An awareness of risk factors is important for the recognition of potential victims of elder abuse or neglect. Risk factors can be divided into two categories: factors associated with the elders and factors associated with the perpetrators (Table 295-2).7,13,14,15,16,17
TABLE 295-2Risk Factors for the Occurrence of Elder Abuse ||Download (.pdf) TABLE 295-2 Risk Factors for the Occurrence of Elder Abuse
|Risk Factors for Elders ||Risk Factors for Perpetrators |
|Cognitive impairment ||History of mental illness |
|Physical dependency ||History of substance abuse |
|Lack of social support ||Excessive dependence on elder for financial support |
|Alcohol abuse ||History of violence within or outside the family |
|History of domestic violence || |
|Female gender || |
|Developmental disability || |
|Difficult behavior (such as aggression or verbal outbursts) || |
|Special medical or psychiatric needs || |
|Limited experience managing finances || |
|Institutionalization || |
Patient characteristics associated with a higher risk for elder mistreatment are cognitive impairment, physical dependency, lack of social support, alcohol abuse, female sex, and a history of domestic violence.14 In addition, developmental disabilities, special medical or psychiatric needs, and difficult behavior (such as aggression or verbal outbursts) also increase the risk for abuse. Individuals with limited experience in managing finances are at increased risk for financial or material exploitation. Although elder abuse is more common in residential than institutional settings, institutionalization is also recognized as a risk factor for neglect and abuse.7,16
Three characteristics of perpetrators have been identified as risk factors: a history of mental illness and/or substance abuse, excessive dependence on the elder for financial support, and a history of violence within or outside of the family.17 Abusers are most often the primary caregiver. Adult children tend to be more inclined to abuse than are spouses, and males engage in abuse more often than females.13 Caregivers may be well intentioned but simply overwhelmed by the amount of care required. They may themselves be impaired by mental or physical problems that serve as barriers to the provision of adequate care.
The approach to the patient interview is important. Potential sufferers of abuse should be interviewed in private. The presence of caregivers, family, or friends may cause the patient to feel intimidated or embarrassed, which limits the amount and accuracy of information obtained. Try to put the patient at ease by making the assessment seem like a routine part of the evaluation.12 Separately interview individuals accompanying the patient. Screening tools are available to aid in the detection of elder abuse.18,19,20 The use of lengthier tools is not feasible in a busy ED, but the American Medical Association has proposed a list of nine screening questions that may be more practical to implement (Table 295-3). An affirmative answer to any of the questions in this screening tool raises concern and mandates further exploration.
TABLE 295-3Screening Questions for Elder Abuse ||Download (.pdf) TABLE 295-3 Screening Questions for Elder Abuse
Has anyone ever touched you without your consent?
Has anyone ever made you do things you didn't want to do?
Has anyone taken anything that was yours without asking?
Has anyone ever hurt you?
Has anyone ever scolded or threatened you?
Have you ever signed any documents you didn't understand?
Are you afraid of anyone at home?
Are you alone a lot?
Has anyone ever failed to help you take care of yourself when you needed help?
During the interview, be prepared to recognize behavioral signs and symptoms that suggest elder abuse. These include depression, fear, withdrawal, confusion, anxiety, low self-esteem, and helplessness. Other history-related indicators that suggest abuse or neglect include a pattern of "physician shopping," unexplained injuries inconsistent with medical findings, and recurrent visits for similar injuries. Additional history taking should explore risk factors for abuse as outlined earlier in "Risk Factors."
Information can be obtained by the physician prior to conducting the private interview or by other members of the healthcare team, such as nurses, who are likely to have more frequent interaction with the patient and caregivers. Observing the interaction between the accompanying individuals can yield valuable clues (Table 295-4).
TABLE 295-4Clues during the Medical Interview That May Suggest Elder Abuse ||Download (.pdf) TABLE 295-4 Clues during the Medical Interview That May Suggest Elder Abuse
The patient appears fearful of his or her companion.
There are conflicting accounts of an injury or illness from the patient and caregiver.
The caregiver displays an attitude of indifference or anger toward the patient.
The caregiver is overly concerned with the costs of treatment needed by the patient.
The caregiver denies the patient the chance to interact privately with the physician.
The caregiver appears overly concerned and attentive.
Physical examination findings range from subtle and nondiagnostic to highly suspicious. Abuse is often detected when examination findings prompt further history taking with results suggesting elder mistreatment. Psychological abuse and financial abuse are especially hard to diagnose in the ED setting because physical examination findings are uncommon. Nonetheless, it is important to perform a detailed evaluation, including obtaining adequate exposure of the body to evaluate for trauma and pressure ulcers. Common physical findings in sufferers of elder abuse are bruising or trauma, poor general appearance and hygiene, malnutrition, and dehydration.19
Although not the most common form of elder abuse, physical abuse is the most easily recognized. Evidence of injury to normally protected areas of the body is highly suspicious for physical abuse.14 Examples include contusions or lacerations on the inner arms or inner thighs and injury to the mastoid area. It is important to expose these areas when examining the patient to avoid missing significant findings. Contusions on the palms, soles of the feet, and buttocks also raise concern for elder abuse.14 Multiple injuries in various stages of healing can suggest abuse, but may also be seen in patients with recurrent falls. Taking a thorough history is especially important in differentiating these two causes. Although older patients may sustain burns through accidental injury (such as coming too close to an open flame while cooking), unusual burns or multiple burns in various stages of healing should also raise concern. Traumatic alopecia is highly suspicious, although not necessarily diagnostic (because it may be seen in patients with some psychiatric conditions). Rope or restraint marks on wrists or ankles13 occur when elders are inappropriately restrained. Midshaft ulnar fractures (nightstick fractures) can occur from attempts to shield blows by raising the forearm. Fractures of the head, spine, and trunk may be more indicative of abuse, although these can occur by other mechanisms.21 Spiral fractures of long bones and fractures with rotational components also raise suspicion of abuse.21
Findings resulting from caregiver neglect or self-neglect are less specific. Perhaps the most identifiable finding is that of multiple or deep pressure ulcers. Ulcers that are uncared for (such as open ulcers lacking appropriate dressings or packing) or those not in lumbar or sacral areas raise suspicion even further. Incapacitated patients should be turned as part of the examination to evaluate for skin breakdown. Poor personal hygiene, inappropriate or soiled clothing, dehydration, malnutrition, contractures, fecal impaction, and excoriations suggest neglect.8
Sexually transmitted diseases or findings of genital trauma, especially in an incapacitated patient, raise concern for sexual abuse. Patients may complain of genital or anal pain, itching, bruising, or bleeding. Torn or stained underwear, with unexplained difficulty walking or sitting, may be present. Oral trauma can also be a manifestation of sexual abuse.
Depression, anxiety, and fear can be manifestations of psychological abuse, although they are nondiagnostic. Observation of interactions with caregivers and companions can provide further important clues to this type of abuse.
Although elder abuse is widely underrecognized and underreported, remember that underlying medical disorders are often associated with findings that could otherwise be identified with abuse. Advanced neurologic disorders such as multiple sclerosis, amyotrophic lateral sclerosis, and Parkinson's disease may lead to immobilization and severe disability. Individuals with such conditions are at risk for pressure ulcers, pneumonia, or venous thromboembolism, even with adequate care.13