Chapter 295: Abuse of the Elderly and Impaired

Elder abuse is an act or omission resulting in harm to the health or welfare of an elderly person. Three key groups have published definitions of elder abuse.^1,2,3 Although the incidence of elder neglect and abuse is unknown and widely felt to be underreported, the rate of different types of abuse among the elderly has been estimated to be in the mid-single digits, or between 500,000 and 1 million U.S. adults.^4,5 Table 295-1 summarizes the categories of elder abuse.

PHYSICAL ABUSE

Physical abuse is the most easily recognized form of elder abuse. It is defined as the use of physical force that might result in bodily injury, physical pain, or impairment. Pushing, slapping, burning, striking with objects, and improper use of restraint are all examples of physical abuse. Chemical restraint (such as intentional overmedication or administration of tranquilizers) is a more subtle form. Regardless of mechanism, physical abuse is carried out with the intention of causing suffering, pain, or other physical impairment to the abused person.

CAREGIVER NEGLECT

Elder neglect is the most common form of elder maltreatment, accounting for more than half of all elder maltreatment cases reported to adult protective services agencies annually.⁶ Elder neglect is defined as the failure of a caregiver to provide basic care to a patient and to provide goods and services necessary to prevent physical harm or emotional discomfort.^7,8 Examples of neglect include deprivation of food, clothing, hygiene, medical care, shelter, or supervision that a prudent person would consider essential for the well-being of another.^7,8

Elder neglect is both underrecognized and potentially lethal. It likely accounts for the majority of cases of unreported abuse.⁹ It is also an independent risk factor for mortality, even taking into account that the deaths themselves may not be immediately ascribed to injury.⁶ Elder neglect may be difficult to diagnose. Although some cases may be obvious (such as in a patient with multiple deep pressure ulcers), it is often more subtle and difficult to detect.

SEXUAL ABUSE

Sexual abuse is broadly defined as nonconsensual sexual contact of any kind with an elderly person. The spectrum of sexual abuse ranges from unwanted touching, indecent exposure, or unwanted innuendo, to rape itself. Although sexual abuse is underreported across all age groups, in the elderly, sexual abuse is even less likely to be reported. Fear of retaliation and shame on the part of patients, as well as stereotyping of older patients as asexual or not sexually desirable by clinicians, police, and others, may be factors in underrecognition and underreporting of sexual abuse.¹⁰

FINANCIAL OR MATERIAL EXPLOITATION

Financial abuse is estimated to be the second most common form of elder abuse, accounting for approximately 20% to 30% of abuse cases.¹¹ Financial or material exploitation is the illegal or improper use of an elder's funds, property, or assets.¹² It occurs when family members, caregivers, or friends take control of the elder person's resources. Coercion or outright theft may occur, with or without the awareness of the elder person experiencing abuse. An elderly person may unwittingly sign over access to savings accounts and other assets when he or she is in an incapacitated state. Social Security checks or pensions may be used by caregivers for personal gain. Theft may be blatant or coerced, with forcible transfer of property, including changing of the elder's will. Abuse may result in a decrease in the standard of living and an inability to pay bills, purchase food, or obtain medications.

EMOTIONAL OR PSYCHOLOGICAL ABUSE

Emotional or psychological abuse is defined as the infliction of anguish, emotional pain, or distress. Examples of psychological and emotional abuse include verbal threats (such as threats of violence, institutionalization, or deprivation), humiliation, intimidation, and harassment. Social neglect and isolation are also forms of abuse. Psychological and emotional abuse can contribute to the development and worsening of mental health problems such as depression, which is common in many older victims.¹²

ABANDONMENT

Abandonment constitutes the desertion of an elderly person by an individual who is that person's custodian or who has assumed responsibility for providing care to the elder. Desertion of an elder in the home, hospital, nursing facility, shopping mall, or other public location may occur.

SELF-NEGLECT

Self-neglect includes those behaviors of an elderly person that threaten his or her own safety. Such behaviors include failure or unwillingness to provide adequate food, clothing, shelter, medical care, hygiene, or social stimulation for oneself. It is the result of an adult's inability, due to diminished capacity, to perform essential self-care tasks. By definition, this applies to one who understands the consequences of his or her choices and makes a conscious decision to engage in acts that threaten his or her own health or safety.¹³ Patients who have cognitive impairment or who are living in poverty are at greater risk of self-neglect and may have increased mortality.⁹

RISK FACTORS

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}

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.

HISTORY

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.

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).

PHYSICAL EXAMINATION

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

Treatment of elder abuse in the ED involves three key components:

1. Addressing associated medical and psychological needs

2. Ensuring patient safety

3. Complying with local reporting requirements (http://www.ncea.aoa.gov)

Medical problems, including injuries, should be stabilized and treated, and may be best managed through hospital admission. In addition to physical injury, metabolic derangements may be present. Patients with dehydration or malnutrition can have a variety of electrolyte abnormalities and may also have coexisting renal failure. Elders left in the same position for an extended period of time may be at risk for rhabdomyolysis. Additional problems may exist due to failure to administer usual medications at home. These issues should all be addressed during the ED visit, including the ability to conduct activities of daily living, such as meal preparation, housework, bathing, dressing oneself, toileting, and managing finances.

Psychological problems brought on by abuse, as well as preexisting psychiatric conditions and substance abuse, should also be addressed. The severity of the problem and planned disposition can affect the extent to which treatment is completed in the ED. For patients requiring hospitalization, concerns and findings should be communicated to the admitting service and documented in the medical record. For patients who are discharged to home, arrangements should be made for appropriate follow-up. Follow-up must be arranged for the patient's medical and psychiatric needs, and arrangements must also be made for monitoring and assessment of home safety and assessment of caregiver stress or substance abuse. A variety of resources are available to assist with these issues (Table 295-5). Social work consultation can be helpful in finding local resources.

Patients in immediate danger should be hospitalized, transferred to the care of a friend or reliable family member, or placed in an emergency shelter. Suspected abuse should be reported to the appropriate state agency (http://www.ncea.aoa.gov) or local adult protective services agency in order to ensure a follow-up investigation and a thorough long-term assessment. Although all 50 states have adult protective services and long-term care ombudsman programs, reporting is not mandated by law in every state. Elderly who live in the community are protected in all states by adult protective services agencies. Elders in institutional settings are protected in all states by long-term care ombudsman programs. Violations specific to nursing home residents might include the following: failure to respond to calls for help, unattended symptoms, injury of unknown origin or falls, physical abuse, poor staff attitudes related to respect or dignity, inappropriate medications or dosages, stolen or lost property, or abuse by other residents. Much long-term facility abuse occurs between residents; many facilities have younger psychiatric patients who are more mobile and aggressive than the older debilitated residents.²² Become familiar with requirements pertaining to your own practice area (http://www.ncea.aoa.gov).

In cases of unintentional neglect, education of the caregiver may be the only intervention necessary. Other support options include home health aide visits, respite services, day programs, accessible transportation, support groups, adult day care, and church activities or pastoral visitations.^16,23 When mistreatment results because the caregiver is overburdened, interventions to decrease stress and anxiety may be welcomed by all parties. Spouses are most likely to be primary caregivers; most of these are women. Lack of sleep and inadequate exercise and nutrition are commonly expressed by caregivers, perhaps leading to anger and risk of abuse. Services for caregivers may be publicly funded or community based with support groups. Some programs provide home-delivered meals, respite care, counseling, and assistance with advance directives and estate planning.²⁴

If available, medical case management teams can provide consultation and support by assisting in the multidisciplinary evaluation of suspected abuse cases and developing treatment plans. Team members generally are composed of a physician, nurses, and social workers.²⁵ Teams may make house calls, arrange physical and occupational therapy, and provide for nutritional improvement and management of disease states. Legal intervention teams can also be used to address financial management, probate and guardianships, and other legal and housing issues. Civil courts can issue protective orders, create guardianships, and issue emergency removal orders.

Recommendations for ED management of cases of elder abuse and neglect are provided in Table 295-6.

BARRIERS TO THE DETECTION OF ELDER ABUSE

Sufferers of elder abuse often have low self-esteem and may blame themselves for the abuse. They may not want to admit vulnerabilities and feel disgraced for having raised a child who would betray them.^23,26

Elder abuse victims may also be unwilling to press charges against a family member. Abused older adults are frequently unaware of available resources.²⁶ In addition, they may harbor a fear of being removed from the home or placed in a nursing institution, of implicating family members, or of experiencing further abuse in retaliation for having divulged information. They may worry about not being believed. Abusers may control access to others and prevent encounters with outsiders to ensure that secrecy is maintained. There may also be differing perceptions as to what constitutes abuse based on cultural background.²⁷

Physicians may fail to report abuse for a variety of reasons. They may not be familiar with reporting laws or adequately understand reporting mechanisms.⁴ They may fear offending patients or their family members. Time constraints in the ED can also be a barrier to recognition and reporting. There are no published studies of physical markers of mistreatment to distinguish prevenTable injury from intentional, inflicted, or avoidable trauma.²⁸ In addition, some physicians may have the misperception that the law requires them to obtain the patient's permission before reporting suspected abuse.²⁹ Hospitals may also lack protocols for identifying or addressing elder abuse.

ABUSE IN LONG-TERM CARE FACILITIES

Elder abuse in nursing homes is well documented. In one study, 36% of nurses and nursing aides working in long-term care facilities reported witnessing at least one act of physical abuse in the previous year.³¹ A study of 2400 deaths in Arkansas nursing homes found 50 cases of suspected abuse or neglect, which indicates that forensic studies need to play a larger role in the investigation of unexplained deaths of older adults in long-term care facilities.³² Abuse in institutional settings manifests in similar ways to abuse in residential settings: theft of money or personal property, unsanitary conditions, poor personal hygiene, sexual assault, physical abuse or unexplained injury, bed sores, physical or chemical restraint, and malnutrition and dehydration. Nursing homes participating in Medicare and Medicaid programs must comply with certain quality-of-care requirements.³³ Suspicion of abuse or neglect among patients in nursing homes should be reported to the state nursing home ombudsman program (http://www.ltcombudsman.org) or to an adult protective services agency.

LEGAL CONSIDERATIONS

Circumstances may occur in which hospital admission is advised, but the patient refuses. If the patient is competent, his or her wishes must be honored, even if those wishes do not appear to be in the patient's self-best interest. Decisional capacity by the patient depends on his/her ability to understand all of the relevant information in order to make a choice, to communicate that choice, and to appreciate the current situation and treatment options. In these cases, it is especially important to interview the patient alone and to explain in detail the concerns of the healthcare provider. The physician should also attempt to explore reasons for the patient's reluctance to stay.

Patients who refuse admission but who lack decision-making capacity should not be discharged back to an unsafe environment. Contact with an adult protective services agency should be initiated. ED social workers can help locate contact information for the local adult protective services agency. If the agency determines that the victim of abuse lacks decision-making capacity, an emergency order for protective services may need to be sought from the courts.