Elder Abuse Treatment & Management

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.

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.

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.

• 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