An under-recognized epidemic of elder abuse needs your awareness and action
Your preventive and protective efforts to combat this public health concern should be refined and redoubled
Obtain the history from several sources; review the records; and carefully examine patterns of injury, in particular assessing functional status and level of dependency on the caregiver. Explanations that do not match injuries signal the need for further investigation and examination.
To help differentiate elder abuse from normal physiologic aging, look at the skin for bruises, rashes that do not heal, and ulcers—all of which could be signs of abuse or neglect. Keep in mind that bruising generally is more common in older adults because of the slower turnover rate of epidermal cells; physiologic bruising tends to occur on dorsal aspects of the hands and arms.4 In contrast, bruising secondary to neglect or physical abuse can manifest as a subgaleal hematoma (caused by traumatic hair pulling), tracking in the peritoneum after genital trauma, Battle’s sign, and raccoon eyes, among other findings.4
In addition, larger bruises (>5 cm in diameter) are more likely the result of elder abuse.34 To complicate matters, many older persons are taking anticoagulant therapy, making bruising more likely. In addition, be on the lookout for burns during the physical exam. Evidence suggests that at least 10% of burns caused by battery and assault occur in the context of elder abuse; most burn facilities do not have formal guidelines for screening for abuse and neglect, however.35 According to one retrospective study, the most common causes of burns in older adults are hot water scalds and radiator contact, and the mortality rate of older burn patients in general is higher than among the overall population.36
Falls and fractures are common among older adults, regardless of whether they are
abused, because of polypharmacy, underlying medical conditions, and functional
limitations. Many abusers, however, use these factors to cover up intentional injury
that might have resulted in the older person falling, including overmedication (a form of physical abuse) and withholding a necessary walking aid (a form of neglect). Maintain a high index of suspicion of elder abuse when (1) the caregiver’s and the older adult’s stories of an injury don’t add up and (2) physical findings that might have been caused by abuse are present.
A number of psychiatric and cognitive symptoms suggest other types of elder abuse. Take note of emotional upset, agitation, and unusual behaviors37—especially if you can follow the patient over time to observe marked changes in the presentation. Likewise, be aware of proposed alterations in guardianship, which should be evaluated by a forensic psychiatrist with analysis of medical history, social attachments, home environment, self-care, and finances.38 Such evaluation should provide clues to the motivation behind a change of guardianship and will help to determine if elder abuse should be suspected.
Brandi et al37 provided an informative table that identifies pertinent signs, symptoms, and other findings that clinicians should be aware of to support a suspicion of elder abuse (Table).
Documentation is of utmost importance in evaluating potential elder abuse; keep in mind that the medical record might be used in an investigation of abuse by social workers, law enforcement, and prosecutors. Your records should be legible, clearly indicate who the main caregiver is and what his (her) responsibilities are, and specify who is present at your encounter with the patient.4 Document your observations of patient behavior, reactions to questions, and family dynamics and conflicts16; make note of warning signs such as fear, silence, and inability to interview the patient alone.
In addition to written documentation, take photographs of injuries, with a ruler in the image to record their size. Serial photographs are helpful; so are photographs from a variety of distances (close-up, regional, wholebody) to capture detail and place the wound in the context of a specific area of the body.4
Safety is paramount. Given the findings of the history and physical exam, it is necessary to determine whether it is safe for the patient to return home with the caregiver, or if alternate accommodations or resources, such as a social worker or a support group, are required. Include details of planned follow-up in your evaluation, and offer consideration of possible psychiatric disorders that can develop as a result of such abuse.
ReportingElder abuse is a criminal offense in all states.39 A clinician who has reasonable suspicion that elder abuse occurred must report it, regardless of whether the proof of abuse is concrete.40 At a point of reasonable suspicion, immediately contact APS, law enforcement, and a social worker. Adult Protective Services, modeled after Child Protective Services, is typically administered by local and state health
departments.41
After a report is filed with APS, an assigned social worker makes an in-person home visit to investigate the allegation and determine whether elder abuse is substantiated, partially substantiated, or unsubstantiated.16 In most states, elder abuse reporting is not anonymous because follow-up may be needed to provide additional evidence, especially if the report was made by a health care provider.16
