Introduction
Elder abuse can be explained as a direct action, inaction, or negligence toward an older adult that harms or places them at risk of harm by a person in a position of presumed trust.[1] This common problem has complex psychosocial and medical considerations.[2] Abuse may also be committed by an outside individual targeting the victim based on age or disability.[3] Elder abuse generally falls into 5 categories: physical abuse, emotional or psychological abuse, sexual abuse, financial abuse, and neglect.[4] Victims often experience multiple forms of abuse simultaneously.
Physical abuse of the older adult consists of intentionally inflicting physical force that may cause pain, injury, and disability to the victim. Means of physical abuse include but are not limited to hitting, restraining a person inappropriately, hair pulling, forcibly feeding a person, pinching, and pushing.
Psychological or emotional abuse encompasses verbal threats, harassment, intimidation, yelling, isolation, and treatment of an older person like a child. This abuse may lead the older adult into depression, anxiety, withdrawal from social interactions, a constant state of fear, and hopelessness.[5]
Sexual abuse of the older adult is considered a nonconsensual sexual act where the victim is forced into the act against their will or cannot understand or consent to the sexual act. Examples of sexual abuse include rape, forced nudity, explicit photography, inappropriately exposing oneself to the victim, and unwanted touching. Sexual abuse is unidentified and underreported far more frequently than other forms of abuse. This discrepancy is likely multifactorial, enabled by society’s false perceptions of sexuality among the older adult population and barriers to the victim reporting the abuse.[6]
Neglect is unique in that it can be intentional or unintentional. This category generally represents a failure of the caregiver to fulfill obligations to the older adult. Forms of neglect include withholding nutrition, water, and appropriate clothing; failing to administer or refill medications; and providing inadequate assistive devices, such as hearing aids, glasses, or walkers. Neglect often manifests as being underweight or dehydrated, having poor personal hygiene, wearing dirty clothing, and having long toenails or fingernails. Neglect can also lead to complications from poorly controlled medical conditions.
Financial exploitation encompasses the withholding or misuse of the older adult’s resources, including money, property, and other assets, to the detriment of the older adult and the benefit of the perpetrator. This form of abuse may include directly stealing assets, forging the older adult’s signature on documents or checks, inappropriate changing of a will, overpaying for goods or services, using the older adult’s assets without their knowledge, or forcing them to make financial changes that are not in their best interest.[7]
Elder abuse has devastating and expensive effects on the victims and society as a whole, yet it often goes unidentified or unreported.[8] Healthcare professionals are in a unique position to identify and intervene in elder abuse, as they may be the only contact the patients have outside of their homes. Therefore, all members of the healthcare team must be aware of the risk factors and signs of elder abuse, as well as the systems in place to assist victims and families.
Etiology
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Etiology
Elder abuse is a complex phenomenon with many risk factors and societal dimensions, including victim and perpetrator characteristics, society’s perceptions, and environmental factors. Victim characteristics strongly associated with elder abuse include increased reliance on a caregiver due to physical, emotional, psychological, or financial dependence. A prevalent belief is that this dependence leads to a high caregiver burden, which may manifest as abuse. Victims are also sometimes hesitant or unable to report the abuse. This hesitancy may be secondary to physical or cognitive inability, fear of retaliation or institutionalization, embarrassment, acceptance of abuse as normal, self-blame, or unawareness that help is available.[9]
Perpetrator characteristics associated with elder abuse include substance abuse, normalization of violence through previous life experiences, financial dependence on the victim, mental illness, personality disorders, and a history of a strained premorbid relationship with the older adult. Each of these factors can make it more challenging to cope with the increased caregiver burden, which may result in abuse.
Societal and environmental factors include high crime rates that may normalize violence, lack of community resources that increase the strain on caregivers and victims, and the belief that older adults are unlikely to be victims of abuse. Healthcare professionals may also have insufficient training in identifying and managing abuse cases appropriately. Furthermore, caregivers, including those working at nursing facilities, may not have adequate training on how to control aggressive patients, such as residents with dementia.
Epidemiology
Elder abuse is a widespread, global problem, with an estimated prevalence of 5% to 10% in the general population of older adults in the U.S. [10]. The abuser is often someone the victim knows, such as a family member, friend, neighbor, caregiver, or staff at long-term care or healthcare facilities. Of the categories of abuse, neglect, psychological abuse, and financial exploitation are the most prevalent, with sexual abuse occurring less frequently. Older adults with cognitive impairment, such as patients with dementia, are at the highest risk, with nearly 5 times the rate of abuse seen compared to adults of advanced age without dementia.
Other groups found to have disproportionately high levels of abuse include women, people older than 80, minority populations, residents of long-term care facilities, and people with multiple comorbidities[10]. Limited and conflicting data has made it difficult to determine whether factors such as race, ethnicity, and gender are independent risk factors of abuse after correcting for confounding factors, such as socioeconomic status and comorbidities.
Demographics do vary by abuse type, with women being victims of sexual abuse much more frequently than men. The exact prevalence of elder abuse is challenging to discern, as only an estimated 5% of abuse cases are reported.
History and Physical
An appropriate patient history focuses on identifying risk factors for elder abuse, as well as patterns that may be concerning for active abuse. A simple question, such as “Do you feel safe at home?” is an ideal start to the screening process, which can later be developed into a more extensive line of questioning and usage of screening tools.
Red flags for possible abuse include unexplained or frequent injuries, delayed care following the onset of illness or injury, noncompliance with the medical regimen, and missed follow-up appointments. When an area of concern is identified, questions must focus on the type of abuse suspected. In some cases, obtaining information from the patient, family members, caregiver, emergency medical services, law enforcement, home health care services, case management, or the patient’s primary care physician may be appropriate to identify areas of concern or inconsistencies in the narrative.
The caregiver should be asked to leave the room, and the discussion must be held in private to obtain a history related to abuse, as vital information may be withheld due to fear of repercussions. History taking should include specific medical and psychosocial factors to help identify areas needing more support to prevent abuse. Questions need to be presented in a nonjudgmental way while giving the patient time to respond, as they will be more likely to confide in the interviewer once they feel comfortable.
In case of an acute visit, a detailed history must be obtained to understand the mechanism of injury or events leading up to the visit, as the important points in the history must correlate with the examination findings from the visit. Family members and caregivers should not be used as translators when abuse is suspected. The history and examination must be detailed and objective, as they may later be part of an investigation.
A comprehensive physical exam is necessary when abuse is suspected. The examination should include observation of the patient-caregiver interaction and patient mannerisms, such as poor eye contact, signs of anxiety, and indicators of uneasiness like fidgeting.
Examination findings concerning for physical abuse are patterned bruises, bite marks, hematomas in different stages of healing, subconjunctival hemorrhages, intraoral injuries, and bruises in suspicious regions like the wrists, the ulnar aspect of the forearms, and nonbony prominences in areas like the face, neck, ears, back, and abdomen.
Physical signs of neglect include malnourishment, dehydration, soiled clothing, long toenails or fingernails, and the presence of pressure ulcers or burn marks. A detailed genital and rectal examination is essential if sexual abuse is considered. Examination findings that may indicate sexual abuse include genital bruises, lacerations or tears, redness, swelling, incontinence, and signs of sexually transmitted diseases, such as genital drainage, warty lesions, or foul odor[11].
Evaluation
The evaluation should be directed by a detailed history and physical examination, focusing on the type of abuse suspected and injuries seen. The patient’s medical history, functional capacity, mechanism of injury, examination and laboratory findings, and imaging results must be considered to find clues of potential abuse.
Unlike child abuse, data is limited regarding specific radiologic patterns pathognomonic of elder abuse [12]. However, radiologic findings possibly suggestive of elder abuse include posterior rib fractures, fractures of varying chronicity, distal ulnar diaphysis fractures, skull fractures, subdural hematomas, small bowel hematomas, and high-energy fractures in the setting of a low-energy mechanism.[13] Laboratory investigations may include assessments for dehydration, malnutrition, infection, endocrinologic etiologies, anemia, coagulopathies, and rhabdomyolysis. Obtaining blood levels of medications may help determine if a patient has been properly taking their medications or overdosing. A urine drug screen can help identify poisoning from drugs or toxic substances.
Communicating any particular areas of concern to the radiologist is essential if imaging is obtained. Information that may be helpful for the radiologist includes the patient's functional capacity and pertinent medical history, as well as the mechanism of injury, to help determine if the findings are consistent with the mechanism described.
Another aspect of the evaluation is determining the individual’s capacity to make their own decisions. A person who can make their own decisions, even in the setting of abuse, may remain in their abusive environment if desired. Orientation assessment and screening tools, such as the Mini-Mental State Exam, are usually insufficient to determine this capacity. Other screening tools, such as the Hopkins Competency Assessment Test, should be considered, as they correlate more frequently with a psychiatrist’s determination of capacity.[14]
Screening tools, such as the Elder Abuse Suspicion Index or the Elder Abuse Vulnerability Index, may also be useful. These tools help identify older adults currently being abused, as well as people at risk of being abused, which can guide the utilization of education and resources.
Treatment / Management
Treatment initially should focus on correcting the acute problem or injury. However, the social and psychological components of elder abuse must also be addressed. Social interventions may include coordination of home health services, meal delivery, transportation for appointments, assistance for setting up insurance, and facilitation of connections to adult day care or centers for older adults.
The patient's protection must be prioritized if they are in immediate danger. Providing protection may require involving law enforcement or hospital security, social work, and the hospital legal team, as well as possibly applying for emergency guardianship. An essential step in managing elder abuse entails reporting the abuse, even if the condition is only suspected and not yet proven. This action prompts the appropriate agency, such as Adult Protective Services, to conduct further investigations and ensure the individual receives the help they need.
Most healthcare professionals qualify as mandatory reporters of suspected elder abuse, although specifics vary by state. However, many cases of possible abuse go unreported. Some reasons for not reporting abuse include concern for the loss of physician control, loss of patient trust, unintended negative consequences, the subtlety of the findings, and retaliation of perpetrators against the victim.[15]
Differential Diagnosis
Exploring alternative diagnoses is crucial when considering elder abuse and its potential consequences. These alternatives encompass conditions that may cause patient behaviors resembling being victimized by abuse or lead to concerning examination or imaging findings unrelated to abuse. For instance, a patient with malignancy, depression, metabolic disturbances, infection, endocrinologic disease, substance abuse, dementia, or dental issues may exhibit signs of neglect, such as dehydration and weight loss, and may appear withdrawn, depressed, or anxious.[16] Additionally, the use of anticoagulants, malignancy, prolonged bed rest, thinning skin, and osteopenia may result in fractures and bruising that could be mistakenly attributed to physical abuse.[17]
Prognosis
Recognizing elder abuse and intervening promptly are crucial to alleviating ongoing physical and psychosocial effects and preventing long-term consequences. This issue significantly increases morbidity and mortality, leading to heightened psychosocial distress, increased hospitalization rates, higher readmission rates, more emergency department visits, and a greater likelihood of long-term care placement.
Complications
Elder abuse has complications for the victims, caregivers, and society as a whole. For the victim, abuse has been shown to lead to physical and mental health problems, posttraumatic stress disorder, poorly controlled chronic disease, high medical bills, decreased quality of life, breakdown of trust or quality of relationships, and even premature death.
Caregivers may suffer from the high burden of care, loss of productivity and the ability to work, and financial strain while caring for older adults. Significant complications for society include the direct costs of providing care, the burden on nursing facilities, and the strain on community, legal, and law enforcement resources.
Deterrence and Patient Education
One challenging aspect of controlling elder abuse is that it frequently goes unidentified and unreported. Efforts to reduce the problem should focus on educating healthcare workers, caregivers, patients, and the community on the prevalence, risk factors, and signs of abuse, as well as making resources readily available. Enhancement of community resources is also needed to ensure support for victims and families.
Identifying and minimizing risk factors, along with supporting affected families, can help reduce abuse and, in turn, lessen the burden on emergency services, hospitals, medical costs, and the need for long-term care placement. Long-term care facilities can minimize the risk of abuse by avoiding understaffing, creating a calm environment, making staff feel appreciated, and providing more education for staff about dealing with difficult or aggressive residents.
Enhancing Healthcare Team Outcomes
Elder abuse is prevalent and has serious consequences, but it is frequently underdetected. Healthcare professionals are uniquely positioned to recognize and address elder abuse, as they are often the only contact the older adult has outside of their home. Quickly detecting and intervening is important, as delays can lead to increased morbidity and mortality.
A suspicion of elder abuse must be promptly addressed and reported to mobilize resources for the victim. These urgent measures are not only moral obligations, but most states consider physicians, psychologists, law enforcement personnel, and nurses as mandatory reporters of suspected elder abuse.
Collaboration and clear communication among first responders, law enforcement, nurses, physicians, social workers, case management, hospital administration, and the hospital legal team are essential. Nurses play a crucial role in detecting abuse, as they often spend more time with the patient and family. Patients may feel more comfortable confiding in nursing staff and sharing information they were reluctant to tell the doctor. Nurses may also observe strained patient-caregiver interactions or uncover additional physical findings while assisting with tasks such as bathing, toileting, and placing a urinary catheter.
Social workers and case managers are also integral parts of the care team. These professionals may be able to identify nonmedical risk factors for abuse that were not initially appreciated and can help organize resources and support for the patient and family. Once identified, any case should be reported to the appropriate agency, such as Adult Protective Services, to ensure the patient has proper follow-up and monitoring after going home.
A comprehensive, interprofessional approach is needed to effectively identify and navigate the medical, psychosocial, and societal complexities of elder abuse. Increasing awareness and collaborating effectively within the interdisciplinary team can reduce the prevalence of elder abuse and pave the way for better care for older patients.
References
Baker PR, Francis DP, Hairi NN, Othman S, Choo WY. Interventions for preventing abuse in the elderly. The Cochrane database of systematic reviews. 2016 Aug 16:2016(8):CD010321. doi: 10.1002/14651858.CD010321.pub2. Epub 2016 Aug 16 [PubMed PMID: 27528431]
Level 1 (high-level) evidenceRosen T, Hargarten S, Flomenbaum NE, Platts-Mills TF. Identifying Elder Abuse in the Emergency Department: Toward a Multidisciplinary Team-Based Approach. Annals of emergency medicine. 2016 Sep:68(3):378-82. doi: 10.1016/j.annemergmed.2016.01.037. Epub 2016 Mar 18 [PubMed PMID: 27005448]
Dong X, Simon MA. Vulnerability risk index profile for elder abuse in a community-dwelling. Journal of the American Geriatrics Society. 2014 Jan:62(1):10-5 [PubMed PMID: 25180376]
Dong XQ. Elder Abuse: Systematic Review and Implications for Practice. Journal of the American Geriatrics Society. 2015 Jun:63(6):1214-38. doi: 10.1111/jgs.13454. Epub 2015 Jun 11 [PubMed PMID: 26096395]
Level 1 (high-level) evidenceRosen T, Stern ME, Elman A, Mulcare MR. Identifying and Initiating Intervention for Elder Abuse and Neglect in the Emergency Department. Clinics in geriatric medicine. 2018 Aug:34(3):435-451. doi: 10.1016/j.cger.2018.04.007. Epub 2018 Jun 15 [PubMed PMID: 30031426]
Bows H. The other side of late-life intimacy? Sexual violence in later life. Australasian journal on ageing. 2020 Jun:39 Suppl 1():65-70. doi: 10.1111/ajag.12728. Epub [PubMed PMID: 32567186]
Mileski M, Lee K, Bourquard C, Cavazos B, Dusek K, Kimbrough K, Sweeney L, McClay R. Preventing The Abuse Of Residents With Dementia Or Alzheimer's Disease In The Long-Term Care Setting: A Systematic Review. Clinical interventions in aging. 2019:14():1797-1815. doi: 10.2147/CIA.S216678. Epub 2019 Oct 22 [PubMed PMID: 31695349]
Level 1 (high-level) evidenceRosen T, Bloemen EM, Harpe J, Sanchez AM, Mennitt KW, McCarthy TJ, Nicola R, Murphy K, LoFaso VM, Flomenbaum N, Lachs MS. Radiologists' Training, Experience, and Attitudes About Elder Abuse Detection. AJR. American journal of roentgenology. 2016 Dec:207(6):1210-1214 [PubMed PMID: 27732066]
Mion LC, Momeyer MA. Elder abuse. Geriatric nursing (New York, N.Y.). 2019 Nov-Dec:40(6):640-644. doi: 10.1016/j.gerinurse.2019.11.003. Epub 2019 Nov 14 [PubMed PMID: 31735449]
Nemati-Vakilabad R, Khalili Z, Ghanbari-Afra L, Mirzaei A. The prevalence of elder abuse and risk factors: a cross-sectional study of community older adults. BMC geriatrics. 2023 Sep 30:23(1):616. doi: 10.1186/s12877-023-04307-0. Epub 2023 Sep 30 [PubMed PMID: 37777720]
Level 2 (mid-level) evidenceRosen T, LoFaso VM, Bloemen EM, Clark S, McCarthy TJ, Reisig C, Gogia K, Elman A, Markarian A, Flomenbaum NE, Sharma R, Lachs MS. Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases. Annals of emergency medicine. 2020 Sep:76(3):266-276. doi: 10.1016/j.annemergmed.2020.03.020. Epub 2020 Jun 10 [PubMed PMID: 32534832]
Level 3 (low-level) evidenceRohringer TJ, Rosen TE, Lee MR, Sagar P, Murphy KJ. Can diagnostic imaging help improve elder abuse detection? The British journal of radiology. 2020 Jun:93(1110):20190632. doi: 10.1259/bjr.20190632. Epub 2020 Mar 4 [PubMed PMID: 32108517]
Lee M, Rosen T, Murphy K, Sagar P. A new role for imaging in the diagnosis of physical elder abuse: results of a qualitative study with radiologists and frontline providers. Journal of elder abuse & neglect. 2019 Mar-May:31(2):163-180. doi: 10.1080/08946566.2019.1573160. Epub 2019 Feb 10 [PubMed PMID: 30741114]
Level 2 (mid-level) evidenceJanofsky JS, McCarthy RJ, Folstein MF. The Hopkins Competency Assessment Test: a brief method for evaluating patients' capacity to give informed consent. Hospital & community psychiatry. 1992 Feb:43(2):132-6 [PubMed PMID: 1572608]
Rodríguez MA, Wallace SP, Woolf NH, Mangione CM. Mandatory reporting of elder abuse: between a rock and a hard place. Annals of family medicine. 2006 Sep-Oct:4(5):403-9 [PubMed PMID: 17003139]
Wysokiński A, Sobów T, Kłoszewska I, Kostka T. Mechanisms of the anorexia of aging-a review. Age (Dordrecht, Netherlands). 2015 Aug:37(4):9821. doi: 10.1007/s11357-015-9821-x. Epub 2015 Aug 1 [PubMed PMID: 26232135]
Chen AL, Koval KJ. Elder abuse: the role of the orthopaedic surgeon in diagnosis and management. The Journal of the American Academy of Orthopaedic Surgeons. 2002 Jan-Feb:10(1):25-31 [PubMed PMID: 11809048]