Elder Abuse

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.