Abuse, Elder

Basics

Description

Elder abuse is an act(s) by a trusted caregiver that causes harm or distress to an elderly individual. Examples of various forms may include:

  • Psychological abuse (also called emotional abuse):
    • Acts done with intent to cause emotional pain or injury
  • Sexual assault
  • Physical abuse:
    • Acts done with intent to cause physical pain, including things like inappropriate restraining
  • Material exploitation:
    • Misappropriation of property or funds
  • Neglect:
    • Failure to meet needs of the individual such as withholding medical care

Epidemiology

Incidence And Prevalence

  • Estimated prevalence of 10%. 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-y 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 nonabused)

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

Diagnosis

Signs And Symptoms

Variable, possibly inconsistent, history, or physical findings

History

  • Not willing or able to obtain adequate food, clothing, or shelter
  • Not providing for personal hygiene/safety
  • Delay in obtaining medical care/previously untreated medical condition
  • Undertreated pain may represent medication diversion by caregiver
  • Vague 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 violent history
    • Controlling behavior (may refuse to leave elder alone with physician) or poor knowledge
    • Significant life stressors
    • Relationship issues
    • Financial difficulties
    • Legal problems

Physical Exam

  • 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 as possible neglect or attempted harm

Essential Workup

  • Obtain history without 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 (eg, 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 support systems
      • Drug and alcohol use
      • Prior adult protective services reports
    • Skin and other physical findings:
      • Photographic documentation
      • Safety assessment

Diagnosis Tests And Interpretation

As appropriate for medical condition(s)

Imaging

As appropriate for medical condition(s)

Diagnostic Procedures/Surgery

As appropriate for medical condition(s)

Differential Diagnosis

  • Patient may present with any chief complaint:
    • Potential differential diagnosis are broad and dependent on the specific complaint for that patient
    • 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
    • Trauma
    • Insomnia
    • Medication noncompliance
    • Dementia
    • Depression
    • Socioeconomic disparities
    • Deconditioning

Treatment

Prehospital

  • 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
  • Utilization of interprofessional 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
    • Mental health support

Follow-Up

Disposition

Admission Criteria

Disposition determined by medical condition and home environment:

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

Discharge Criteria

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

Issues For Referral

  • 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)

Pearls And Pitfalls

  • Entertaining the possibility of abuse or neglect in an elderly patient offers the best possibility of diagnosis and successful intervention
  • Current data are inconclusive about the effectiveness of interventions for diminishing recurrence of elder abuse
  • Obtain the aid of social worker, physicians trusted by the patient, even an ethics consultant, should a vulnerable competent elder decline an elder abuse/neglect investigation
  • Utilize (or help to create) interprofessional/multidisciplinary teams to address elder abuse management

Additional Readings

  1. Connolly M, Brandl B, Breckman R. The elder justice roadmap. https://www.justice.gov/elderjustice/file/829266/download
  2. Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373:1947–1956.  [PMID:26559573]
  3. Peterson JC, Burnes DPR, Caccamise PL, et al. Financial exploitation of older adults: a population-based prevalence study. J Gen Intern Med. 2014;29:1615–1623.  [PMID:25103121]
  4. Rosen T, Elman A, Mulcare M, Stern ME. Recognizing and managing elder abuse in the emergency department. E Med. 2017;49(5):200–207.
  5. Storey, JE. Risk factors for elder abuse and neglect: a review of the literature. Aggress Violent Behav. 2020;50:101339.
  6. World Health Organization. Abuse of older patients. 2024. http://www.who.int/mediacentre/factsheets/fs357/en/

Authors

Michael Hohl

Theresa Kim