help concept, special toned photo f/x, focus point selectiveHave you ever identified elder abuse in a patient in your ED? The signs can often be subtle, can look like one of many other medical or traumatic problems, and can be mistaken for aging-related changes. This is an unpleasant topic, but rather than bury our heads in the sand and pretend it doesn’t happen, let’s face it and see what we can do to intervene and help. How can you miss it less often? And what are your legal obligations if you suspect elder abuse?

What constitutes elder abuse and neglect?

Elder abuse is defined as1:

Intentional actions that cause harm or a serious risk of harm to a vulnerable elder by a caregiver or person who stands in a trust relationship with the elder, or failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.

According to the National Center for Elder Abuse (NCEA), elders who experience abuse have a 300% increased risk of death, as well as worse physical and mental health. Elder abuse and neglect lead to about $5.3 billion in annual health care expenditures in the U.S., and financial exploitation is estimated to cost elders $2.9 billion annually.

We often think of abuse as physical violence. However, in older patients the primary forms of abuse are intentional neglect, followed by financial exploitation and emotional abuse.

The different forms of abuse are as follows (adapted from: 1, NCEA, and Tintinalli’s textbook of EM)

  • Neglect – Refusal or failure by those responsible to provide food, shelter, health care or protection for a vulnerable elder
  • Exploitation – Illegal taking, misuse, or concealment of funds, property, or assets of a vulnerable elder
  • Physical Abuse – Inflicting, or threatening to inflict, physical pain or injury on a vulnerable elder, or depriving them of a basic need
  • Emotional Abuse – Inflicting mental pain, anguish, or distress on an elder person through verbal or nonverbal acts, including threats, intimidation, and harassment
  • Sexual Abuse – Non-consensual sexual contact of any kind, coercing an elder to witness sexual behaviors
  • Abandonment – Desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person

Some sources also include self-neglect:

  • Self-Neglect – failure or inability to provide oneself with sufficient food, clothing, shelter, medical, or hygiene, or inability to perform self-care tasks

In a study by the DHHS and the NCEA of 71,000 substantiated claims of abuse (many of which involved multiple types of abuse), neglect occurred in almost half of cases, psychological and financial abuse in 35% and 30% respectively, and physical abuse in 25% of cases.

How common is it?

It is difficult to know the true prevalence, as victims often do not report abuse. However, studies suggest that in any given year, abuse or neglect occur in about 1 in 10 older adults.2 About half of patients with dementia have experienced some type of abuse or neglect.3,4 According to the NCEA only about 1 in 14 individuals experiencing abuse or neglect are ever brought to the attention of the appropriate authorities.

Which patients are most at risk?

There are a number of risk factors that have been identified for elder abuse (adapted from Tintinalli’s). These include:

  • Advanced age
  • Alcohol abuse
  • Dementia
  • Difficulty managing finances
  • Female gender
  • History of domestic violence
  • Institutionalization
  • Lack of social support
  • Physical or developmental disabilities

There are also characteristics of the perpetrator that place the patient at higher risk, including:

  • Financial dependence on the elder
  • History of violence
  • Mental illness
  • Substance abuse

Most often, abuse occurs in the home, and the abuser is most often a family member, particularly a child of the patient. However, abuse and neglect also occur in nursing and long-term care facilities. Per the NCEA, when surveyed, 44% of nursing home residents admitted to having experienced abuse or neglect. In a study of nursing home caregivers in Israel, 50% admitted in the last year to having mistreated (one third of cases) or neglected (two thirds of cases) a patient.5

 abuse-graph

How can I identify abuse or neglect in the ED?

1. The first step is to be aware of the possibility of abuse. If you don’t think about it, you will almost always miss it.

2. The next step is to speak with the patient in private. Patients often do not report abuse for fear of repercussions to the perpetrator, who is most often the primary caregiver, and is a family member in 90% of cases. The patient may also fear retaliation.

3. Ask specific questions. Rather than asking if the patient has ever experienced abuse or neglect, the American Medical Association recommends the following 9 questions, which you could tailor to the situation depending on what you are concerned about.1

  • 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? (in all honesty though, most of us have…)
  • 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.

4. Keep your eyes open for clues. Many of these are non-specific, and can be part of or exacerbated by chronic illnesses or frequent falls from an unsteady gait. So their presence should lead to further questions, but usually no single finding is diagnostic of abuse1:

  • Unexplained injuries, burns, fractures, or lacerations, or patters that suggest defensive injuries such as mid-shaft ulnar fractures, spiral long-bone fractures, or multiple injuries in different stages of healing. In cases of physical abuse, upper extremity and face/skull injuries are most common sites.6
  • Inconsistent stories of how injuries occurred
  • Poor hygiene, uncared-for pressure ulcers, malnutrition, and dehydration can all be signs of neglect.

5. Interview the family members alone when concerned about unexplained injuries, but also to assess whether the family members are simply unable to adequately care for the patient, or may not be aware of the patient’s medication and health-care needs, and may benefit from additional services or referrals.

What about unintentional or self-neglect?

Sometimes patients may have poor care due to self-neglect. Alternatively, the family member who is a caregiver may be overwhelmed by the elder’s healthcare needs, or may be unable to care for the patient due to their own illness or disability or due to poor health literacy, and so may unintentionally neglect the patient. The caregiver may require better education on how to care for a bed-bound patient, or on medication administration. Or they may simply lack the resources if, for example, they work during the day and the patient must be left alone. Some patients and families of low socio-economic status may have difficulty obtaining medications or adequate nutrition, leading to unintentional neglect. Clearly these patients and families need our help and assistance, not condemnation. In these cases, a social worker may be able to help connect the patient to available resources. Adult protective services may also be able to help assess the situation and connect them with services.

What should I do if I suspect elder abuse or neglect?

If the patient will be admitted for medical reasons, be sure to communicate your concerns to the admitting team. The inpatient case manager or social worker can help facilitate reporting to adult protective services if needed. If a patient is being discharged, make sure they are going to a safe place. If there is any concern for immediate danger, do not send the patient home. Most states have mandatory reporting laws for suspected elder abuse. In these cases, it should be reported to adult protective services (APS). In many EDs, the social worker or case manager can assist with this. APS will then investigate. The NCEA has state-by-state resources for reporting. You should become familiar with your own hospital’s resources and the reporting laws in your state. If you are unsure, call the resources listed for your state to find out your reporting obligations.

Take-home points

As with many social and societal problems, we are on the front lines in the ED, and can potentially help vulnerable individuals by admitting high-risk patients, helping gain access to services for self-neglect, and reporting abuse or neglect to APS when applicable.

  1. Keep elder abuse or neglect in mind, particularly when you see patients with poor care, malnutrition, or unexplained or suspicious injuries.
  2. Interview the patient alone and ask specific rather than general questions about signs or symptoms of abuse or neglect.
  3. Most states have mandatory reporting laws. If in doubt, contact your state’s APS, and find out the reporting laws or guidelines.
  4. Keep in mind self-neglect and unintentional neglect due to inability of care-givers to meet the patient’s needs, or financial difficulties. The caregiver or patient may need additional resources, and APS may be able to help in these cases as well.
1.
Bond M, Butler K. Elder abuse and neglect: definitions, epidemiology, and approaches to emergency department screening. Clin Geriatr Med. 2013;29(1):257-273. [PubMed]
2.
Acierno R, Hernandez M, Amstadter A, 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(2):292-297. [PubMed]
3.
Cooper C, Selwood A, Blanchard M, Walker Z, Blizard R, Livingston G. Abuse of people with dementia by family carers: representative cross sectional survey. BMJ. 2009;338:b155. [PubMed]
4.
Wiglesworth A, Mosqueda L, Mulnard R, Liao S, Gibbs L, Fitzgerald W. Screening for abuse and neglect of people with dementia. J Am Geriatr Soc. 2010;58(3):493-500. [PubMed]
5.
Ben N, Ariela L. Study of factors that affect abuse of older people in nursing homes. Nurs Manag (Harrow). 2010;17(8):20-24. [PubMed]
6.
Murphy K, Waa S, Jaffer H, Sauter A, Chan A. A literature review of findings in physical elder abuse. Can Assoc Radiol J. 2013;64(1):10-14. [PubMed]
Christina Shenvi, MD PhD
ALiEM Associate Editor
Assistant Professor
Assistant Residency Director
University of North Carolina
www.gempodcast.com
Christina Shenvi, MD PhD

@clshenvi

Emergency Medicine and Geriatrics trained, Assistant Residency Director, mother of 4, excited about #MedEd, #EM, #Geriatrics, and #FOAMed.