Elder abuse is an act or omission resulting in harm to the health or welfare of an elderly person. Three key groups have published definitions of elder abuse.^1,2,3 Although the incidence of elder neglect and abuse is unknown and widely felt to be underreported, the rate of different types of abuse among the elderly has been estimated to be in the mid-single digits, or between 500,000 and 1 million U.S. adults.^4,5 Table 295-1 summarizes the categories of elder abuse.

PHYSICAL ABUSE

Physical abuse is the most easily recognized form of elder abuse. It is defined as the use of physical force that might result in bodily injury, physical pain, or impairment. Pushing, slapping, burning, striking with objects, and improper use of restraint are all examples of physical abuse. Chemical restraint (such as intentional overmedication or administration of tranquilizers) is a more subtle form. Regardless of mechanism, physical abuse is carried out with the intention of causing suffering, pain, or other physical impairment to the abused person.

CAREGIVER NEGLECT

Elder neglect is the most common form of elder maltreatment, accounting for more than half of all elder maltreatment cases reported to adult protective services agencies annually.⁶ Elder neglect is defined as the failure of a caregiver to provide basic care to a patient and to provide goods and services necessary to prevent physical harm or emotional discomfort.^7,8 Examples of neglect include deprivation of food, clothing, hygiene, medical care, shelter, or supervision that a prudent person would consider essential for the well-being of another.^7,8

Elder neglect is both underrecognized and potentially lethal. It likely accounts for the majority of cases of unreported abuse.⁹ It is also an independent risk factor for mortality, even taking into account that the deaths themselves may not be immediately ascribed to injury.⁶ Elder neglect may be difficult to diagnose. Although some cases may be obvious (such as in a patient with multiple deep pressure ulcers), it is often more subtle and difficult to detect.

SEXUAL ABUSE

Sexual abuse is broadly defined as nonconsensual sexual contact of any kind with an elderly person. The spectrum of sexual abuse ranges from unwanted touching, indecent exposure, or unwanted innuendo, to rape itself. Although sexual abuse is underreported across all age groups, in the elderly, sexual abuse is even less likely to be reported. Fear of retaliation and shame on the part of patients, as well as stereotyping of older patients as asexual or not sexually desirable by clinicians, police, and others, may be factors in underrecognition and underreporting of sexual abuse.¹⁰

FINANCIAL OR MATERIAL EXPLOITATION

Financial abuse is estimated to be the second most common form of elder abuse, accounting for approximately 20% to 30% of abuse cases.¹¹ Financial or material exploitation is the illegal or improper use of an elder’s funds, property, or assets.¹² It occurs when family members, caregivers, or friends take control of the elder person’s resources. Coercion or outright theft may occur, with or without the awareness of the elder person experiencing abuse. An elderly person may unwittingly sign over access to savings accounts and other assets when he or she is in an incapacitated state. Social Security checks or pensions may be used by caregivers for personal gain. Theft may be blatant or coerced, with forcible transfer of property, including changing of the elder’s will. Abuse may result in a decrease in the standard of living and an inability to pay bills, purchase food, or obtain medications.

EMOTIONAL OR PSYCHOLOGICAL ABUSE

Emotional or psychological abuse is defined as the infliction of anguish, emotional pain, or distress. Examples of psychological and emotional abuse include verbal threats (such as threats of violence, institutionalization, or deprivation), humiliation, intimidation, and harassment. Social neglect and isolation are also forms of abuse. Psychological and emotional abuse can contribute to the development and worsening of mental health problems such as depression, which is common in many older victims.¹²

ABANDONMENT

Abandonment constitutes the desertion of an elderly person by an individual who is that person’s custodian or who has assumed responsibility for providing care to the elder. Desertion of an elder in the home, hospital, nursing facility, shopping mall, or other public location may occur.

SELF-NEGLECT

Self-neglect includes those behaviors of an elderly person that threaten his or her own safety. Such behaviors include failure or unwillingness to provide adequate food, clothing, shelter, medical care, hygiene, or social stimulation for oneself. It is the result of an adult’s inability, due to diminished capacity, to perform essential self-care tasks. By definition, this applies to one who understands the consequences of his or her choices and makes a conscious decision to engage in acts that threaten his or her own health or safety.¹³ Patients who have cognitive impairment or who are living in poverty are at greater risk of self-neglect and may have increased mortality.⁹

RISK FACTORS

An awareness of risk factors is important for the recognition of potential victims of elder abuse or neglect. Risk factors can be divided into two categories: factors associated with the elders and factors associated with the perpetrators (Table 295-2).^{7,13,14,15,16,17}

Patient characteristics associated with a higher risk for elder mistreatment are cognitive impairment, physical dependency, lack of social support, alcohol abuse, female sex, and a history of domestic violence.¹⁴ In addition, developmental disabilities, special medical or psychiatric needs, and difficult behavior (such as aggression or verbal outbursts) also increase the risk for abuse. Individuals with limited experience in managing finances are at increased risk for financial or material exploitation. Although elder abuse is more common in residential than institutional settings, institutionalization is also recognized as a risk factor for neglect and abuse.^7,16

Three characteristics of perpetrators have been identified as risk factors: a history of mental illness and/or substance abuse, excessive dependence on the elder for financial support, and a history of violence within or outside of the family.¹⁷ Abusers are most often the primary caregiver. Adult children tend to be more inclined to abuse than are spouses, and males engage in abuse more often than females.¹³ Caregivers may be well intentioned but simply overwhelmed by the amount of care required. They may themselves be impaired by mental or physical problems that serve as barriers to the provision of adequate care.

HISTORY

The approach to the patient interview is important. Potential sufferers of abuse should be interviewed in private. The presence of caregivers, family, or friends may cause the patient to feel intimidated or embarrassed, which limits the amount and accuracy of information obtained. Try to put the patient at ease by making the assessment seem like a routine part of the evaluation.¹² Separately interview individuals accompanying the patient. Screening tools are available to aid in the detection of elder abuse.^18,19,20 The use of lengthier tools is not feasible in a busy ED, but the American Medical Association has proposed a list of nine screening questions that may be more practical to implement (Table 295-3). An affirmative answer to any of the questions in this screening tool raises concern and mandates further exploration.

During the interview, be prepared to recognize behavioral signs and symptoms that suggest elder abuse. These include depression, fear, withdrawal, confusion, anxiety, low self-esteem, and helplessness. Other history-related indicators that suggest abuse or neglect include a pattern of “physician shopping,” unexplained injuries inconsistent with medical findings, and recurrent visits for similar injuries. Additional history taking should explore risk factors for abuse as outlined earlier in “Risk Factors.”