Older adult abuse

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Older adult abuse, also referred to as elder abuse, is any form of maltreatment of an individual ≥ 60 years of age by a trusted person or caregiver. Signs of older adult abuse include lack of control of medical conditions, delays in seeking appropriate medical care, and unexplained soft tissue injuries. Screening recommendations for older adult abuse vary, and there are no tests or screening tools to definitively confirm the diagnosis. If older adult abuse is suspected on clinical evaluation or on laboratory analysis (e.g., evidence of dehydration, malnutrition, and/or medication nonadherence), further evaluation is warranted. Management includes treating acute medical conditions, ensuring patient safety, and mandatory reporting in most states.

• Older adult abuse: any form of physical, emotional, sexual, psychological, or financial mistreatment or neglect of an adult ≥ 60 years of age by a caregiver or someone the individual trusts ^[2][3]

Approximately 10% of older adults experience older adult abuse. ^[2][4][5]

Epidemiological data refers to the US, unless otherwise specified.

• Female sex
• Large household
• Residence in an assisted living facility
• Dementia
• Functional impairment or poor physical health
• Social isolation and/or lack of support
• Low income
• Financial dependency of the caregiver on the older adult

Not all individuals with these risk factors are mistreated or abused. Not all individuals who experience abuse have these risk factors. ^[6]

On history ^[2][6][7]

• Delay between onset of illness or injury and seeking medical care
• Lack of control of medical conditions despite an adequate care plan
• Frequent ED visits
• Reports of theft or unusual loss of belongings or money
• Depression, suicidal ideation

On examination ^[2][6]

• Soft tissue injuries that are unexplained or characteristic of older adult abuse
  • Bruises > 5 cm; especially in unusual locations (e.g., abdomen, medial aspect of arms, and posterior aspect of legs and neck)
  • Injuries to the head, neck, and upper extremities
  • Facial injuries
  • Ligature marks, bite marks
  • Pressure ulcers, multiple burns, cuts ^[7]
• Anogenital trauma, pelvic pain, and/or postmenopausal bleeding
• Dehydration and/or malnutrition
• Unusual or unexplained fractures

Observed interactions with caregivers ^[2][6][7]

• An inconsistent history between the patient and caregiver
• Patient shows fearful, avoidant, or hostile behavior (e.g., avoiding eye contact), especially if this is reported to be new behavior.
• Caregiver is frustrated, overwhelmed, or lacks knowledge about the patient's needs.

Indications for screening ^[8][9]

Screening recommendations for older adult abuse and neglect (including self-neglect) vary.

• The American Medical Association, American College of Emergency Physicians, and American Academy of Neurology make general recommendations for routine screening, but without specifying any particular tool. ^[10][11][12]
• The American Academy of Family Physicians suggests routine screening for risk factors for older adult abuse. ^[6]
• According to the USPSTF, there is insufficient evidence to recommend either for or against routine screening for older adult abuse. ^[3]

Consider routine screening for older adult abuse in all individuals > 60 years of age.

Screening tools ^[9]

• There is insufficient evidence on the best method to screen for older adult abuse. ^[3][9]
• Follow hospital protocols when available.
• Screening for cognitive impairment is recommended before screening for abuse. ^[6]
• Examples of tools include:
  • Elder Abuse Suspicion Index for use in ambulatory care settings ^[6]
  • Emergency department senior abuse identification tool, which incorporates cognitive screening, for use in the ED ^[9][13][14]

If there is any suspicion of older adult abuse, refer the patient to Adult Protective Services, social services, or their equivalent, for further evaluation. ^[6]

• General principles ^[6][8]
  • If presenting in the emergency room, conduct a primary survey; see “Trauma in older adults.”
  • Obtain informed consent for every diagnostic and management step.
  • Attempt to speak to the patient privately.
  • Maintain a low threshold for notifying hospital security about suspected older adult abuse to ensure the safety of the patient and staff.
  • Involve a multidisciplinary team early.
  • Follow local protocols for preparing accurate medical documentation for potential criminal proceedings.

Approach ^[2][6]

There are no diagnostic studies that can definitively confirm older adult abuse.

• Perform a clinical evaluation in patients with either of the following:
  • Red flags for older adult abuse
  • Positive routine screening for older adult abuse
• Consider additional diagnostic studies, based on clinical suspicion, to:
  • Identify findings that may be consistent with older adult abuse
  • Exclude organic causes of signs and symptoms

Signs of older adult abuse may be difficult to distinguish from features of age-related conditions (e.g., poor wound healing, osteoporosis, dementia) or adverse effects of prescribed medication (e.g., steroid purpura). ^[6]

Clinical evaluation ^[2][6][8]

The goal of clinical evaluation is to identify and/or further evaluate red flags for older adult abuse to determine whether there is a reasonable suspicion for abuse. It is essential to interview patients and their caregivers separately.

• Perform a cognitive screening test.
  • Cognitive impairment likely: Depending on the nature of the deficit, a reliable history may be difficult to obtain; consider modifying or proceeding to physical exam. ^[2][9][15]
  • Cognitive impairment unlikely: Proceed through the following steps.
• Obtain a detailed medical history.
  • Ask specific questions about abuse.
    • Indirect questions may be less intimidating.
    • Ask direct questions if necessary.
  • Perform a medication review.
  • Perform a brief functional status assessment.
• Perform a thorough physical examination.
  • See “Red flags for older adult abuse.”
  • If there is concern for sexual assault, a forensic exam should be performed by a trained professional.

Patients' self-reported clinical history may be unreliable, e.g., due to cognitive impairment, fear, shame, or cultural and/or language barriers. ^[2][6][9]

Laboratory studies ^[4][6]

• CMP: Hypernatremia and increased BUN:creatinine ratio may indicate dehydration.
• Urinalysis: Increased urine concentration may indicate dehydration.
• CPK and urine myoglobin: Increased CPK or urine myoglobin may indicate rhabdomyolysis secondary to prolonged immobility.
• CBC: Anemia may indicate malnutrition.
• Coagulation studies: Coagulopathy may explain excessive bruising.
• Prescribed medication drug levels:
  • Low or undetectable levels may indicate neglect in providing medications as prescribed.
  • Supratherapeutic levels may suggest intentional or unintentional overdose.

Imaging ^[4][6]

• Obtain imaging studies based on history and physical examination.
• Notify the radiologist if abuse of an older adult is suspected.

Treatment ^[4]

• Treat traumatic injuries (e.g., fractures) and acute medical conditions.
• Manage any exacerbations of chronic conditions.
• See also “Trauma in older adults.”

Reporting ^[8]

General principles

• Physicians have a legal obligation to protect their patients and report older adult abuse in most states, even if reporting goes against the patient's wishes. ^[8][16]
• State-specific information can be found on the state's Department of Health website. ^[17]

Specific scenarios ^[18][19][20]

• Danger from the perpetrator is immediately life-threatening: Notify law enforcement authorities. ^[21]
• Danger from the perpetrator is not immediately life-threatening.
  • Notify Adult Protective Services if the patient lives in the community.
  • Notify the Long-Term Care Ombudsman program if the patient lives in a facility (e.g., nursing home).

Disposition

Admit to the hospital or create a safe discharge plan.

In the US, the appropriate agency for reporting older adult abuse can be found by calling Eldercare Locator (1-800-677-1116) or visiting the National Adult Protective Services Association website (https://www.napsa-now.org/help-in-your-area/). ^[4][8]