Description

• Emotional abuse:
  • Insults
  • Humiliation
  • Threats to institutionalize or abandon
• Physical and/or sexual abuse:
  • Hitting
  • Slapping
  • Pushing
  • Burning
  • Inappropriate restraining
  • Forced sexual activity
• Material exploitation:
  • Stealing or coercion involving patient money or property
• Neglect:
  • Behavior by a patient or caregiver that compromises the patient's health or safety
  • Failure to provide adequate food, shelter, hygiene, and/or medical attention

Epidemiology

• Estimated prevalence of 10% (likely an underestimate of overall prevalence due to lack of accurate sampling from cognitively impaired elders—a group at higher risk of abuse and exploitation). The absolute number of victims may increase in the near term as US age demographics continue to shift
• Number of people aged 60+ affected by different forms of abuse (pooled global prevalence data):
  • 4.2% neglect
  • 2.6% physical mistreatment
  • 11.6% emotional mistreatment
  • 0.9% sexual abuse
  • 6.8% financial abuse
• Family members, including partners and adult children, are most common perpetrators
• In one New York study, for every case of abuse reported, 24 cases unreported
• 1-yr prevalence of financial exploitation 2.7%; lifetime prevalence 4.7%
• Elder abuse is associated with a 300% greater risk of death (and 300% greater risk of hospitalization) as well as increased rates of additional health problems such as chronic pain, bone/joint, digestive or psychological disorders (compared to the non-abused)

Etiology

• Caregiver stress, dependency, or psychopathology
• Victim dependency or diminishment of ability to perform activities of daily living
• Victim cognitive impairment or social isolation increase risk of abuse and neglect
• Long-term care facility residents are at increased risk of abuse from staff and also from other facility residents

Signs and Symptoms

• Not willing or able to obtain adequate food/clothing/shelter
• Not providing for personal hygiene/safety
• Delay in obtaining medical care/previously untreated medical condition
• Undertreated pain (may represent medication diversion by a caregiver)
• Vague (or implausible/inappropriate) explanations
• Disparities between histories given by patient and caregiver
• Caregiver who insists on giving the patient's history
• Medication difficulties:
  • Incorrect doses
  • Lost medications
  • Unfilled prescriptions
• Altered interpersonal interactions:
  • Withdrawn
  • Indifferent
  • Demoralized
  • Fearful
  • Substance abuse
• Caregiver with:
  • Financial dependence on patient
  • Substance abuse or psychiatric or violence history
  • Controlling behavior (may refuse to leave elder alone with physician) or poor knowledge
  • Significant life stressors
  • Relationship issues
  • Financial difficulties
  • Legal problems

• Inconsistent findings:
  • Skin mark patterns or variable-age bruises, burns, lacerations/abrasions, fractures:
    • Consider especially bruising of the face, lateral aspect of the right arm, back, chest, lumbar or gluteal regions (these findings alone may not make the diagnosis of abuse but might motivate further investigation)
  • Unusual sites of bruising (not over bony prominences, such as inner arm, torso, buttocks, scalp)
  • Larger areas of bruising than proposed mechanism of injury suggests
  • Poor hygiene (inadequate care of skin, nails, teeth)
• Defensive injuries:
  • Bruising over extensor surfaces of arms/forearms
• Unexplained injuries:
  • Bruised or bleeding genital or rectal area
  • Wrist or ankle lesions suggestive of restraint use
• Findings that may be consistent with neglect or delay in seeking/obtaining medical attention:
  • Dehydration
  • Weight loss
  • Decubitus ulcer
  • Malnutrition:
    • Lower albumin
    • Anemia

Diagnostic Tests and Interpretation

• Perform any exam and lab or radiographic studies as indicated by the patient's condition.
• Consider any under or overdosing of medications or unexpected illicit substance use (on medication or drug level testing) as possible neglect or attempted harm (undertreatment or poisoning)

Essential Workup

• Obtain history without family members/caregivers present:
  • Abused elders may fear institutionalization if they report caregivers
  • Many may feel embarrassment and responsibility for abuse
  • Frequently will not volunteer information
  • Ask patient specifically about abuse or neglect (in private)
• Patient's medical condition may influence quality of history obtained
• Obtain history from caregivers/other relatives/friends/neighbors
• Consider use of a validated screening tool (e.g., Elder Abuse Suspicion Index [EASI]—6 questions—available online)
• Document a clear and detailed description of findings including the following:
  • Statements of the patient as they pertain to the abuse
  • Psychosocial history:
    • Family and other social relationships
    • Caregiver burdens/coping mechanisms
    • Drug/ethanol (Etoh) use
    • Prior adult protective services reports
  • Skin and other physical findings:
    • Photographic documentation
    • Safety assessment

Interpretation

As appropriate for medical condition(s)

Imaging
As appropriate for medical condition(s)

Diagnostic Procedures/Other
As appropriate for medical condition(s)

Differential Diagnosis

• Patient may present with any chief complaint:
  • Potential differential diagnosis is nonspecific
  • Abuse best identified by asking patient directly in a setting apart from caregivers/family and correlating with risk factors and provider findings
• Differentiate findings consistent with other disease entities from abuse/neglect:
  • Dehydration
  • Ill-fitting dentures
  • Burns
  • Ecchymosis
  • Insomnia
  • Medication noncompliance
  • Dementia
  • Depression

Pre Hospital

• Observe details of the patient's environment that may not be immediately available to the hospital care team, including the following:
• Interpersonal interactions at the scene:
  • Embarrassment
  • Shame
  • Fear of reprisal, abandonment, and/or institutionalization
• Conditions in the physical environment that present a potential danger

Initial Stabilization/Therapy

• ABCs
• Treat life-threatening medical/traumatic conditions as appropriate

Ed Treatment/Procedures

• May require separation of the patient and the caregiver or family member
• Utilization of interprofessional/multidisciplinary team where available
• Social work referral:
  • Safety planning
  • Respite planning for caregiver
  • Adult protective services referral
• Competent elder patients are free to accept or decline treatment or disposition despite risks they may incur
• General measures appropriate to the medical/traumatic conditions identified, including:
  • Fluids
  • Medications
  • Surgery
  • Diet
  • Activity
  • Nursing care
  • Physical therapy
  • Psychiatric/psychological support

Disposition

• Medical condition requiring admission
• Abuse or neglect renders home conditions unsafe
• Need for more information or time to enhance objective decision making and patient management

• Medical condition(s) addressed
• Safe environment available
• Abuse or neglect successfully countered by social services and/or law enforcement

• Virtually all states have mandatory reporting requirements:
  • Comply with area legal requirements
• Alcohol/drug treatment as appropriate
• Notify adult protective services

Follow-Up Recommendations

As appropriate for medical condition(s)