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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.