eMedicine Specialties > Emergency Medicine > Psychosocial

Elder Abuse

Author: Monique I Sellas, MD, Staff Physician, Department of Emergency Medicine, Massachusetts General Hospital; Clinical Instructor, Harvard Medical School
Coauthor(s): Laurel H Krouse, MD, Staff Physician, Department of Emergency Medicine, Paoli Hospital
Contributor Information and Disclosures

Updated: Apr 20, 2009

Introduction

Background

Over the past 35 years, tremendous strides have been made in identifying and increasing awareness about patterns of abusive relationships. Child abuse and domestic violence have received significantly more recognition than elder abuse and continue to receive more attention in both public and medical domains, although abuse clearly occurs in persons of all ages.

With current medical advances and the adoption of healthier lifestyles, people are living longer. Older Americans now comprise the fastest growing segment of the United States population. According to the US Census Bureau, people 65 years of age and older accounted for 12.5% of the US population in 2000.¹ By the year 2020, this group will increase by 5.5%, and by 2050, older Americans are projected to account for 25% of the population.¹

As a result of the sheer number of older Americans, the number of elder abuse cases will increase, and the impact of elder abuse as a public health issue will grow. Victims of violence have twice as many physician visits compared with the general US population, allowing opportunities for discovery and intervention. Due to the relative isolation of many elders who are mistreated, an unexpected visit to the emergency department may be the only opportunity for detection. Emergency physicians are in a unique position to affect diagnosis and management of this vulnerable population.

Elder mistreatment is a multidimensional phenomenon that encompasses a broad range of behaviors, events, and circumstances. Unlike random acts of violence or exploitation, elder abuse usually consists of repetitive instances of misconduct. It encompasses any act of commission or omission that results in harm or threatened harm to the health and welfare of an older adult.

The US National Academy of Sciences defines elder abuse as follows:

• Intentional actions that cause harm or create a serious risk of harm (whether or not harm is intended), to a vulnerable elder by a caregiver or other person who stands in a trusted relationship to the elder
• Failure by a caregiver to satisfy the elder's basic needs or to protect the elder from harm.

Systematically, the terminology used to describe elder abuse is not consistent. Terms vary among researchers, and usage is not consistent in the laws of different states. Even the age at which a person is considered elderly, usually 60 or 65 years, is debated. Seven categories of elder abuse have been described by the National Center on Elder Abuse (NCEA).² Categories include the following:

• Physical abuse - Any act of violence that causes pain, injury, impairment, or disease, including striking, pushing, force-feeding, and improper use of physical restraints or medication
• Emotional or psychological abuse - Conduct that causes mental anguish including threats, verbal or nonverbal insults, isolation, and humiliation. Some legal definitions require identification of at least 10 episodes of this type of behavior within a single year to constitute abuse.
• Financial or material exploitation - Misuse of an elderly person's money or assets for personal gain. Acts such as stealing (money, social security checks, possessions) or coercion (changing a will, assuming power of attorney) constitute financial abuse.
• Neglect - Failure of a caretaker to provide for the patient's basic needs. As in the previous examples of abuse, neglect can be physical, emotional, or financial. Physical neglect is failure to provide eyeglasses or dentures, preventive health care, safety precautions, or hygiene. Emotional neglect includes failure to provide social stimulation (leaving an older person alone for extended periods). Financial neglect involves failure to use the resources available to restore or maintain the well-being of the aging adult.
• Sexual abuse - Nonconsensual intimate contact or exposure or any similar activity when the patient is incapable of giving consent. Family members, friends, institutional employees, and fellow patients can commit sexual abuse.
• Self-neglect - Behavior in which seniors compromise their own health and safety, as when an aging adult refuses needed help with various daily activities. When the patient is deemed competent, many ethical questions arise regarding the patient's right of autonomy and the physician's oath of beneficence.
• Abandonment - The 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 of an elder.

Frequency

United States

Due to the inconsistencies in the working definitions of elder abuse, differences in sampling and survey methods, and underreporting of cases, obtaining accurate information on the incidence of elder abuse and neglect is difficult. A 2003 report from the National Research Council suggests that 1-2 million Americans age 65 years or older have been injured, exploited, or otherwise mistreated by someone on whom they depended for care or protection.³ Other studies suggest that 3-10% of elders are abused or neglected.

Many factors play a role in the underestimation of the number of abused elders. Patient factors include fear, shame, guilt, or ignorance. Healthcare providers underestimate and underreport elder abuse due to decreased recognition of the problem, lack of awareness of reporting requirements, including who to report to, and concerns about physician-patient confidentiality.

In addition, many studies routinely exclude certain populations such as persons unable to respond to a survey, speakers of languages other than English, and persons with mental illness, further complicating accurate tallies of the number of older persons who are abused. Despite difficulty in identifying the exact frequency of elder abuse, the occurrence is common enough to be encountered regularly in daily clinical practice. As a result, healthcare providers must maintain a high index of suspicion.

Mortality/Morbidity

Elders who are victim to physical abuse, caregiver neglect, or self-neglect have triple the mortality of those never reported as abused. Early detection and intervention by healthcare professionals in elder abuse cases may lead to decreased morbidity and mortality. Healthcare provider involvement is paramount, as studies have shown that only 1 in 6 victims are likely to self-report mistreatment to the appropriate legal authorities.

Race

Elder abuse occurs among members of all racial, socioeconomic, and religious backgrounds. The NCEA found the following racial and ethnic distribution among older persons who had been abused:

• White, non-Hispanic – 66.4%
• Black – 18.7%
• Hispanic – 10%
• Other – 4.9%

Sex

Women are believed to be the most common victims of abuse, perhaps because they report abuse at higher rates or because the severity of injury in women typically is greater than in men. Numerous studies, however, have found no differences based on sex.

Age

By definition, elder abuse occurs in the elderly, although there is no universally accepted definition of when old age begins. Typically, 60 or 65 years is considered the threshold of old age.

Clinical

History

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.

Physical

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.

Causes

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.

• Search for CME/CE on This Topic »

• Domestic Violence (Emergency Medicine)

• Skin, Hair, and Nails Center
• Bruises Overview
• Bruises Symptoms
• Bruises Treatment
• Bruises Causes

• Should Physicians Inform Relatives of Genetic Risks, Without the Consent of the Patient?
• Abuse of Elderly With Dementia by Family Caregivers Common, Survey Suggests

• The Prevalence of Elder Abuse and Neglect: A Systematic Review
• Gender Differences in Coping With Victimization
• Forensic Nursing: Part 2. Inside Forensic Nursing