Geriatric Abuse and Neglect

Key Concepts

Elder mistreatment, which includes physical abuse, sexual abuse, neglect, emotional/psychological abuse, abandonment, financial/material exploitation, and self-neglect, is common and may have serious medical and social consequences.
Elder mistreatment is under-recognized by emergency clinicians and under-reported to the authorities.
Signs suggestive of potential elder abuse and neglect that should be recognized by emergency clinicians may exist in the medical history, physical examination, and medical/laboratory markers.
Emergency clinicians should be vigilant in assessing for the possibility of elder abuse or neglect and routinely ask elderly patients about mistreatment, even in the absence of signs and symptoms. Screening protocols may be helpful.
Using a team-based approach including social workers and other emergency department (ED)-based professionals may improve elder abuse detection, and Emergency Medical Services can play a critical role.
ED management of elder abuse should include the following: treating acute medical and psychological issues, ensuring patient safety, and proper reporting to the authorities. Trauma-informed care should be provided.
Emergency clinicians should hospitalize elderly patients who are in immediate danger or implement a care plan that prevents them from having any contact with the suspected abuser(s) but must respect the wishes of an older adult with decision-making capacity who refuses interventions and desires to return to an abusive situation. Trauma-informed care should be provided.
Emergency clinicians should document completely and accurately the history and all physical findings in cases of suspected elder abuse or neglect, as this documentation may be critical to ensure justice for the victim.

Foundations

Background

An ED encounter offers an important opportunity to identify and initiate intervention for elder abuse and neglect, a common but under-recognized phenomenon that may have serious medical and social consequences. Elder abuse and neglect includes: any actions or negligence that may cause harm or risk of harm committed by someone in a relationship of trust or when the victim is targeted due to age or disability, Table 181.1 . Many victims may suffer concurrently from multiple types of abuse.

TABLE 181.1

Types of Elder Abuse and Neglect

Adapted from National Center on Elder Abuse: Types of abuse. Available at https://ncea.acl.gov/Suspect-Abuse/Abuse-Types.aspx .

Type	Definition	Examples
Physical abuse	Intentional use of physical force that may result in bodily injury, physical pain, or impairment	Slapping, hitting, kicking, pushing, pulling hair Use of physical restraints, force-feeding Burning, use of household objects as weapons, use of firearms and knives
Sexual abuse	Any type of sexual contact with an elderly person that is non-consensual or sexual contact with any person incapable of giving consent	Sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photographing Unwanted touching, verbal sexual advances Indecent exposure
Neglect	Refusal or failure to fulfill any part of a person’s obligations or duties to an elder, which may result in harm—may be intentional or unintentional	Withholding of food, water, clothing, shelter, medications Failure to ensure elder’s personal hygiene or to provide physical aids, including walker, cane, glasses, hearing aids, dentures Failure to ensure elder’s personal safety and/or appropriate medical follow-up
Emotional/psychological abuse	Intentional infliction of anguish, pain, or distress through verbal or nonverbal acts	Verbal berating, harassment, or intimidation Threats of punishment or deprivation Treating the older person like an infant Isolating the older person from others
Abandonment	Desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder or by a person with physical custody
Financial/material exploitation	Illegal or improper use of an older adult’s money, property, or assets	Stealing money or belongings Cashing an older adult’s checks without permission and/or forging his or her signature Coercing an older adult into signing contracts, changing a will, or assigning durable power of attorney against his or her wishes or when the older adult does not possess the mental capacity to do so
Self-neglect	Behavior of an older adult that threatens his/her own health or safety—excluding when an older adult who understands the consequences of his or her actions makes a conscious and voluntary decision to engage in acts that threaten his/her health or safety	Refusal or failure of an older adult to provide himself or herself with basic necessities such as food, water, shelter, medications, and appropriate personal hygiene Disregard for maintenance of safe home environment and/or hoarding

Epidemiology and Scope of the Problem

As many as 10% of older adults living in the community and more than 20% of nursing home residents experience some form of abuse, neglect, or exploitation each year. Psychological/emotional abuse, financial mistreatment, and neglect are most commonly reported, while physical and sexual abuse are less common. Elder abuse is strongly associated with adverse health outcomes, including depression, exacerbations of chronic illness, and dramatically increased mortality. Older adults suffering abuse are more likely to present to the ED, be hospitalized, and be placed in a nursing home. The direct medical costs of elder abuse and neglect, though challenging to quantify, are estimated to be many billions of dollars annually and growing as the geriatric population continues to increase.

Despite its frequency and potential for harm, elder abuse and neglect is under-recognized and under-reported, with many sufferers enduring it for years before discovery. Studies suggest that as few as 1 in 24 cases of elder abuse is reported to the authorities, and much of the associated morbidity and mortality is likely due to delay in identification and intervention.

Many factors contribute to elder abuse and neglect ( Table 181.2 ), and researchers have attempted to identify risk factors for becoming a victim or perpetrator. Findings have been inconsistent and difficult to interpret, partly due to methodological limitations, and to the heterogeneity of elder mistreatment cases. Potential risk factors for becoming a victim or perpetrator based on existing evidence are described in Box 181.1 . Cognitively impaired older adults are more likely to be victimized. Sub-populations including military veterans and lesbian/gay/bisexual/transgender older adults may be at particularly high risk. Many cases of elder mistreatment occur in the absence of risk factors, however, and the phenomenon crosses ethnic and socioeconomic boundaries.

TABLE 181.2

Selected Theories of the Underlying Causes of Elder Abuse and Neglect

Adapted from: Jones JS, Holstege C, Holstege H. Elder abuse and neglect: understanding the causes and potential risk factors. Am J Emerg Med . 1997;15:579-583.

Theory	Description
Transgenerational violence	Family violence is a learned behavior, and abused children grow up to potentially abuse not only their own children but also perhaps parents
Psychopathology of the abuser	Mental health issues of the abuser, including personality disorders, poorly treated mood disorders or schizophrenia, alcoholism, and other substance abuse problems, lead to abusive behavior
Dependency	Increasing frailty, including functional and cognitive disability, result in overwhelming care needs that leave an older adult vulnerable to abuse by an overburdened caregiver
Stressed caregiver	A caregiver who has become increasingly stressed (from caregiving or other causes) may be more likely to be abusive
Isolation	Greater social isolation due to disability, illness, and age increases an older adult’s vulnerability to abuse or neglect

BOX 181.1

Potential Risk Factors for Elder Abuse

Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health . 2010;100:292-297; Amstadter AB, Zajac K, Strachan M, et al. Prevalence and correlates of elder mistreatment in South Carolina: the South Carolina elder mistreatment study. J Interpers Violence . 2011;26:2947-2972; Pillemer K, Burnes D, Riffin C, et al. Elder abuse: background paper for the world report on ageing and health. Gerontologist . 2016;56(Suppl 2):S194-205; Gibbs LM. Understanding the medical markers of elder abuse and neglect: physical examination findings. Clin Geriatr Med . 2014;30:687-712.

For Becoming a Victim

Functional dependence or disability
Poor physical health
Cognitive impairment/dementia
Poor mental health
Low income/socioeconomic status
Social isolation/low social support
Previous history of family violence
Previous traumatic event exposure
Substance abuse

For Becoming a Perpetrator

Mental illness
Substance abuse
Caregiver stress
Previous history of family violence
Financial dependence on older adult

Identifying Elder Abuse and Neglect in the Emergency Department

The ED visit provides an opportunity to identify elder abuse or neglect. For many older adults, assessment by health care providers is their only contact outside the family. Limited research suggests that elder abuse and neglect victims are less likely to see a primary care provider but receive ED care more frequently than other older adults, often for management of acute illnesses or injuries. A recent study found that 7% of cognitively intact older ED patients reported a history of physical or psychological mistreatment during the previous year. The actual prevalence is likely much higher, as abuse is more common among cognitively impaired older adults, and because neglect and financial exploitation were not included. Additionally, the nature of an ED encounter increases the potential for detection, as an older adult is typically assessed over several hours by multiple providers.

Despite the opportunity, emergency clinicians seldom identify and report elder abuse and neglect. Several reasons exist for this missed opportunity, including inadequate training, difficulty distinguishing between intentional and unintentional injuries, lack of time to conduct a thorough evaluation for abuse, concern about involvement in the legal system, a victim’s unwillingness to report, and a victim’s inability to report due to cognitive impairment. For the health of our patients, it is critical that all emergency care providers embrace the challenge of identifying and initiating care for victims of elder abuse and neglect.

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