> Table of Contents > Elder Abuse
Elder Abuse
Nitin Budhwar, MD
Kimberly Kone, MD
image BASICS
DESCRIPTION
  • The National Center of Elder Abuse divides abuse into three categories (older than age 60) (1)[A]:
    • Domestic: Abuse from someone who has a special relationship with the elderly individual (spouse, child, friend, or in-home caregiver) that occurs in the home of the elderly or caregiver.
    • Institutional: Occurs in the setting of a facility that is responsible for caring for the elderly, such as a nursing home or long-term care facility.
    • Self-neglect: The behavior of the elderly individual leads to harm.
  • Types of abuse in estimated order of occurrence:
    • Self-neglect (estimated 50%). The most common form of abuse (2)[C].
    • Financial
    • Neglect
    • Emotional
    • Physical
    • Sexual
    • Taken advantage of: Misinformation and unregulated online pharmaceutical, financial companies, and so forth, that specifically target the elderly leading to deleterious outcomes (3)[C].
EPIDEMIOLOGY
Incidence
Estimate is that as many as 1:10 have been victims of abuse, placing a conservative number at 50,000 cases per year. Majority of whom are believed to be women (4)[A].
Prevalence
A recent national survey measuring prevalence of abuse in individuals of at least 60 years and older found that 11.9% of the surveyed population suffered some form of abuse:
  • 5.2% encountered financial mistreatment by family members
  • 5.1% suffered potential neglect
  • 4.6% encountered emotional mistreatment, mostly by humiliation or verbal abuse
  • 1.6% encountered physical mistreatment, mostly through battery
  • 0.6% sexually mistreated, mostly through forced intercourse
ETIOLOGY AND PATHOPHYSIOLOGY
The etiology of elder abuse is a complex biopsychosocial combination of increased dependence on the caregiver by the victim in a suboptimal environment with poor behavioral coping methods, which is compounded by increased stress.
Genetics
Not contributory
RISK FACTORS
  • The victim:
    • Advanced age
    • Exploitable resources
    • Prior history of abuse in life
    • Dementia or other cognitive impairment
    • Female gender
    • Disability in caring for him/herself
    • Depression
    • Social isolation
    • Stress: health, financial, or situational
  • The abuser:
    • Mental illness
    • Financial dependency
    • Substance abuse
    • History of violence
    • Other antisocial behavior (5)[C]
GENERAL PREVENTION
  • Improve patient social contact and support.
  • Identify and correct potential risk factors for elder abuse:
    • Home visit to identify for potential risks of fall hazards and barriers to ambulation that could lead to fractures and functional decline that could leave the individual vulnerable to abuse
    • Evaluate for assistive devices that help the patient independently complete his/her ADLs and prevent caregiver dependence.
    • Screen for depression using validated tools like the Geriatric Depression Scale.
    • Early identification and treatment of cognitive impairment
  • Identify caregiver stress and burden; refer to community programs that aid with emotional assistance.
  • Advance life directives planning, including identifying possible caregivers, choosing a medical power of attorney (MPOA), estate, and will planning, and so forth.
COMMONLY ASSOCIATED CONDITIONS
Most common associated conditions with elder abuse are also identified as risk factors: social isolation, increased dependence for ADL/IADLs, depression, cognitive impairment, and aggressive behavior (5) [C],(6)[B].
image DIAGNOSIS
A high index of suspicion when risk factors are present is important; types of abuse should be kept in mind as some types might not be obvious. It can be difficult to diagnose elder abuse in a single clinic visit, so it is important to get social services involved and to consider doing home visits, when abuse is suspected (5)[C].
PHYSICAL EXAM
  • It is important objectively to document positive and negative findings in your physical exam and to be very detailed because it can be admissible in court if abuse is suspected.
  • Vital signs: Check weight and assess for progressive loss in weight; BP and pulse rate can be an indicator of dehydration that could be secondary to neglect.
  • General overall appearance:
    • Wasting or cachexia
    • Poor hygiene, unkempt clothing
    • If the patient is bedbound, it is important to assess the integrity of the mattress and sheets. Look for excessive skin flakes, hair, or urine-soiled mattresses.
  • Oral exam:
    • Assess for poor dentition, oral ulcers, or abscesses.
  • Skin exam:
    • Most bruises from elder abuse are large (>5 cm) and located on the face, lateral arm, or back.
    • Bite or burn marks
    • It is important to check for pressure ulcers on the bony prominences of the patient: elbows, sacrum, heels, and scapula
  • Mental/psychiatric:
    • Withdrawn, anxious, fearful, blunted
  • Genital/rectal exam if sexual abuse is suspected (4)[A].
DIFFERENTIAL DIAGNOSIS
  • Advanced dementia can present with individuals appearing withdrawn and they are often malnourished.
  • Elderly with advanced dementia of Alzheimer type or Lewy body dementia can present with delusions of persecution and aggression that can be confused for elder abuse.
  • Patients with Parkinson disease often fall and may exhibit fractures and bruises on a frequent basis that may mimic recurrent physical abuse.
  • Coagulopathy seen in patients in advanced malignancy with bone marrow suppression or invasion, and those on chronic antiplatelet therapy can appear with bruising that can be easily confused with elder abuse.
  • Wasting from malignancy, infections, chronic disease
  • Thyroid disorder can present with altered mental status (AMS), depression, or anxiety.
  • Chronic lung disease can present with decreased weight.
  • Delirium from acute electrolyte disturbances, infectious etiology, or cardiovascular compromise can all present similar to elder abuse.
  • Impaired financial status can also be confused with self-neglect.
DIAGNOSTIC TESTS & INTERPRETATION
The following workup is recommended:
  • Nutritional assessment: iron, vitamin B12, folate, thiamine, albumin, prealbumin, CBC, LFTs, electrolytes
  • Malignancy workup, as per current guidelines
  • If bruising is noted, check for coagulopathies (e.g., platelets, bleeding times, PT/INR, and PTT)
  • If cognitive impairment is observed, check thyroid-stimulating hormone, vitamin B12 level; consider syphilis and HIV testing if indicated.
  • Assessment of infection: may include urinalysis and culture, chest radiograph, blood count, and cultures
  • Radiographic imaging of areas below soft tissue injury is indicated if there is evidence of infection (osteomyelitis) at a pressure ulcer site or bruising of a limb (fracture).
  • If physical abuse is suspected and cognitive impairment present, then cranial imaging to look for hemorrhage (e.g., subdural) is indicated using CT scan or MRI.
Diagnostic Procedures/Other
  • Pulse test: Check BP and pulse in presence and absence of suspected abuser. Elevation of either in the presence of the suspected abuser should raise suspicion. Useful in patients with dementia or other condition that makes history-taking difficult.
  • Folstein Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MOCA), or other validated tools to assess for cognitive impairment if suspected
  • P.333

  • Geriatric Depression Scale if suspected
  • Documentation: Practitioners may make statements of “suspected mistreatment,” but should avoid making definitive diagnosis of abuse in their initial assessment, unless it is very obvious.
image TREATMENT
Most states require all health care providers to report suspected elder abuse to a local agency such as the Adult Protective Services (http://www.nccafv.org/state_elder_abuse_hotlines.htm).
MEDICATION
None
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
  • Victims of elder abuse should be admitted to the hospital if there are no safe discharge alternatives.
  • Management of uncontrolled chronic conditions due to neglect (i.e., wound care from ulcers or infections)
  • Cases of suspected abuse must be reported to the state's Adult Protective Services agency or a designated alternative (e.g., if patient resides in nursing home, then report to that state's regulatory entity). Social services may help. If physical harm has occurred, consider reporting to local law enforcement for investigation.
  • Hospital security may need to be notified if restricted visitor access to a patient is required, and the patient's name may be hidden from the public hospital census.
  • If the patient is a victim of elder abuse, he/she must be relocated to a safer alternative and may need admission for sequelae caused by the abuse.
Discharge Criteria
Victims should not be discharged to a potentially abusive environment. Alternatives to discharge to the unsafe environment may include:
  • Friend or family member
  • Nursing home
  • Personal care home
  • Assisted living facility
  • Local victims' rescue or sheltering program if available
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Victims of abuse should not be discharged without adequate follow-up, including:
  • Primary care physician visit within 1 week
  • Follow-up with Adult Protective Services or other agency; a home visit should be scheduled prior to discharge if the patient is going back home.
  • Home Health Agency for assessment of safety (physical therapy)
  • Follow-up with appropriate mental health care
Patient Monitoring
The patient should have frequent visits and be followed through the appropriate agencies to reduce continuation of abuse and to identify recurring abuse.
PATIENT EDUCATION
  • For Elder Abuse Resources in your state, you can go to the National Center of Elder Abuse at www.ncea.aoa.gov
  • Or your local representative by calling 1-800-677-1166
PROGNOSIS
Elder abuse and self-neglect are associated with an overall increased risk in mortality (7)[B].
REFERENCES
1. National Center on Elder Abuse. Elder Abuse Prevalence and Incidence. Washington, DC: National Center on Elder Abuse; 2005.
2. Mosqueda L, Dong X. Elder abuse and self-neglect: “I don't care anything about going to the doctor, to be honest…” JAMA. 2011;306(5):532-540.
3. Liang BA, Lovett KM, Mackey TK. Elder abuse. J Am Geriatr Soc. 2012;60(2):398-400.
4. Committee opinion no. 568: elder abuse and women's health. Obstet Gynecol. 2013;122(1):187-191.
5. Halphen JM, Varas GM, Sadowsky JM. Recognizing and reporting elder abuse and neglect. Geriatrics. 2009;64(7):13-18.
6. Acierno R, Hernandez MA, Amstadter AB, 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;100(2):292-297.
7. Dong X, Simon M, Mendes de Leon C, et al. Elder self-neglect and abuse and mortality risk in a community-dwelling population. JAMA. 2009;302(5):517-526.
Additional Reading
&NA;
  • Burnett J, Dyer CB, Halphen JM, et al. Four subtypes of self-neglect in older adults: results of a latent class analysis. J Am Geriatr Soc. 2014;62(6): 1127-1132.
  • Cooper C, Katona C, Finne-Soveri H, et al. Indicators of elder abuse: a crossnational comparison of psychiatric morbidity and other determinants in the ad-hoc study. Am J Geriatr Psychiatry. 2006;14(6):489-497.
  • Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364(9441):1263-1272.
  • Lachs MS, Williams CS, O'Brien S, et al. Adult protective service use and nursing home placement. Gerontologist. 2002;42(6):734-739.
  • Lachs MS, Williams CS, O'Brien S, et al. The mortality of elder mistreatment. JAMA. 1998;280(5): 428-432.
  • Widera E, Steenpass V, Marson D, et al. Finances in the older patient with cognitive impairment: “He didn't want me to take over”. JAMA. 2011;305(7):698-706.
  • Wiglesworth A, Austin R, Corona M, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191-1196.
  • Wiglesworth A, Mosqueda L, Mulnard R, et al. Screening for abuse and neglect of people with dementia. J Am Geriatr Soc. 2010;58(3):493-500.
Codes
&NA;
ICD10
  • T74.11XA Adult physical abuse, confirmed, initial encounter
  • T74.21XA Adult sexual abuse, confirmed, initial encounter
  • T74.01XA Adult neglect or abandonment, confirmed, initial encounter
Clinical Pearls
&NA;
  • Elder abuse, or elder mistreatment, is a condition in which the physical, psychological, or financial wellbeing of an older adult is infringed upon through intentional acts or lack of action, even if harm is not intended.
  • It is important to identify vulnerable individuals through proper evaluation of potential risk factors for abuse (social isolation, depression, cognitive impairment, disability requiring assistance, and financial dependence by the caregiver).
  • Correction of risk factors is important to reduce the incidence of elder abuse (strengthen the patients' social support, treat depression, provide the patient with assistive devices, screen for cognitive impairment with a trial of medication if possible, and identify caregiver burn out).
  • Clearly document your physical exam with only specific objective findings.
  • Contact APS or your local resources if elder abuse is suspected; it is unlawful not to report suspected elder abuse.