Elder Abuse

Continuing Education Activity

Elder abuse comes in many forms, including physical, psychological, and sexual abuse, as well as less obvious forms, such as financial exploitation and neglect. Elder abuse is a common problem with complex social and medical considerations that medical professionals are uniquely positioned to identify and address. This issue often affects vulnerable individuals due to age-related factors like physical frailty, cognitive decline, and social isolation. People at risk include those who depend on others for care, live in institutional settings, or experience financial instability. Addressing this problem requires a multifaceted approach, including stronger legal protections, better caregiver training, community support programs, and raising public awareness to ensure early intervention and prevention. This topic for healthcare professionals is designed to enhance learners' proficiency in identifying older individuals who may be experiencing abuse, as well as managing associated problems. Participants gain a deeper understanding of the condition's risk factors, evolutionary mechanisms, and best practices for evaluation and therapy. Greater competence enables clinicians to collaborate within an interprofessional team caring for older individuals who are victims of abuse.

Objectives:

• Identify the signs and symptoms indicative of elder abuse.
• Create a clinically guided plan to evaluate suspected elder abuse cases.
• Implement personalized management plans for elder abuse.
• Apply effective strategies to improve care coordination among interprofessional team members to facilitate positive outcomes for older patients experiencing abuse.

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 misusing of the older adult’s resources, including money, property, and other assets, to the detriment of the older adult and the perpetrator's benefit. 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

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 must be presented nonjudgmentally while giving the patient time to respond, as they are more likely to confide in the interviewer once they feel comfortable. In the case of an acute visit, a detailed history must be obtained to understand the mechanism of injury or events leading up to the visit. 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.

When abuse is suspected, a comprehensive physical exam is necessary. The examination should include observation of the patient-caregiver interaction and patient mannerisms, such as poor eye contact, signs of anxiety, and uneasiness like fidgeting. Examination findings concerning 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. If imaging is obtained, communicating any particular areas of concern to the radiologist is essential. Information that may be helpful for the radiologist includes the patient's functional capacity, pertinent medical history, and 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 capacity determination.[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 should initially 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 coordinating 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. If the patient is in immediate danger, the patient's protection must be prioritized. 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 needed help. 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 is 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 societal complications 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 increase 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 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.

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Disclosure: Jagmohan Jandu declares no relevant financial relationships with ineligible companies.

Disclosure: Arvindselvan Mohanaselvan declares no relevant financial relationships with ineligible companies.

Disclosure: Mark Johnson declares no relevant financial relationships with ineligible companies.

Disclosure: Howard Fertel declares no relevant financial relationships with ineligible companies.