Elder Abuse Clinical Presentation

The American Medical Association recommends that doctors routinely ask geriatric patients about abuse, even if signs are absent.^[4] However, no randomized trials have been performed of elder abuse screening in asymptomatic populations to support this practice. Much remains to be done to achieve consensus on what constitutes an appropriate screen or assessment instrument for detecting elder abuse. The lack of research in the field of elder mistreatment has hindered the evolution and development of helpful instruments, as performance characteristics have not been validated across an array of clinical settings, populations, and healthcare providers.

Substantial evidence exists for the following risk factors of elder abuse:

• Shared living situation with abuser, likely due to an increased opportunity for contact
• Dementia
• Social isolation
• Pathologic characteristics of perpetrators such as mental illness and alcohol misuse

Healthcare providers should keep these "red flags" in mind in all interactions with elder patients. They indicate that a more in-depth history should be taken. However, even without these indicators, maintaining a high index of suspicion is important.

Some general recommendations when evaluating a patient for possible elder abuse include keeping questions direct and simple and asking in a nonjudgmental or nonthreatening manner. It is also helpful to interview the patient and caregiver together and separately to detect disparities offering clues to the diagnosis of abuse.

Accurate and objective documentation of the interview is essential. Documentation of all findings may be entered as evidence in criminal trials or in guardianship hearings. Documentation must be complete, thorough, and legible. It is helpful to quote direct statements made by the patient.

In a systematic summary of the published work on forensic markers of elder abuse with respect to physical findings, there is a paucity of primary data. Most research on clinical findings purported to be common in elder abuse derives from anecdotes, case reports, or small case series. As a result, consider abuse in the differential diagnosis of every elderly person entering the ED.

Thoroughly disrobe the patient to evaluate for unexpected injuries. Roll the patient to evaluate for back injuries and/or decubitus ulcers.

Although not guided strongly by evidence, a number of clinical findings and observations make elder abuse a strong possibility, including the following:

• Several injuries in various stages of evolution
• Unexplained injuries
• Delay in seeking treatment
• Injuries inconsistent with history
• Contradictory explanations given by the patient and caregiver
• Laboratory findings indicating underdosage or overdosage of medications
• Bruises, welts, lacerations, rope marks, burns
• Venereal disease or genital infections
• Dehydration, malnutrition, decubitus ulcers, poor hygiene
• Signs of withdrawal, depression, agitation, or infantile behavior

During the physical examination, note the size, shape, and location of all injuries. Incorporate the use of body maps/charts in cases of extensive injuries. Photographing the injuries is helpful for forensic documentation.

Many theories have been developed to explain abusive behavior toward elderly people. Clearly, no single answer exists to explain behavior in an abusive relationship. A number of psychosocial and cultural factors are involved.

Theories of the origin of mistreatment of elders have been divided into 4 major categories, as follows: physical and mental impairment of the patient, caregiver stress, transgenerational violence, and psychopathology in the abuser.

Physical and mental impairment of the patient

Recent studies have failed to show direct correlation between patient frailty and abuse, even though it had been assumed that frailty itself was a risk factor for abuse.

Physical and mental impairment nevertheless appear to play an indirect role in elder abuse, decreasing seniors' ability to defend themselves or to escape, thus increasing vulnerability.

Caregiver stress

This theory suggests that elder abuse is caused by the stress associated with caring for an elderly patient, compounded by stresses from the outside world.

The effect of stress factors (eg, alcohol or drug abuse, potential for injury from falls, incontinence, elderly persons' violent verbal behavior, employment problems, low income on the part of the abuser) may all culminate in caregivers' expressions of anger or antagonism toward the elderly person, resulting in violence.

This theory, however, does not explain how individuals in identically stressful situations manage without abusing seniors in their care. Stress should be seen more as a trigger for abuse than as a cause.

Transgenerational violence

This theory asserts that family violence is a learned behavior that is passed down from generation to generation. Thus, the child who was once abused by the parent continues the cycle of violence when both are older.

Psychopathology in the abuser

This theory focuses on a psychological deficiency in the development of the abuser. Drug and alcohol addiction, personality disorders, mental retardation, dementia, and other conditions can increase the likelihood of elder abuse. In fact, family members with such conditions are most likely to be primary caretakers for elderly relatives because they are the individuals typically at home due to lack of employment.

Other risk factors in abuse are (1) shared living arrangements between the elder person and the abuser, (2) dependence of the abuser on the victim, and (3) social isolation of the elder person.