Elder Abuse

AUTHORS

Maegan Reynolds, MD, Clinical Assistant Professor of Emergency Medicine, The Ohio State University, Columbus

Sara Hurley, MD, Emergency Medicine Resident, The Ohio State University, Columbus

PEER REVIEWER

Steven M. Winograd, MD, FACEP, Attending Emergency Physician, Trinity Health, Albany, NY

EXECUTIVE SUMMARY

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Elder abuse is a substantial public health concern with devastating consequences for its victims. The authors highlight the characteristic findings and management strategies to protect our oldest patients.

— Ann M. Dietrich, MD, Editor

Case Study

A 75-year-old woman presents to the emergency department (ED) via ambulance to a trauma center with a head laceration after a fall from standing. On the primary survey, she is confused but able to follow commands and has a Glasgow Coma Scale (GCS) score of 14. The secondary survey reveals scattered bruising over the upper extremities and a Stage 3 sacral decubitus ulcer. Trauma imaging is negative for acute processes, although it does show remote rib fractures. When should you suspect abuse in elder trauma patients? Would routine screening of older adults better allow us to identify and prevent elder mistreatment? What interventions are in place to help patients who are victims of elder abuse? What ethical and legal responsibilities do healthcare providers have to identify and address elder abuse?

Definition

Elder abuse is a global public health concern. The World Health Organization defines elder abuse as a “single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.”¹ The definition of elder abuse or elder mistreatment tends to encompass five major categories: physical abuse, psychological or verbal abuse, sexual abuse, financial exploitation, and neglect.^2-4 (See Table 1.) Abandonment and self-neglect also sometimes are included in the definition of elder abuse, although they will not be the focus of this review. Victims of elder abuse tend to experience multiple types of abuse concurrently.^4,5

Epidemiology

By 2030, one in every five Americans is projected to be age 65 years or older, and the population of Americans age 85 years and older is expected to grow nearly 200% by 2060.⁶ Globally, one in six community-dwelling older adults aged 60 years and older experience mistreatment over the course of a year.⁷ As the population of older adults increases, elder mistreatment also is expected to increase.¹ Increased rates of elder mistreatment already were seen in recent years during the COVID-19 pandemic.⁸

Studies examining the prevalence rate of elder abuse, although they lack consistency in how they measure and define elder abuse, show that elder abuse is a widespread and often underreported public health problem.^3,9,10 One New York study found an incidence rate of elder mistreatment 24 times greater than the number of cases referred to social services or law enforcement.¹¹

In the United States, an estimated 5% to 15% of community-dwelling older adults experience elder mistreatment each year.^12-14 The most commonly reported type of elder abuse in the community is psychological abuse, with sexual abuse being the least commonly reported type of abuse.^3,7 Older adults residing in facilities are at higher risk for elder mistreatment, which may be perpetrated by either facility staff or other residents.^12,15 One meta-analysis of studies from multiple countries found that nearly two-thirds of elderly facility staff self-reported having perpetrated elder mistreatment over the past year.¹⁶

Older adults at higher risk for experiencing mistreatment include those with functional dependence, physical disability, poor physical health, cognitive impairment, poor mental health, and those with lower income or socioeconomic status.³ Other risk factors for individuals experiencing elder mistreatment include older adults who are socially isolated or lack social support, who have a previous history of family violence or previous traumatic event exposure, or who have substance use disorder.⁵ Living with a caregiver but otherwise being socially isolated also is a risk factor for elder abuse.¹⁷

Elder abuse is associated with increased mortality and has been linked to increased disability.^18,19 Elder abuse is associated with increased rates of ED use, increased rates of hospitalization, increased use of behavioral health services, and increased placement in nursing homes.^20-23

Findings Suspicious for Elder Abuse

In pediatrics as well as the field of intimate partner violence, there are certain clinical and radiographic findings that are highly associated with abuse and, thus, should raise provider suspicion for abuse when found on exam.^24-26 Similarly, there may be patterns of injury or forensic markers of abuse in older adults that, when present, should raise suspicion for abuse.^27-29 However, unlike in pediatrics, there are no pathognomonic physical signs of elder abuse, and education on the recognition of elder abuse signs is uncommon for clinical geriatricians and other healthcare professionals.³⁰

However, it can be difficult to distinguish physical exam findings resulting from chronic disease from those resulting from abuse or neglect.³¹ Elder abuse victims may present to the ED for injuries or illnesses unrelated or indirectly related to abuse.³² Neglect and physical abuse are the most common types of abuse detected during an ED visit with subsequent diagnosis of elder abuse.³² The following will briefly review findings on exam or workup that should raise the provider’s and staff’s suspicions for various types of elder abuse. Specific findings that are suspicious for abuse are displayed in Table 2 and in Figure 1.

Physical Abuse

Nearly one-quarter of ED visits by elder abuse victims are related to injury.³³ Two-thirds of injuries in elder abuse are in the upper extremities and maxillofacial region.³⁴ While older adults certainly can have traumatic injuries that are acquired accidentally, certain findings should raise suspicion for a non-accidental etiology of injury. Many patients who are victims of elder abuse initially present reporting a “fall,” emphasizing the need for tools to better identify patients at risk for abuse among the group of older adult patients who present following a fall.³⁵ Victims of elder physical abuse experience more severe injuries than older adult trauma patients who are not abused.¹⁷

Traumatic injuries to areas not commonly injured in daily activity or not commonly injured secondary to accidental trauma should raise suspicion for possible abuse.³⁶ This includes injuries to the ears, neck, axilla, inner ankles and wrists, genitalia, buttocks, inner thighs, and top or soles of the feet.^36,37 Delayed presentations after or remote to the date of injury or not consistent with the given history also are suspicious for possible abuse.^35,36 Bruises on older adults who have been physically abused commonly are significantly larger and more commonly found on the face, lateral aspect of the right arm, and posterior torso compared to bruises on older adults who have not been abused.³⁸ Bruises in multiple stages of healing may be indicative of abuse, although the color of a bruise is not a reliable indicator of the age of the bruise in older adults.^37,39

Specific findings in the upper extremities that should raise suspicion for abuse are contusions and abrasions to the axilla or inner aspects of the arms, which may indicate either being grasped or restrained by the abuser or attempted self-defense.³⁴ Accidental bruises are more commonly seen on flexor surfaces. Studies also have indicated a higher likelihood of abuse with upper extremity injuries above the level of the wrist.³⁵ Specific findings in the head and neck region suspicious for abuse include injuries to the eyes, ears, nose, and mouth, including injury to the buccal mucosa and injuries to the left cheek or zygoma.²⁸ A finding more unique to elder abuse is traumatic alopecia (different distribution of hair loss than that of normal aging).³⁶

Ziminski et al correlated the mechanism of injury with the physical location of bruises in elder abuse victims, comparing the location of bruises in patients who endorsed undergoing a specific mechanism of abuse with the location of bruises in patients who did not report undergoing that specific mechanism of abuse.²⁶ Elder abuse victims who endorsed being choked were more likely to have bruises on the lumbar region, head and neck, and left anterior upper arm compared to victims who were not choked. Victims who endorsed being grabbed were more likely to have bruises on the lateral and/or anterior arm. Victims who endorsed being punched or hit were more likely to have bruises on the head, neck, and right lateral upper arm. Victims who endorsed being beat up were more likely to have injuries on the head and neck. Finally, victims who endorsed being slammed against a wall were more likely to have bruises on the lumbar region. Although the study sample size was small, it is a useful step in highlighting injury patterns present in elder abuse victims.²⁶ Additionally, the location of bruises may indicate more severe underlying injuries, such as posterior rib fracture with back bruises or forearm bruising with distal ulnar styloid fractures.³⁰

Fractures and bruising can result from minimal trauma in older adults because of physiologic changes associated with aging, comorbid conditions, and medications such as blood-thinners, thus making it difficult for healthcare workers to differentiate accidental and non-accidental trauma.³² Careful history taking and review of injuries can help identify when injury patterns do not match the provided history. Subsequently, healthcare team members may be able to distinguish accidental injuries and age-related changes from signs of elder abuse.⁴⁰ Table 3 displays a list of common mimickers of abuse. Providers, nurses, and team members should be aware of these when screening for possible victims of abuse.

Other types of physical elder abuse include force-feeding, which may result in aspiration or choking, improper use of physical or chemical restraints, as well as intentionally inflicted burns.³⁶ In burn injuries, patterns of burns similar to those seen in child abuse may be seen in elder abuse, such as patterns consistent with immersion burns or cigarette burns.⁴¹ Inflicted traumatic head injuries can result in intracerebral hemorrhages. When intracranial bleeds are associated with trauma, they typically are multiple and located on the cerebral surface.³⁶ This pattern is somewhat different than the subdural hemorrhages, which frequently result from accidental falls in the elderly.³⁶

Neglect

Findings that may raise concern for neglect include if the patient is malnourished, dehydrated, or has subcutaneous wasting of tissue. It can be difficult to differentiate whether the cause of these clinical signs is from neglect or from chronic medical conditions, natural aging changes, or frailty.³¹ Patients who have poor hygiene, untreated injuries (including decubitus ulcers), or with improperly treated or untreated medical conditions may be victims of neglect.^31,36 Ulcerations in non-lumbar and non-sacral locations can result from improper restraint or leaving someone in a certain position for an extended period of time. Elder abuse complicates management of chronic disease.³³ Medical neglect can lead to exacerbations of chronic medical diseases, for example, denying an older person with type 2 diabetes insulin may lead to gangrenous diabetic foot wounds.³⁶ However, this can be difficult to differentiate from natural progression of an organic process.

Elder self-neglect is a different public health issue but should be considered in older adult patients presenting to the ED. Self-neglect is defined in the 2010 Elder Justice Act as “the inability, due to physical or mental impairment or diminished capacity, to perform essential self-care.”⁴² Elder self-neglect is associated with higher mortality, poor psychological well-being, and higher healthcare resource utilization. Signs such as hoarding, inadequate nutrition, or inability to pay bills such as gas or electric may be more subtle to detect during clinical visits. However, if suspected, multidisciplinary teams including social workers with community resources may be able to screen elders through home visits for additional signs of self-neglect. In most U.S. states, healthcare professionals also are mandated to report if elder self-neglect is suspected. However, interventions may be limited based on the older adult’s capacity.⁴²

Sexual Abuse

Sexual abuse is the most under-reported type of elder mistreatment.³⁶ Vaginal or anorectal bleeding can be seen in elder sexual abuse. However, traumatic injuries associated with sexual abuse also can present in non-genital areas, including injuries to the hard and soft palate, bite marks, and injuries associated with restraints, asphyxiation, or blunt force trauma. It can be difficult to delineate whether anogenital injuries are caused from abuse or caused from organic disease, since changes associated with aging predispose older adults to anogenital injury.³⁶

Emotional/Psychological Abuse

Potential indicators of psychological abuse include changes in mood, confusion, withdrawal, and depression, as well as unexplained paranoia and agitation.⁴⁰

Financial Abuse

Potential indicators of financial abuse include inability to pay bills or pay for medications, inability to buy necessities, absence of medical supplies including hearing aids, disappearance of property, or making dramatic financial decisions.⁴⁰

Screening for Elder Mistreatment

Historically, identification of victims of elder abuse has been challenging for a variety of reasons. Older adult patients may be unwilling or unable to disclose that they have experienced mistreatment.² They may be unwilling to disclose because of a fear of retaliation, self-denial, embarrassment, or blaming themselves for the abuse.⁴³ Patients may be unable to disclose if they are unable to communicate effectively as a result of other medical conditions such as dementia or because of language or cultural barriers.² It is vital to create a trustworthy, nonjudgmental environment for patients to feel comfortable disclosing abuse, which can be difficult in the time-limited and often chaotic setting of the ED.⁴⁴ Specifically in older adults, signs of abuse may be conflated with chronic medical conditions, leading to both false-positive and false-negative findings on examination of patients.²

Emergency providers and staff have a unique opportunity to identify victims of elder mistreatment. Many victims of elder mistreatment are isolated, and the ED may be the first point of contact for a victim of elder mistreatment.⁴⁰ Additionally, visits to the ED are unplanned, not affording perpetrators or victims time to hide signs of abuse or align stories.⁴⁵ Victims of elder abuse are more likely to use the ED compared to non-abused older adults.²² Patients often spend a significant amount of time with various providers and staff from different specialties, allowing a multitude of opportunities for healthcare workers of different disciplines to screen for or identify signs of elder abuse.⁴⁵

However, emergency providers and team members have a poor track record for identifying elder mistreatment. A 1997 survey of emergency medicine physicians found that 74% of ED physicians were uncertain or did not believe that clear-cut medical definitions of abuse exist. It also found that 58% of physicians were uncertain or did not believe that emergency physicians can accurately identify cases of mistreatment.⁴⁶ A more recent analysis of ED visits in 2012 found that only 0.013% of ED visits by older adults resulted in a diagnosis of elder abuse.³² Physicians and healthcare team members may miss identifying elder mistreatment if they miss signs of abuse or neglect, mis-attribute signs of abuse or neglect to a separate disease process, fail to screen patients for abuse or neglect, or if they are worried about offending the patient or caregiver when inquiring about possible abuse or neglect.⁴³ Physicians and nurses also may fail to report elder mistreatment if they are unaware of available resources or mandatory reporting laws. Healthcare professionals also can be concerned about their own safety, feel constrained by time, or worry reporting may result in older adult patients moving from one undesirable environment to a different undesirable environment in care facilities.^43,47 Multidisciplinary teams that include social workers may assist with screening and reporting patients identified by the healthcare team as being possible abuse victims.

A screening question such as “Do you feel safe at home?” is unlikely to detect elder mistreatment.⁴⁸ Patients may be concerned about being removed from their home if they disclose that they do not feel safe at home. Forms of elder abuse including financial, psychological, and neglect may not be screened for with this question, as they may not affect a patient’s individual sense of safety. Additionally, this question often is asked without removing the patient from their caregiver or family members (who may be the perpetrators) and does not provide a way to screen for abuse in non-cognitively intact patients.⁴⁸ Providers should make sure to interview patients separately from caregivers and to ask the patient to self-describe how the injury occurred.⁵ Even patients with cognitive impairment often can relate how they sustained an injury when asked.^26,38 If the patient and caregiver history of injury do not align, this should raise suspicion for abuse and prompt further investigation by healthcare team members.

There is a clear need for identification of methods to better detect elder abuse in the ED.⁴⁹ There are several screening tools that have been proposed to identify elder mistreatment in a variety of clinical practices.^44,50 A recent review through the Geriatric Emergency Care Applied Research (GEAR) Network identified four screening tools for elder mistreatment for use specifically in the ED.⁵¹ The four tools are: Elder Assessment Instrument (EAI), Identifications of Seniors at Risk (ISAR), Emergency Department Senior Abuse Identification (ED-Senior AID), and Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS).^52-58 There also is an emergency medical services (EMS)-based screening tool developed in 2019 called the Detection of Elder Mistreatment Through Emergency Care Technicians (DETECT).^59,60 In many states EMS personnel are mandatory reporters.

Screening tools differ both in the intended tool assessor as well as how they screen for abuse, with some relying on self-report from patients whereas others focus on clinical observation and inspection for signs of abuse.⁵³ The ISAR primarily focuses on identifying older people at increased risk of abuse.⁵⁴ Brief cognitive screens included in screening tools can help differentiate patients who are able to self-report abuse from patients who must be inspected for signs of abuse.⁴⁸ Targeted screening may be theoretically advantageous compared to universal screening because of decreased need for resources; however, targeted screening is more likely to miss cases of elder abuse.⁴⁸ Any screening that is instituted in the ED must be weighed against the potential harms of falsely identifying elder abuse. It is suggested that screening tools in the ED should be used to identify patients as possible victims, thus triggering additional assessment by a multidisciplinary team to determine whether there is indeed suspicion of elder abuse.³² In 2018, the United States Preventive Services Task Force concluded that evidence is insufficient to recommend universal screening for elder mistreatment or to assess the balance of benefits or harms of screening for abuse or neglect in elderly patients.⁶¹ Further research is needed to assess whether screening improves outcomes for victims of elder abuse, as well as to identify best practices in screening for elder abuse and preventing adverse outcomes.^51,62

Interventions

In recent years, there has been an increased focus on creating and implementing interventions to identify and prevent elder mistreatment. Possible avenues for interventions include educating healthcare professionals about elder mistreatment as well as the development of multidisciplinary teams to assist in identifying elder abuse.⁴⁵ A recent review of interventions found the majority of currently available interventions target educational programs or developing multidisciplinary teams.⁶³ These interventions may be particularly helpful when cases do not meet criteria for referral to Adult Protective Services but additional resources could be helpful to assist older patients.⁴⁵ However, there remains a lack of adequate evidence to assess the effects of interventions in preventing the occurrence or recurrence of elder mistreatment.¹⁰ Educational interventions may improve detection of elder abuse, but there is very low-quality evidence on whether targeted educational interventions improve relevant knowledge of health professionals and caregivers.¹⁰ Geriatric Emergency Department Guidelines, developed in collaboration with the American College of Emergency Physicians (ACEP), American Geriatrics Society, Emergency Nurses Association (ENA), and the Society for Academic Emergency Medicine (SAEM), recommend that trainee and continuing education should include content on elder abuse and neglect.⁶⁴ However, there is no evidence-based method on the best way to educate providers and staff or implement educational interventions.¹⁰

Rosen et al developed and described the Vulnerable Elder Protection Team (VEPT) in 2017 as a consultation service in the ED.⁶⁵ To begin, ED providers were provided training about elder abuse. When ED providers suspected elder abuse, they placed a VEPT consult, allowing a multidisciplinary team including a separate geriatric ED provider and social worker to further assess for possible mistreatment.⁶⁵ In an initial assessment of the first two years of the program, 62% of patients assessed by VEPT were found to have high or moderate suspicion for elder abuse.⁶⁶ Not only did VEPT increase the identification of elder abuse, it also allowed for interventions to take place both on the inpatient side and through collaboration with community partners. The intervention succeeded by providing 75% of patients who were found by VEPT to have high or moderate suspicion for elder abuse to be discharged with new or additional home services or facilitated a change in their living situation.⁶⁶ Previous studies have shown that many patients who experience elder abuse frequently are discharged back to the care of the abuser, even after physical abuse is identified during their visit.^17,35 Future studies are needed to examine longer-term impacts of the VEPT, as well as the ability to implement this intervention in other areas and review cost-benefit analysis given the resource-heavy intervention.⁶⁶

When providers suspect abuse, they first should ensure the immediate safety of the patient. Other initial interventions include reporting suspected abuse according to state mandates, consulting interprofessional teams to help address elder abuse when available, and ensuring that every patient has a safety plan.² Specific steps providers can take include documentation and treatment of injuries when present, optimizing resources such as home healthcare or need for other services, stopping loss of financial resources as soon as possible (considering the need for guardianship or referral to local law enforcement if appropriate), and referring for mental health treatment if needed.²

Legal and Ethical Requirements

Physicians, nurses, and healthcare team members have a moral obligation to their patients to identify and support victims of elder abuse. ACEP recommends that emergency providers be familiar with signs and symptoms of elder maltreatment and neglect and that EDs engage in interdisciplinary approaches for screening and interventions for elder maltreatment and neglect.⁶⁷ The American Medical Association Code of Medical Ethics states, “physicians have an ethical obligation to take appropriate action to avert the harms caused by violence and abuse”— including considering abuse as a factor in presentation of medical complaints, routinely inquiring about abuse, and reporting suspected violence and abuse in accordance with legal requirements.⁶⁸ Additionally, other emergency medicine organizations have recognized the need for increased education for healthcare professions. At their 2023 general assembly, the ENA resolved to create and support geriatric nurse accreditation and education, including the recognition and treatment of elder abuse.⁶⁹

Physicians specifically should become familiar with documentation of abuse. Whenever a provider suspects abuse, they should take care to obtain a detailed history and thorough physical assessment of the patient.⁹ Using a body chart or clinical photographs (with consent) can help objectively document injuries.⁷⁰ Injury documentation should be categorized, including the size, location, stage of healing, and whether any inconsistencies are noted between the clinical exam and the provided mechanism of injury.⁵ Documentation also should include observations of behavior, the patient’s functional status, living situation, the patient’s reactions to questions (using the patient’s own words when possible), and family or caregiver dynamics.^5,9 This documentation can provide further information for the Adult Protective Services (APS) investigation as well as guide other members of the healthcare team in how to best support the patient.⁹

Forty-nine states have mandatory reporting laws that require physicians to report suspected elder abuse to APS, law enforcement, or another designated regulatory body.² New York is the only state that does not have a mandatory reporting law for elder abuse, although a bill that would mandate reporting of elder abuse currently is in the state senate as of spring 2024.⁷¹ When a patient resides in a nursing home and there is suspicion for elder abuse, mandated reporters should contact the state ombudsman office.² Healthcare providers should both further investigate and report cases where they have reasonable suspicion of elder abuse, even if they do not have definitive evidence of abuse.^9,62 In many states, all members of the healthcare team, including nurses, EMS personnel, mental health providers, and social workers, are mandatory reporters.

Ensuring the safety of the patient and separating them from their abuser if they are in imminent danger is paramount.⁵ It is important to note that APS investigations will not be concluded or resolved while the patient is in the ED.⁵ Thus, when reporting possible elder abuse, the ED provider should consider how to ensure safe disposition for the patient when they leave the ED. In some cases, patients may require admission to the hospital for safe discharge planning. In some cases, the abuser may be the patient’s legal guardian or have healthcare decision-making power; in these cases, there should be a low threshold to engage social work, hospital administration, risk management, and law enforcement to ensure patient safety.⁵ If the patient has decision-making capacity, they may choose to return to an unsafe environment. However, when there are doubts about whether an older patient truly has capacity, ED providers and staff can engage Psychiatry for further assessment of capacity.⁵ Even if patients return to an unsafe environment, ED providers and staff still should discuss safety planning and community resources with the patient.⁵

Government agencies have been established for the protection of older adults, both nationally and at state and local levels. APS, National Center on Elder Abuse (NCEA), National Council on Aging (NCOA), state ombudsman offices, and state and county offices on aging are just a few of the resources that exist to help identify and prevent elder abuse. When healthcare team members are concerned that a crime has been committed or that a patient is in imminent danger, they also should consider contacting local law enforcement.⁵ Healthcare professionals should be familiar with and engage community resources to advocate for the safety and well-being of older patients.

Summary

Elder abuse is common, affecting at least one in 10 older adults in the United States. However, it often goes unidentified and underreported. There are different types of elder abuse, including physical abuse, neglect, emotional abuse, sexual abuse, and financial abuse. Healthcare professionals should be aware of these types of abuse and how they may manifest in their patients. When patients present with trauma-related injuries, providers should consider whether their injuries align with the provided mechanism history and whether any factors of elder abuse could have played a role in the presentation. More research is needed on best practices for screening and intervention for elder abuse. If abuse is suspected, physicians and the healthcare team should treat the patient’s acute injuries and illness, ensure patient safety, and report to the appropriate authorities.⁵

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