Elder Abuse Clinical Presentation
- Author: Trevor John Mills, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD, FACEP more...
The American Medical Association recommends that doctors routinely ask geriatric patients about abuse, even if signs are absent. 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
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
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.
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.
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.
Werner, C. The Older Population: 2010. United States Census Bureau. Available at http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf. Accessed: February 25, 2015.
U.S. Population Projections. U.S. Census Bureau: Population Division. August 2008. Available at http://www.census.gov/population/www/projections/summarytables.html.
Sooryanarayana R, Choo WY, Hairi NN. A Review on the Prevalence and Measurement of Elder Abuse in the Community. Trauma Violence Abuse. 2013 Jul 22. [Medline].
National Center on Elder Abuse. Types of abuse. Updated September 28, 2007. Available at http://www.ncea.aoa.gov/NCEAroot/Main_Site/FAQ/Basics/Types_Of_Abuse.aspx. Accessed: April 20, 2009.
Monfort JC, Villemur V, Lezy AM, Baron-Laforet S, Droes RM. From paedophilia to gerontophilia. Lancet. 2011 Jan 22. 377(9762):300. [Medline].
Wagenaar DB, Rosenbaum R, Page C, Herman S. Primary care physicians and elder abuse: current attitudes and practices. J Am Osteopath Assoc. 2010 Dec. 110(12):703-11. [Medline].
Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health. 2010 Feb. 100(2):292-7. [Medline]. [Full Text].
American Medical Association. Diagnostic treatment guidelines on elder abuse and neglect. Chicago, IL: American Medical Association; 1992. 4-37.
Heath JM, Kobylarz FA, Brown M, Castano S. Interventions from home-based geriatric assessments of adult protective service clients suffering elder mistreatment. J Am Geriatr Soc. 2005 Sep. 53(9):1538-42. [Medline].
Allison EJ, Ellis PC, Wilson SE. Elder abuse and neglect: the emergency medicine perspective. Eur J Emerg Med. 1998 Sep. 5(3):355-63. [Medline].
American College of Emergency Physicians. Management of elder abuse and neglect. Policy statement. Ann Emerg Med. Jan 1998. 31(1):149-150. [Medline].
Birrer R, Singh U, Kumar DN. Disability and dementia in the emergency department. Emerg Med Clin North Am. 1999 May. 17(2):505-17, xiii. [Medline].
Carney MT, Kahan FS, Paris BE BE. Elder abuse: is every bruise a sign of abuse?. Mt Sinai J Med. 2003 Mar. 70(2):69-74. [Medline].
Ciccarello MJ. Recent legal trends affecting your older patients. Clin Obstet Gynecol. 2007 Sep. 50(3):790-9. [Medline].
Clarke ME, Pierson W. Management of elder abuse in the emergency department. Emerg Med Clin North Am. 1999 Aug. 17(3):631-44, vi. [Medline].
Dyer CB, Heisler CJ, Hill CA, Kim LC. Community approaches to elder abuse. Clin Geriatr Med. 2005 May. 21(2):429-47. [Medline].
Fulmer T, Guadagno L, Bitondo Dyer C, Connolly MT. Progress in elder abuse screening and assessment instruments. J Am Geriatr Soc. 2004 Feb. 52(2):297-304. [Medline].
Jogerst GJ, Daly JM, Brinig MF. Domestic elder abuse and the law. Am J Public Health. 2003 Dec. 93(12):2131-6. [Medline].
Jones JS, Holstege C, Holstege H. Elder abuse and neglect: understanding the causes and potential risk factors. Am J Emerg Med. 1997. 15(6):579-583. [Medline].
Jones JS, Veenstra TR, Seamon JP, Krohmer J. Elder mistreatment: national survey of emergency physicians. Ann Emerg Med. 1997. 30(4):473-479. [Medline].
Kahan FS, Paris BE BE. Why elder abuse continues to elude the health care system. Mt Sinai J Med. 2003 Jan. 70(1):62-8. [Medline].
Kennedy RD. Elder abuse and neglect: the experience, knowledge, and attitudes of primary care physicians. Fam Med. 2005 Jul-Aug. 37(7):481-5. [Medline].
Kleinschmidt KC. Elder abuse: a review. Ann Emerg Med. 1997 Oct. 30(4):463-72. [Medline].
Koenig RJ, DeGuerre CR. The legal and governmental response to domestic elder abuse. Clin Geriatr Med. 2005 May. 21(2):383-98. [Medline].
Kruger RM, Moon CH. Can you spot the signs of elder mistreatment?. Postgrad Med. 1999 Aug. 106(2):169-73, 177-8, 183. [Medline].
Lachs MS, Pillemer K. Abuse and neglect of elderly persons. N Engl J Med. 1995 Feb 16. 332(7):437-43. [Medline].
Lachs MS, Pillemer K. Elder abuse. Lancet. 2004 Oct 2-8. 364(9441):1263-72. [Medline].
Lachs MS, Williams CS, O'Brien S, et al. ED use by older victims of family violence. Ann Emerg Med. 1997. 30(4):448-454. [Medline].
McDonald AJ, Abrahams ST. Social emergencies in the elderly. Emerg Med Clin North Am. 1990 May. 8(2):443-59. [Medline].
Nelson HD, Nygren P, McInerney Y, Klein J. Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the U. S. Preventive Services Task Force. Ann Intern Med. 2004 Mar 2. 140(5):387-96. [Medline].
Paris BE, Meier DE, Goldstein T, et al. Elder abuse and neglect: how to recognize warning signs and intervene. Geriatrics. 1995 Apr. 50(4):47-51. [Medline].
Profiles of General Demographic Characteristics. 2000 Census of Population and Housing: United States. U.S. Census Bureau: Population Division. May 2001. Available at http://www.census.gov/prod/cen2000/dp1/2kh00.pdf.
Quinn K, Zielke H. Elder abuse, neglect, and exploitation: policy issues. Clin Geriatr Med. 2005 May. 21(2):449-57. [Medline].
Rosenblatt DE, Cho K, Durance PW. Reporting mistreatment of older adults: the role of physicians. J Am Geriatr Soc. 1996. 44:65-70. [Medline].
Swagerty DL, Takayashi PY. Elder mistreatment. American Family Physician. 1999. 59(10):
Tintinalli JE, Ruiz E, Krome RL. Emergency Medicine: A Comprehensive Study Guide. McGraw Hill Text; 1996. 1377-78.