Basics

Description

Elder abuse may include the following:
  • 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:
    • Behaviors by a patient or caregiver that compromise the patient's health or safety
    • Failure to provide adequate food, shelter, hygiene, and/or medical attention

Epidemiology

Incidence and Prevalence Estimates
  • In the US., 1–2 million cases age 65 or older mistreated by someone on whom they depend (these numbers likely will increase in the near term as US age demographics shift):
    • 55% neglect
    • 14.6% physical mistreatment
    • 12.3% financial exploitation
    • 7.7% emotional mistreatment
    • 0.3% sexual abuse
    • 6.1% all other types
    • 4% unknown
  • Family members, including partners and adult children, are perpetrators in approximately 90% of cases
  • For every case of financial exploitation reported, 25 cases likely unreported
  • Elder abuse (even modest abuse) is associated with a 300% greater risk of death 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

Diagnosis

Signs and Symptoms

Variable, possibly inconsistent, history or physical findings

History
  • 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
  • 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    • Withdrawn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

Physical Exam
  • Inconsistent findings:
    • Patterns or variable-age bruises, burns, lacerations/abrasions
    • Unusual sites of bruising (inner arm, torso, buttocks, scalp)
    • Poor hygiene (inadequate care of skin, nails, teeth)
  • 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

Diagnostic Tests and Interpretation

Perform any exam and lab or radiographic studies as indicated by the patient's condition.

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
  • 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

Diagnostic Tests and 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

Treatment

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
  • 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

Ongoing Care

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 enhance objective decision making and patient management

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

Issues for Referral
  • Many 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 elder patient offers the best possibility of diagnosis and successful intervention.
  • Only ∼1/3 of healthcare providers identified a case of elder abuse in the past year.
  • 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 seek to decline an elder abuse/neglect investigation.

Additional Reading

Codes

ICD-9

  • 995.80 Adult maltreatment, unspecified
  • 995.81 Adult physical abuse
  • 995.82 Adult emotional/psychological abuse
  • 995.83 Adult sexual abuse
  • 995.84 Adult neglect (nutritional)
  • 995.85 Other adult abuse and neglect

ICD-10

  • Adult physical abuse, confirmed, initial encounter
  • Adult psychological abuse, confirmed, initial encounter
  • Unspecified adult maltreatment, confirmed, initial encounter
  • Adult sexual abuse, confirmed, initial encounter
  • Adult neglect or abandonment, confirmed, initial encounter

SNOMED

  • 95921002 elderly person maltreatment (event)
  • 242041001 Emotional abuse of elderly person
  • 242040000 Physical abuse of elderly person
  • 242042008 Deprivation of nourishment of elderly person
  • 242043003 Abandonment of elderly person

Authors

Helen Straus


© Wolters Kluwer Health Lippincott Williams & Wilkins

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