Elder abuse affects many older adults and can be life threatening. Older adults both in the community and long-term care facilities are at risk. An emergency department visit is an opportunity for an abuse victim to seek help. Emergency clinicians should be able to recognize the signs of abuse, including patterns of injury consistent with mistreatment. Screening tools can assist clinicians in the diagnosis of abuse. Physicians can help victims of mistreatment by reporting the abuse to the appropriate investigative agency and by developing a treatment plan with a multidisciplinary team to include a safe discharge plan and close follow-up.
Key points
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Emergency physicians should consider elder abuse and neglect when evaluating older adults in the emergency department (ED), because these conditions are both common and dangerous.
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The utilization of elder abuse screening tools in the ED can increase the detection of elder mistreatment.
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ED clinicians are mandatory reporters of suspected elder abuse in most US states. In addition to reporting suspected mistreatment, an ED physician should ensure a patient’s safety and utilize a multidisciplinary team if available to develop a treatment plan for vulnerable older adults.
Background
Emergency medicine clinicians are trained to identify and treat life-threatening medical conditions. Although elder abuse is difficult to diagnose and challenging to treat and prevent, physicians must be trained to address this morbid and potentially mortal condition. Elder mistreatment is defined as action or negligence against an older adult that causes harm or risk of harm committed by a person in a relationship with an expectation of trust or when an older person is targeted based on age or disability. Several different types of maltreatment exist ( Table 1 ), and each poses different diagnostic and treatment hurdles to physicians. Approximately 10% of Americans over the age of 65 experience some form of mistreatment.
| Type | Definition | Examples |
|---|---|---|
| Physical abuse | Intentional use of physical force that may result in bodily injury, physical pain, or impairment |
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| Sexual abuse | Any type of sexual contact with an elderly person that is nonconsensual or sexual contact with any person incapable of giving consent |
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| Neglect | Refusal or failure to fulfill any part of a person’s obligations or duties to an elder, which may result in harm—may be intentional or unintentional |
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| Emotional/psychological abuse | Intentional infliction of anguish, pain, or distress through verbal or nonverbal acts |
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| Abandonment | Desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder or by a person with physical custody |
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| Financial/material exploitation | Illegal or improper use of an older adult’s money, property, or assets |
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| Self-neglect | Behavior of an older adult that threatens his/her own health or safety—excluding when an older adult who understands the consequences of his or her actions makes a conscious and voluntary decision to engage in acts that threaten his/her health or safety |
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Most older adults live at home, with approximately 95% of older people living either independently or with their spouses, children, or other relatives, rather than in institutions. Therefore, the home is where most elder abuse occurs. As older adults age in place, the increased dependency on others for care that occurs for some puts them at higher risk for abuse. Victims of elder abuse most commonly are female and older than age 74. , Some studies also suggest victims of abuse are more likely to have mental health disorders. Cognitive impairment also increases a person’s risk for abuse, with older adults diagnosed with dementia approximately 5 times as likely to experience abuse than those without this diagnosis. , Social isolation also increases risk dramatically whereas a strong social support system is protective against elder abuse.
Elder abuse is perpetrated most commonly by someone close to the victim, frequently a male spouse or adult child. Mental illness, substance abuse, and financial dependency on the victim make someone more likely to commit abuse.
Although a small percentage (4.5%) of older adults live in nursing facilities, many will at some point in their lives (35%). A paucity of data exists to describe the prevalence of abuse in long-term care facilities, but experts believe and studies suggest it may be higher than in the community. There are two types of abuse that exist in nursing facilities: staff-to-resident abuse and resident-to-resident abuse. In resident-to-resident abuse, two forms of mistreatment are occurring simultaneously—the abuse itself and neglect by staff members who are not supervising effectively to prevent these events.
Despite popular perception, resident-to-resident abuse actually may be more prevalent than staff-to-resident abuse at nursing facility. This may be, due to the number of nursing residents with cognitive impairments, such as dementia and related behavioral disturbances. Page and colleagues report a 20.2% 1-month prevalence of resident-to-resident elder mistreatment. Although most cases of elder abuse revolve around the perpetrator’s intent, in these cases, the abuser frequently is confused and both the victim and the abuser may suffer harm from the encounter.
Outcomes of abuse
The effects of elder abuse are far-reaching. Older adults who suffer from abuse have worse outcomes from preexisting health conditions and are more likely to be placed in a long-term care facility. All types of abuse increase the risk of depression and anxiety, and abuse victims may have an increased risk for thoughts of suicide compared with unexposed peers. Given this fact, abuse victims use more behavioral health services than other older adults. Physical abuse victims experience physical pain and may sustain injuries, including fractures, wounds, and head injuries. Most importantly, studies repeatedly have shown victims of abuse have a higher risk of mortality than older adults who have not been victimized. Older people exposed to abuse are more likely to utilize an emergency department (ED) and to require hospitalization, because they are less likely to have a primary care doctor and may suffer from acute injury. Therefore, the direct health care expenditures associated with this phenomenon are significant.
Identifying elder abuse and neglect in the emergency department
History
When obtaining a history from an older adult, it is important to interview the patient both with and without the caregiver present, especially if there is concern for abuse or neglect. The patient may be less forthcoming with reports of mistreatment if the caregiver remains in the room during the history-taking. If the patient presents to the ED for evaluation of a trauma, the physician should ask the patient directly if they were hit, punched, kicked, pushed, or struck. Patients with cognitive impairment can be poor historians, but studies suggest that even patients with some cognitive deficits can report mistreatment reliably. Emergency practitioners should not rely solely on their history-taking to identify signs of elder abuse and neglect. While obtaining the history, the emergency clinician should be perceptive of any signs of tension between the patient and the caregiver ( Box 1 ).
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Older adult and caregiver provide conflicting accounts of events
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Caregiver interrupts/answers for the older adult
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Older adult seems fearful of or hostile toward caregiver
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Caregiver seems unengaged/inattentive in caring for the older adult
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Caregiver seems frustrated, tired, angry, or burdened by the older adult
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Caregiver seems overwhelmed by the older adult
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Caregiver seems to lack knowledge of the patient’s care needs
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Evidence that the caregiver and/or older adult may be abusing alcohol or illicit drugs
A Critical Role for Other Health Care Team Members
Other members of the care team also can provide valuable data. Emergency medical service (EMS) providers, including paramedics, have the unique advantage of seeing inside a patient’s home and can comment on habitability and availability of resources, such as food and medication. These professionals sometimes develop relationships with patients who frequently use their services and can report signs of physical decline or worsening living conditions to the care team in the ED. Physicians should utilize the EMS perspective when evaluating patients with other suggestions of abuse or neglect.
Nursing staff are likely to spend more time with patients and their caregivers in the ED. As such, they can relay their observations of the interactions between these two parties and may pick up on subtle signs of mistreatment. Nurses and patient care technicians also perform a majority of the personal care tasks for patients in the ED and may be better positioned to notice soiled clothing, poor hygiene, nonhealing wounds, or other clues of abuse. By educating ED nursing and support staff about the prevalence of abuse and neglect in this population and informing them of the signs and symptoms, physicians can encourage an open dialogue and improve the chances of detection of mistreatment in the ED. Social workers working in the ED, who are trained to assess for abuse and interpersonal violence and provide resources and referrals, should evaluate older adult patients if any concern for mistreatment exists. Their perspective can inform the level of suspicion and appropriate next steps.
Physical Signs
Physical abuse may be the most amenable form of abuse to detection in the ED, but the diagnosis remains challenging because geriatric patients are prone to unintentional injuries and normal aging processes can mimic abuse. When examining an older person after a trauma, clinicians should look for signs of injury that are not typical of accidental trauma ( Box 2 ).
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Injuries in the maxillofacial, dental, and neck areas and the upper extremities
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Injuries to the head and neck without injury to other parts of the body—a fall usually results in other signs of injury to extremities, back, or trunk.
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Neck injuries—the head and shoulders typically protect the neck from injury in a fall.
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Ear injuries—ear injuries typically are not seen in falls and are very concerning for nonaccidental trauma.
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Left-sided facial injuries—many abusers are right-handed and punches or hits affect the left side of the victim’s face.
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Ligature marks
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Bruises larger than 5 cm or in the shape of objects
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