eMedicine Specialties > Emergency Medicine > Psychosocial

Elder Abuse

Monique I Sellas, MD, Staff Physician, Department of Emergency Medicine, Massachusetts General Hospital; Clinical Instructor, Harvard Medical School
Laurel H Krouse, MD, Staff Physician, Department of Emergency Medicine, Paoli Hospital

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.

Differential Diagnoses

Other Problems to Be Considered

Apathy
Dehydration
Falls
Gait disturbances
Pathologic fractures

Workup

Laboratory Studies

• Evaluate for evidence of infection, dehydration, electrolyte abnormalities, malnutrition, improper medication administration, and substance abuse in patients who have been abused.
  • CBC
  • Chem-7
  • Urinalysis
  • Calcium, magnesium, phosphorus
  • Serum levels of relevant medications
  • Urine drug screen
  • Ethanol level

Imaging Studies

• X-rays of relevant body parts - To detect fractures (unusual or pathologic)
• Head CT scan - To detect intracranial bleeding as a result of abuse or to detect a possible explanation for injuries (hydrocephalus causing ataxia leading to falls) or altered mental status

Procedures

• Pelvic examination with forensic evidence collection in cases of sexual assault

Treatment

Emergency Department Care

Medical visits are often the only times victims leave their homes or are allowed out by the abuser. Because older adults do not usually self-report instances of elder abuse, the responsibility for identification, reporting, and intervention rests largely with healthcare professionals, social service agencies, and police departments.

Many factors are involved in the management of older persons who have been abused, including immediate care, long-term assessment and care, education, and prevention.

Elder abuse and neglect are not problems that can be assessed quickly. Intervention can be a lengthy process, especially in a busy ED. Due to the wide variations of types of abuse, interventions vary from simple social service referral to the extreme of removing the patient from the home. The clinician's highest priority in suspected abuse cases is in balancing the safety versus the autonomy of the patient. The ultimate goal is to provide the aging adult with a more fulfilling and enjoyable life.

Once it is suspected, elder mistreatment should be reported to adult protective services. However, most healthcare professionals feel unprepared to fulfill this role, lacking guidance on how to proceed. Most hospitals have no protocols for identifying or addressing elder abuse; therefore, even if the physician did recognize a case, he or she may not know the proper management involved. The NCEA web site is a valuable tool in identifying state-specific resources to assist in the reporting of elder abuse to the appropriate authorities.

More research on elder mistreatment is needed to inform practice. Despite the need for more data on interventions, a reasonable approach is a multidisciplinary one, specifically tailored to the situation, ideally involving multiple team members with varied expertise. The multidisciplinary team should include physicians, nurses, office-based social workers, community-based social workers, visiting nurses, and Adult Protective Services case workers.

Immediate care in the emergency department focuses on treating the physical manifestations of abuse and assuring the safety of the patient. This may include the following:

• Admitting the patient to the hospital
• Obtaining a court protective order
• Placing the patient in a safe home
• Permitting return home if the patient has the capacity to make an informed decision and refuses intervention

Referral to social services and Adult Protective Services are also vital to decrease morbidity and mortality and to further guide patient care after the ED encounter.

Consultations

• Psychiatry consultation - For patients who are demented, depressed, suicidal, disoriented, or to determine issues of capacity
• Geriatrics consultation - For specialized care of the geriatric patient
• Neurology or neurosurgical consultation - For patients with focal neurological findings, or intracranial injuries
• Orthopedics consultation - For patients with fractures

Medication

No specific medication is used to treat elder abuse. Avoid anxiolytics and hypnotics because they make patients less able to defend themselves against acts of abuse.

Follow-up

Further Outpatient Care

• Long-term assessment and care vary with the needs of the patient. Assessment usually involves a visit to the home to evaluate the patient's functional status, living environment, and the condition of the caregiver. The services needed to optimize the care of the patient can be determined only after a home visit.
  • In a descriptive study of in-home geriatric assessment in two New Jersey counties, it was discovered that this assessment was able to contribute at least one relevant intervention for 81% of referred adult protective services (APS) clients to collaboratively help mitigate elder mistreatment circumstances.⁵ This underscores the importance of referral to the appropriate services and agencies.
• Stress to competent patients who refuse help that abuse rarely resolves—it usually escalates. Inform patients that a number of agencies can provide help; provide phone numbers and addresses of these agencies. Develop safety and follow-up plans before the patient leaves the ED.

Patient Education

National Committee for the Prevention of Elder Abuse

National Adult Protective Services Association

The National Center for Victims of Crime

National Center on Elder Abuse

U.S. Administration on Aging - Eldercare Locator 
1-800-677-1116

Miscellaneous

Medicolegal Pitfalls

• No federal statute is specifically dedicated to preventing the mistreatment of elderly persons similar to those targeted at child abuse and domestic violence. Currently, elder abuse is defined by state laws, but state definitions vary considerably from one jurisdiction to another. They contain multiple sections regarding who is protected, who must report, definitions of reportable behavior, requirements for investigation of reports, penalties, and guardianship.
• Mandatory reporting laws for healthcare providers exist in all 50 states and the District of Columbia for confirmed cases of elder abuse and 43 states mandate reporting of suspected cases. Cases of suspected elder abuse should be reported to Adult Protective Services.
• Thirty states have penalties for failing to report suspected elder abuse, and some states require that licensed professionals who have not fulfilled their obligations to report elder abuse can be reported to the appropriate licensing authority.
• Every state has at least one statute providing immunity from civil or criminal liability to anyone who makes a report of abuse in good faith.
• Physicians must educate themselves concerning the laws, legislation, and channels for reporting abuse in their province.
• Mandatory reporting of elder abuse in competent patients is a controversial topic.
  • Many feel that mandatory reporting of abuse of mentally competent victims of elder abuse disempowers the abused individual.
  • The laws created for elder abuse were based upon child abuse laws; therefore, the inability of patients to make decisions in their own best interests was presumed. The laws are weak on matters such as financial abuse, since children generally have no money to exploit.
• Nonetheless, while the state laws are not perfect, a diagnosis of elder abuse is reportable.

Special Concerns

• Barriers to recognizing and reporting elder abuse also must be addressed. The lack of uniform definitions has been a major obstacle. Conceptual problems in defining elder abuse have hampered clinical, educational, and research efforts.
• Various factors serve as barriers to reporting elder abuse. These include lack of knowledge, denial, ageism, fear of making the situation worse, desire to maintain family relationships, fear of ending up in court, or lack of belief that the situation will improve. The key to eradicating these barriers is education that increases both public and professional awareness.
• Increasing awareness is considered instrumental in the prevention of elder abuse. Services for seniors, such as meals on wheels, home health care, homemaker, and chore services, are thought to aid in abuse prevention, although preventing elder abuse needs further study.

References

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Keywords

elder mistreatment, elder abuse, elderly abuse, domestic violence, abusive relationship, elder neglect, self-neglect in elderly persons, elder abuse prevention

Contributor Information and Disclosures

Author

Monique I Sellas, MD, Staff Physician, Department of Emergency Medicine, Massachusetts General Hospital; Clinical Instructor, Harvard Medical School
Monique I Sellas, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Laurel H Krouse, MD, Staff Physician, Department of Emergency Medicine, Paoli Hospital
Disclosure: Nothing to disclose.

Medical Editor

Steven A Conrad, MD, PhD, Chief, Department of Emergency Medicine; Chief, Multidisciplinary Critical Care Service, Professor, Department of Emergency and Internal Medicine, Louisiana State University Health Sciences Center
Steven A Conrad, MD, PhD is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American College of Emergency Physicians, American College of Physicians, International Society for Heart and Lung Transplantation, Louisiana State Medical Society, Shock Society, Society for Academic Emergency Medicine, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert Harwood, MD, MPH, FACEP, FAAEM, Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine
Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP, Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, University Hospitals, Case Medical Center
Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Clinical guidelines

Elder abuse prevention. Daly JM. Elder abuse prevention. Iowa City (IA): University of Iowa Gerontological Nursing Interventions Research Center, Research Dissemination Core; 2004 Dec. 68 p

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