metro area; 6) Urban population of 2,500 to 19,999, adjacent to a metro area; 7) Urban population of 2,500 to 19,999, not adjacent to a metro area; 8) Completely rural or less than 2,500 urban population, adjacent to a metro area; and 9) Completely rural or less than 2,500 urban population, not adjacent to a metro area. The nine categories were collapsed into metro (1–3) and nonmetro (4–9) county designations for analysis.

Statistical analysis

Descriptive analyses were completed to assess the distributions of response variables. T-test was used to compare continuous variables, and Pearson chi-square test was used to compare categorical variables. Although there might have been some overlap of participants between the years 2002 and 2022, they were considered as independent samples, since the surveys were 20 years apart. Responses to the questions that were “unsure” or “uncertain” were included in the denominators in tables 2 and 3. A logistic model was used to evaluate whether elder abuse cases seen in practice or the reporting of those cases with each of the potential associated factors: age, gender, years as MD, metro/nonmetro area, summation of 8 knowledge questions (dichotomized 0–6 correct questions vs 7–8 correct questions), asks patient direct question regarding abuse, office has written protocol, attends mandatory training, perceives training helpful, familiar with community services for victims, office staff attends training, uses state’s reporting form, perceives reporting as beneficial, perceives few older adults are abuses, most cases abuse are in institutions, clear definitions of abuse, family physicians can identify abuse, most abuse not seen by family physicians, most abuse has minor injuries, Iowa had sufficient resources to meet needs of mistreated, most older adults are able to get help, identity of reporter will be disclosed, chance of reporter having a court appearance, prompt action will be taken, and reporting is effective in dealing with abuse. Each factor was tested individually in the logistic model. Factors with a p < .15 (Heinze & Dunkler, 2017) were included in the multivariable model, and backward stepwise method was used to remove the variables one at a time. Variables with p < .05 were considered as significant in the final multivariable model. Multicollinearity was assessed using the variance inflation factor but was not detected among the variables remaining in the final models. The highest variance inflation factor among the variables was 1.06 well below < 5. All statistical analyses were performed using SAS version 9.4 (SAS Institute Inc, Cary, NC).

Results

Three hundred and eighty-eight (36.4%) physicians of 1065 returned the questionnaire. Respondents had a mean age of 51 years (range 30–74), were licensed for a mean of 19 years (range 0.3 to 46 years) and 198 (51.0%) were male. Two hundred and twenty-nine (59.0%) respondents lived in metro areas compared to 159 (41.0%) who lived in nonmetro areas. There was a trend that responders had more years of experience as physicians than non-responders, 19.4 versus 18.0 years (p = .058) and their mean age of 50.8 versus 49.3 years was older (p = .018). Ages ranged from 30 to 74 years.

The mean number of elder abuse cases seen, within a year, by Iowa family physicians was 1.5 (SD 2.5) in 2022, a significant increase from 1.0 (SD 1.4) in 2002. Currently, 228 (58.9%) of physicians perceive elder abuse as prevalent as spouse or child abuse, up from 165 (45.0%) in 2002. Neglect was selected as the most frequent type of elder abuse seen in a physician’s career with a significantly higher percent of 67.9% in 2002 versus 52.1% in 2022 (p < .001). The types of abuse seen in practice differed with more exploitation being suspected in 2022 (Table 1).

Table 1. Physicians’ experience with & perceptions of prevalence & types of elder Abuse.

	Respondents 2002 N = 378	Respondents 2022 N = 388	p-value
Cases EA seen in last year, mean (SD)	1.0 (1.4)	1.5 (2.5)	<.001
Prevalence of EA, N. (%) Less than spouse & child abuse Same as spouse & child abuse More than spouse & child abuse	184 (5.1) 165 (45.0) 17 (4.6)	100 (25.8) 228 (58.9) 59 (15.3)	<.001*
Most frequent type of EA seen in career, N. (%) Emotional Exploitation Neglect Physical Sexual	57 (2.6) 18 (6.5) 188 (67.9) 13 (4.7) 1 (.4)	52 (15.4) 107 (31.7) 176 (52.1) 2 (.6) 1 (.3)	<.001*

*Chi-square test; EA = elder abuse.

For seven of the eight knowledge questions, physicians responding in 2022 had a higher percentage of correct answers than those responding in 2002. Six of those percentages were significantly higher (Table 2).

Table 2. Physician’s knowledge of elder abuse legislation, comparing 2002 and 2022.

Knowledge Variables	Respondents 2002 n = 378 n (% correct)	Respondents 2022 n = 388 n (% correct)	p-value*
Know to whom to report domestic EA	290/371 (78.2)	364/384 (94.8)	<.001
Know to whom to report institution EA	232/368 (63.0)	315/384 (82.0)	<.001
Familiar with Iowa EA laws	255/370 (68.9)	307/384 (8.0)	<.001
Iowa EA and CA laws similar	286/368 (77.7)	342/385 (88.8)	<.001
Litigation protection for physicians	307/367 (83.7)	309/383 (8.7)	0.125
Do not need victim’s consent	305/367 (83.1)	338/383 (88.3)	0.017
EA report my responsibility	361/367 (98.4)	379/382 (99.2)	0.566
Not violation of victims’ rights	322/364 (88.5)	363/383 (94.8)	0.005

*Chi-square test; EA = elder abuse; CA = child abuse.

There was a significant increase in positive responses to nine perception and practice questions in 2022. These items included asking patients direct questions about elder abuse, observed a case of elder abuse in the past month, suspected elder abuse in their career, reported all cases seen in last year to DHHS, had office elder abuse protocol, used state’s reporting form, attended mandatory reporter training, felt mandatory training was helpful, and definitions for elder abuse were clear. Five perceptions and practice question positive responses decreased significantly in 2022 from 2002. These included familiarity with community elder abuse victim resources, perceiving very few older adults are abused, most cases of elder abuse are never seen by a physician, most of elder abuse occurs in institutions, and possible court appearance a reason for not reporting abuse (See Table 3). Many physicians’ perceptions and practices concerning elder abuse have changed since 2002.

Table 3. Comparisons of physicians’ elder abuse perceptions and practices, Year 2002 and 2022.

Predictor Variable	Respondents 2002	Respondents 2022	p-value
	n = 378 n (% true)	n = 388 n (% true)
Asked patients direct questions on elder abuse	50/365 (13.7)	109/378 (28.8)	<.001
Observed >0 EA cases in last month	38/364 (10.4)	48/378 (12.7)	.004
Suspected EA case in your career	320/371 (86.3)	370/385 (96.1)	<.001
Reported all cases in last 12 months to DHHS	106/198 (53.5)	214/304 (70.4)	<.001
Office has EA protocol	88/369 (23.9)	118/379 (31.1)	.039
Used state’s reporting form	111/354 (31.4)	185/372 (49.7)	<.001
Office staff attended mandatory reporter training	248/360 (68.9)	252/379 (66.5)	.251
Physician attended mandatory reporter training	342/371 (92.2)	374/386 (96.9)	.006
Mandatory training was helpful	216/357 (60.5)	279/378 (73.8)	<.001
Familiar with community resources for elder abuse victims	187/370 (50.5)	151/386 (39.1)	<.001
Very few older adults are abused	51/364 (14.0)	31/385 (8.1)	.019
Most EA cases involved only minor injuries	105/369 (28.5)	80/377 (21.2)	.069
Iowa has sufficient resources to meet needs of mistreated elders	42/368 (11.4)	34/383 (8.9)	.501
Most cases of EA are never seen by physicians	195/369 (52.9)	167/384 (43.5)	.021
Most EA occurs in institutions	13/369 (3.5)	9/385 (2.3)	.011
Reporting EA benefits patient	282/364 (77.5)	299/384 (77.9)	.677
There are clear definitions for EA	167/369 (45.3)	208/384 (54.2)	.050
FP can identify EA	202/368 (54.9)	217/383 (56.7)	.153
After report, prompt action taken	124/363 (34.2)	129/383 (33.7)	.929
Mandatory reporting is effective	100/363 (27.6)	99/383 (25.9)	.236
Possible court appearance reason for not reporting abuse	48/368 (13.0)	36/384 (9.4)	<.001
Most older adults can get help for abusive situations	51/368 (13.9)	42/384 (10.9)	.477
Reporter’s identity disclosed	84/367 (22.9)	79/383 (20.6)	.750

EA = elder abuse; CA = child abuse; DHHS = Department of Human Services; FP = Family Physician

Stepwise logistic regression analysis for a physician having seen an elder abuse case in the last year was performed using predictor variables of the physician’s age, gender, number of years as a physician, metro vs nonmetro area, knowledge score and the significant variables listed in Table 3. Asking patient direct questions on elder abuse, not using the state’s reporting form, and perceiving prompt action taken after reporting abuse were associated with physicians seeing a case of elder abuse in the past year as well as sensing that not reporting is related to fear of possible court appearances. Along with the regression analysis, Table 4 shows the different percentages of seeing or not seeing an abuse case for each of the predictor variables (Table 4).

Table 4. Multivariable logistic regression analysis of whether a physician Saw a case of elder abuse in the past Year, 2022.

Predictor Variable	Respondents		Respondents Saw Case EA		Regression Analysis Odds Ratio (95% CI) n = 333	p-value
	Yes n (%)	No n (%)	Yes (%)	No (%)
Asked patients direct questions on EA (n = 349)	98 (28.1)	251 (71.9)	67.4	56.6	1.708 (1.000–2.918)	.050
Familiar with community resources for EA victims (n = 357)	133 (37.2)	224 (62.8)	66.9	55.8	1.615 (0.984–2.649)	.058
Used state’s reporting form (n =345)	171 (49.6)	174 (50.4)	56.7	64.9	0.540 (0.337–0.866)	.011
After report, prompt action taken (n = 355)	122 (34.4)	233 (65.6)	67.2	56.6	1.703 (1.034–2.805)	.037
Possible court appearance reason for not reporting EA (n = 355)	176 (49.6)	179 (50.4)	65.3	55.3	1.728 (1.087–2.746)	.021

EA = elder abuse

Regression analysis for reporting all cases of abuse seen was carried out using the same predictor variables used for analyzing the outcome of having seen a case of abuse in the last year. Higher knowledge of elder abuse legislation, perceiving there were clear definitions for elder abuse and that reporting abuse benefits patients all were associated with reporting cases. Along with the regression analysis, Table 5 shows the different percentages of reporting or not reporting all abuse cases seen for each of the predictor variables.

Table 5. Multivariable logistic regression analysis of physician reporting of elder abuse cases, 2022.

Predictor Variable	Respondents		Respondents Who Reported All Cases Seen		Regression Analysis Odds Ratio (95% CI) n = 209	p-value
	Yes n (%)	No n (%)	Yes (%)	No (%)
Knowledge score* (n = 210)	165 (78.6)	45 (21.4)	79.4	48.9	4.509 (2.152–9.448)	<.001
Clear definitions for EA (n = 209)	62 (29.7)	147 (70.3)	83.9	68.0	3.225 (1.412–7.364)	.005
Reporting EA benefits patient (n = 210)	55 (26.2)	155 (73.8)	76.8	61.8	2.098 (1.031–4.270)	.041

*Yes is > 6 questions correct; No = 6 or less questions correct.

EA = elder abuse.

The most common reasons indicated for not reporting abuse were that the patient was not a dependent adult (N = 76), victim denied abuse (N = 67), did not recognize signs of abuse at time of visit (N = 56), abuse reported by other officials (N = 41) and concern that a report would make the situation worse (N = 24).

Discussion

Elder abuse is a condition encountered by family physicians, especially those with a large proportion of their practices composed of older adults. This study provided the opportunity to assess Iowa family physicians’ trends in knowledge, attitudes, and practices regarding elder abuse over the last 20 years.

The mean number of elder abuse cases seen by Iowa family physicians has increased from 1 to 1 ½ cases per year over the past twenty years. In 2002, 86% of physicians had seen an adult abuse case in their career and this increased to 96% in 2022. These results differ from a random sample of general practitioners in Ireland who returned a mailed survey and reported 65% had encountered elder abuse and that most of these cases were identified during home visits (O’Brien et al., 2014). Family physicians in Ohio reported identifying more cases of elder abuse than internists. However, only 13% of responding Ohio family physicians indicated that they had discussed with colleagues or another health care professional about an instance of suspected elder abuse in the last year (Kennedy, 2005). Overall, there appears to be increased involvement of family physicians in caring for older adult victim of abuse over the last 20 years in Iowa and more involvement than seen in previous studies of physicians in Ohio and Ireland.

Approximately 75% of physicians now and 50% in 2002 perceived elder abuse to be at least or more prevalent as spouse and child abuse compared to 18% of physicians in Ohio (Kennedy, 2005). The types of abuse seen in practice have also changed with less neglect 52% versus 68%, but more exploitation 32% versus 12% in 2002. Neglect remained the most common type of abuse seen in practice, decreasing over the last twenty years, but there appears to be more awareness of exploitation by family physicians. Similarly, the Irish physicians reported self-neglect and psychological abuse as the most common type of abuse, which was the same as physicians from Ohio (Kennedy, 2005; O’Brien et al., 2014). Exploitation awareness may have been influenced by recent emphasis on financial exploitation in news reports and other state initiatives (Richardson & Gruber-Miller, 2022). In 2021, 75% of adults 65 years of age and older were using the Internet and 45% were using social media along with increasing use of smart phones and online banking (Faverio, 2022). With the increase in social media and online banking and shopping, reports of fraud have increased with a reported loss of $600 million in 2020, an increase of 36% from 2019 (Federal Trade Commission, 2021). Physicians in 2020 seemed to be more aware than 2002 physicians of the threat of exploitation impacting their older and vulnerable patients.

The physicians’ perspectives on the prevalence of elder abuse and types of abuse seen in their practices may not closely correspond to results from epidemiologic studies in domestic and institutional settings. The older adult populations seen by physicians are seeking medical care on their own or are brought by another individual to a medical facility for care. This would eliminate older populations unable to obtain healthcare services. The prevalence study conducted in the U.S. closest to the year 2002 was the Pillemer & Finkelhor study of elders in Boston (Pillemer & Finkelhor, 1988). They found 32/1000 persons 65 years and older were being abused with 20/1000 experiencing physical abuse, 11/1000 chronic verbal aggression, and 4/1000 neglect. Exploitation was not investigated by Pillemer & Finkelhor (Pillemer & Finkelhor, 1988). In the last prevalence study of abuse in the U.S., Acierno in 2010 found the one-year prevalence was 4.6% for emotional abuse, 1.6% for physical abuse, 0.6% for sexual abuse, 5.1% for potential neglect and 5.2% for current financial abuse by a family member (Acierno et al., 2010). These findings seem to compare more closely with the 2022 physician responses and that physicians were recognizing more potential exploitation (financial abuse). Another possible prevalence comparator to our study would be the 2017 systematic review and meta-analysis by Yon et al (Yon et al., 2017). They found of the 38,544 studies initially identified, 52 were eligible for inclusion. These studies were geographically diverse and included 28 countries. The pooled prevalence rate for overall elder abuse was 15.7%, psychological abuse 11.6%, financial abuse 6.8%, neglect 4.2%, physical abuse 2.6%, and sexual abuse 0.9% (Yon et al., 2017). Here again financial abuse appears more common than neglect. Financial abuse can be discovered by many potential reporters of abuse in communities (social workers, bankers, etc.) and may be less apparent to a physician in the context of providing medical care.

Physicians’ knowledge of Iowa dependent adult abuse statutes overall has improved since 2002 with knowing where to report being similar of Ohio physicians’ reporting knowledge (Kennedy, 2005). Iowa law which was in place in 2002 required for the maintenance of a medical license; that physicians must complete 2 hours of dependent adult abuse training within 6 months of starting practice and repeat this training every 5 years. This training was not required by other U.S. states (Jogerst et al., 2003). This Iowa requirement was updated in 2019 to state that the renewal of training is every 3 years and there is a standardized 2-hour training program provided by the state to fulfill this requirement. The standardization of training for mandatory reporters may have also contributed to the physician’s increased knowledge scores in 2022.

Many physicians’ perceptions and practices concerning elder abuse have changed over a span of 20 years. Notably, twice as many physicians are asking all their patients direct questions on elder abuse. Although the percent remains low at 29%, the trend is increasing. Other physicians’ perceptions may help explain reasons for less than a third of physicians asking direct questions. Included in these beliefs leading to not asking about abuse are, prompt action will not be taken after reporting abuse, only half of physicians think there are clear definitions of elder abuse, and less than half are familiar with available community resources to help victims. Another contributing factor for not asking about abuse in practice is the 2018 United States Preventive Services Task Force (USPSTF) recommendation which states that the current evidence was insufficient to assess the balance of benefits and harms of screening for abuse and neglect in all older or vulnerable adults (Feltner et al., 2018).

Beyond not having a USPSTF recommendation to screen for elder abuse, a key factor for not asking about abuse may be physicians’ belief that Iowa does not have sufficient resources to meet the needs of mistreated older adults. Only 11% of physicians thought adequate resources were available in the year 2002 and 9% in 2022 (Oswald et al., 2004). This view is consistent with a study of emergency physicians, 8% of whom thought their states did have sufficient resources to meet the needs of elder abuse victims (Jones et al., 1997). Why ask about abuse if you’re not sure there are resources to improve the situation if you discover mistreatment?

Another view of the finding that 29% of physicians report that they ask all their patients direct questions about possible abuse is that the percent is too high, considering there is no national recommendation to screen for abuse and the resources are not available to help is abuse is discovered. Possible explanations include that 31% of physician’s offices had protocols for reporting abuse, which could have included screening questions. Also, the inclusion of abuse questions in an office template addressing home safety for Medicare Wellness Visits, which started in 2011, could boost the impression that all patients are asked about abuse. An example question is “Has anyone ever intentionally tried to harm you?”. Further, all patients being admitted to the hospital are asked about potential abuse. The above circumstances may inflate the physicians’ perception of asking all their patients about abuse.

The regression analysis for factors related to having seen a case of elder abuse in the last year provided valuable insights. Cases are discovered, if direct elder abuse questions are asked during a physician visit and, the physician believes prompt action will be taken on the patient’s behalf if a report is made. There was a trend in the regression that if the physician is familiar with community resources, more cases are seen. Thinking that a court appearance is a reason for not reporting abuse leads to more case finding makes less intuitive sense. This may represent a deeper understanding of elder abuse issues and the perception that other physicians may not report abuse for fear of court appearances and time away from the office practice. Not using the state’s reporting form was also related to increased abuse case finding. A possible explanation is that this question represents a surrogate for a question like “Do you have practice resources to help you with elder abuse reporting?” Physician practices may have social worker or other support personnel to help fill out state reporting forms, relieving physicians of this task. Finding a case of elder abuse in a family physician’s office can be a “schedule buster” leading to delays in seeing other scheduled patients and prolonging office hours if support is not readily available to help address the needs of the mistreated patient. As O’Brien suggests, the patient-centered medical home, or another model of interdisciplinary care, may change the assessment and interventions for elder abuse in the office setting (O’Brien, 2010).

Knowledge of elder abuse legislation in 2022 physicians did not relate to increased elder abuse case finding, which is the same as the 2002 results (Oswald et al., 2004). However, this knowledge did relate to reporting all cases of abuse found in practice. Thinking there were clear definitions for elder abuse and that reporting elder abuse benefits patients, both improved reporting rates. There may be reluctance to report abuse if the physician is not clear about the existence of abuse, as defined by state law, even though suspicion of abuse is the only threshold needed to cross to warrant reporting. The most frequent respondents’ reason for not reporting abuse was that the patient was not a dependent adult. This reason could be eliminated with knowledge of Iowa Code Chapter 235F, which provides protection for all persons sixty years of age or older, even those who are not dependent. Physicians weigh risk versus benefit in all decisions, so reluctance to report abuse in cases where benefits are questionable is understandable, especially in a state environment where less than one-tenth of physicians believe Iowa has sufficient resources to meet the needs of mistreated older adults.

Several study limitations are identified. The response rate was 36%, similar to the 2002 response rate, and therefore may not represent all Iowa family physicians. Physicians with more experience with, or knowledge of elder abuse may be more interested in the topic and therefore found time to complete the questionnaire. The findings are not generalizable, especially to other states which may not have elder abuse training requirements. Since the questionnaire was completed at two distinct times 2002 and 2022, answers did not capture fluctuations of perceptions and practices that may have occurred threw out these 20 years and the same physician may have answered the questionnaire at each time-period. Reliability testing was not performed on the 2002 questionnaire. Although the same questions were used in the 2022 survey no multicollinearity was discovered for the variables in the final models.

There is a continued need for more research on elder abuse and the role of the physician in identifying, reporting, and caring for older adults who are mistreated. Despite mandatory reporting laws, physicians may be reluctant to report abuse because of a lack of time, limited knowledge, and a sense of inability to make a difference (Dong, 2015). Physicians who report abuse to an overwhelmed Adult Protective Service may not be satisfied with the response and may be reluctant to make future reports (O’Brien, 2015). Knowledge of elder abuse in our sample does not appear to be a concern. Research should focus on the availability of adequate resources and the coordination of physician’s care with the state’s Adults Protective Service and the legal system.

Conclusions

Physicians in 2022 reported that elder abuse was at least as prevalence as spouse and child abuse, that neglect was the most common type of abuse seen in practice and that more exploitation was seen in 2022 than in 2002. Although increased from 2002, only 29% of physicians ask their patients direct questions about elder abuse in 2022. More elder abuse cases were seen in 2022 than in 2002 by Iowa family physicians. Identifying an elder abuse case was associated with asking direct questions about abuse and the belief that prompt action would be taken. Knowledge of elder abuse legislation was associated with reporting all abuse cases, along with thinking there were clear definitions of abuse and that reporting benefits patients. Over 90% of family physicians perceive there is a lack of sufficient resources in Iowa to meet the needs of mistreated older adults. This perceived lack of resources places the physician in the precarious position of weighing the risks versus benefits of discovering and reporting elder abuse.

Data availablity statement

Data from this study are available upon reasonable request.

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/08946566.2023.2297228.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.