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The definition of elder abuse in the United States, varies on the basis of each state's statutes and regulations.[1] Researchers also use different definitions to describe and study the issue. However, the World Health Organization (WHO)[2] and US Department of Justice (USDOJ)[3] define elder abuse as follows:
"Elder abuse is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person."
The National Center on Elder Abuse (NCEA)[4] and the Centers for Disease Control and Prevention (CDC) use similar language.[5] Thus, a broad definition of elder abuse is intentional actions that injure or put a vulnerable elder (typically considered age ≥60 years) at risk of injury by a caregiver or another person who has a relationship with the elder. Elder abuse also includes the failure of a caregiver to provide for the elder's basic needs or to protect the elder from harm.[1-5]
Image courtesy of Dreamstime/Skypixel.
The prevalence and extent of elder abuse may surprise many. Worldwide and in the United States, approximately 8%-10% of all seniors will experience some form of elder abuse every month.[2,4] This translates to an annual estimate of 5 million older Americans suffering elder abuse, neglect, or exploitation.[7] However, underreporting is likely, with roughly only 1 in 23 to 24 cases of elder abuse reported to authorities,[2,3,5,7] and it is a growing problem[8]—as recognized by the launch of World Elder Abuse Awareness Day on June 15, 2006, by the International Network for the Prevention of Elder Abuse and the WHO at the United Nations.[8]
By 2050, the global population of those aged 60 years and older is estimated to double (from 900 million in 2015 to about 2 billion),[2] and the US population of those aged 65 years and older is expected to comprise 20% of the US population, of which approximately 19 million will be people aged 85 years or older.[4] Thus, elder abuse will continue to have significant wide-ranging social, financial, and individual and public health implications.[2-4,8]
Graph courtesy of the NCEA.[4]
Elder abuse is difficult to detect, and cultural and language barriers can further hinder the discovery of abuse. For example, in some Asian cultures, the elderly may hesitate to seek help for abuse because they consider it a private family issue. In these cultures, it is also considered shameful if the young do not respect their elders—thus, if a senior reports abuse by an adult child, the elder may equate this to admitting that he or she did not raise the child with appropriate values.[9]
Other cultures also have varying opinions about what qualifies as abuse. For instance, disrespecting a senior, as discussed above, is considered abuse in some Asian cultures, whereas other Asian cultures believe treating the elderly as hired help for housekeeping is abuse. Regardless, elder mistreatment is pervasive across all cultures and has been documented in North and South America, Europe, Asia, Australia, and Africa.[10]
Images courtesy of Paul Maguire (left top), Szefei (left center), Witthayap (left bottom) and Bgopal (right), all via Dreamstime.
The average clinician is likely to encounter a patient who is experiencing elder abuse at home and therefore must be vigilant about looking for signs of abuse, as the patient is unlikely to be forthcoming.[6]
Types of elder abuse are generally classified into the following five groups[1-6], but they can also occur in combination (polyvictimization)[3]:
Each type of elder abuse has different presentations, and clinicians should become familiar with the signs of each. In addition, note that elderly polyvictimization, in which an older adult suffers two or more forms of abuse concurrently, is estimated to occur in between 10.5% and 50% of seniors internationally.[3] In the United States, about 30%-40% of seniors experience multiple forms of victimization by the same offender.[3]
Adapted table courtesy of the US Government Accountability Office (GAO).
Seniors with dementia are at a higher risk for mistreatment[4,10]: Elderly patients with Alzheimer disease are 5 times more likely to experience abuse than their counterparts without dementia.[10] However, although dementia, cognitive decline, functional impairment, and poor physical health are the greatest risk factors for abuse, other factors also place elders at increased risk of mistreatment, including the following[2,10]:
The senior's primary caregiver, frequently the patient's spouse or adult child, is most likely to be the abuser.[4,6,11] Abusers are also more likely to be male, have mental health disease, and/or have active or past substance abuse. Caregivers who are unemployed or under financial stress or those who are socially isolated also have a greater likelihood of becoming abusive.[4,6,11]
Adapted image courtesy of National Institute of Justice.
Although investigators of child abuse have been able to identify injuries that are diagnostic of pediatric abuse, researchers have not been able to achieve the same feat in elder abuse studies. Nonetheless, clinicians can still use clinical clues to look for elder mistreatment if the provided explanation for an injury does not fit the expected pattern.
For example, splash burns should not have sharp demarcations or "stocking-glove" patterns, which suggest forced immersion in hot liquid.[12,13] Patterned injuries, such as bruises in the shape of a hand, bite marks, or ligature marks should be regarded as the result of abuse—until proven otherwise. An eye examination that reveals subconjunctival (shown) or vitreous hemorrhage should trigger further investigation for abuse.[12,13] Clinicians should also look for signs of dehydration, fecal impaction, unexplained weight loss, or missing medications.[2-5,13]
Image courtesy of WikimedialCommons/James Heilman, MD.
If clinicians suspect elder abuse, the law mandates they report it.[3] Clinicians should contact adult protective services (APS) and file a report.
If the senior is in immediate danger, call 9-1-1 immediately and transport him/her to the nearest emergency department (ED) via emergency medical services (EMS). Notify the appropriate agency of the elder's presence in the ED, where forensic evidence may be collected.
The US Department of Justice (USDOJ) provides resources to report elder abuse by state, as well as for Puerto Rico, American Samoa, Guam, the Mariana Islands, and the US Virgin Islands at https://www.justice.gov/elderjustice/support/resources.html.
Adapted APS example flow chart courtesy of NCEA/National Adult Protective Services Association (NAPSA).
In general, bruises in a senior should not be larger than 5 cm, and they should not appear on the face, back, or over bony prominences without a plausible explanation.[12] In addition, older patients with limited mobility are unlikely to have bruising on the abdomen, genitals, buttocks, inner thighs, or feet as a result of accidental injury.[13]
In cases of elderly physical abuse, injuries to the upper extremity are most common. Clinicians should look for contusions in the axilla as well as on the inner aspects of the arm—locations that are unlikely to be injured in accidental trauma.[12] Self-defense injuries may also be present, such as bruises or abrasions obtained when victims hold up their hands or arms to protect their face and/or head.
Image courtesy of Dreamstime/Hriana.
If clinicians suspect physical abuse of their elderly patients, they should investigate further for signs of other types of abuse.[6] Perform a complete skin examination; if appropriate, a genital examination may be warranted, as determined on an individual basis.
Also seek or obtain additional sources of information. These include using the electronic medical record (EMR) to evaluate for multiple ED or outpatient appointments.[6] Numerous ED visits may be indicative of abuse or neglect. Review appointment records to evaluate if the patient's medical problems are being appropriately managed. Consider contacting the patient's pharmacy to confirm medications are being filled on schedule.[6]
Image courtesy of doc-stock/Visuals Unlimited.
Mimics of elder abuse
As is well documented in child abuse, some physical conditions can mimic abuse. In cases of suspected elder abuse, clinicians must determine whether findings are the result of normal aging, disease processes, or intentional mistreatment.[13]
For example, the picture shown depicts a contact dermatitis; however, if this patient presented to the ED and was unable to provide a history, the lesion could easily be mistaken for a burn.[13] Stevens-Johnson syndrome and toxic epidermal necrolysis can also present with the appearance of burns and scalds.
Similarly, many elderly patients are on anticoagulant agents and may bruise easily because of their medications.[13] In addition, bruising that resembles the shape of fingers around the extremities may be the result of a caregiver trying to move a patient and is not a guarantee of abuse. Other examples of abuse mimics include senile and steroid purpura, and fractures from osteoporosis or Paget disease.[13]
Image of a urushiol-induced contact dermatitis courtesy of Wikimedia Commons/Nunyabb.
The elderly population is also at risk for sexual abuse.[1-6] This abuse may be inflicted by a family member, an institutional caregiver, or by another elderly person, such as a co-resident in a nursing home.[14] Of note, if a patient lacks decision-making capacity, he/she is also unable to consent to sex.[5,14]
Some findings of sexual abuse are obvious or will be reported by the patient, whereas others are more elusive. In addition to contusions on the external genitalia or inner thighs, potential indicators of sexual abuse include the following[6,14]:
If sexual abuse is suspected, clinicians should also assess for the presence of genital ulcers, which may signal syphilis, herpes, or chancroid, and consider obtaining tests for gonorrhea and chlamydia.
Conditions that mimic sexual assault in elderly patients include cystoceles or uterine prolapse, inflammatory bowel disease (IBD), vaginitis, vaginal bleeding/excoriation from low estrogen levels, perineal excoriation from incontinence or lichen sclerosis, fixed drug eruption, and decreased anal sphincter function.[13]
Image of a primary stage syphilis chancre on the surface of a tongue courtesy of the CDC.
Decubitus ulcers are often identified as a cardinal sign for neglect, but they can occur even with good caretaking. The elderly have several risk factors for decubitus ulcers, including the following[15]:
However, any elderly patient with a nonhealing wound and/or decubitus ulcer should raise the suspicion for abuse, and clinicians may need to file a report for neglect or abuse. These types of wounds may be an indication that the patient is not being repositioned often enough or is being left in soiled garments for prolonged periods.
Image of pressure ulcer stage classifications courtesy of Wikimedia Commons/Nanoxyde.
Signs of nutritional deficiencies can also be signals for neglect.[3] Some are obvious, such as purpura and petechiae in the setting of a vitamin C deficiency or pellagra (shown) caused by a lack of niacin. However, other nutritional deficiencies, such as thiamine and folic acid, can have a more insidious presentation. Undernutrition has also been shown to accelerate cognitive decline, decrease energy levels, and/or depress mood.[15-17]
Note that not all nutritional deficiencies are the result of neglect; elderly people experience changes in taste, smell, and digestive hormone secretion; delayed gastric emptying; and impairment of appetite regulatory mechanisms—all of which may decrease their appetite and put them at risk for nutritional deficiencies.[18]
Conditions that mimic starvation include IBD, hypothyroid-induced malabsorption, diabetes-induced weight loss, and mental illness–related anorexia.[13]
It is the responsibility of the clinician to determine if the patient's undernutrition is the result of abuse and neglect or from some other cause.[17]
Images of pellagra in a patient courtesy of DermNet NZ.
Seniors are at especially high risk for financial abuse, and the problem is so widespread that multiple federal agencies across different systems have missions to combat it (shown).[19] Financial exploitation is not only the fastest growing form of elder abuse,[1] it is also the most prevalent in conjunction with neglect.[3] This combination of abuse may be the most difficult to detect because the signs can be subtle.
If an elderly patient begins to frequently miss clinical appointments or is unable to fill his/her prescriptions, clinicians should further investigate by evaluating the senior's functional status and asking the patient if his/her needs are being met by the caregiver.[6] Frequent visits to the ED for conditions that should be well controlled or the presence of unexplained weight loss should also prompt further evaluation. If the patient's caregiver is newly unemployed or is making extravagant purchases, he/she may be financially exploiting the patient.[6]
Image courtesy of GAO.
Appropriate documentation of elder abuse is critical. In 2016, with the collaboration of experts on elder abuse, the CDC released a publication of uniform definitions and recommended core data elements for possible use in standardizing the collection of elder abuse data locally and nationally. Elements to include in the documentation are as follows[20]:
If available, also note who and how many perpetrators were involved in the most recent incident, the estimated date of the abuse onset, how often it occurred over the past 12 months, and whether previous reports were filed and/or substantiated.[20]
Descriptions and pictures of injuries and/or signs of abuse can help clinicians at future encounters to determine chronicity as well as identify any new injuries. This evidence may also support any legal action taken against the abuser.
Bruises, skin tears, burns, and other skin findings should be measured and described by shape and location. If a sexual assault is suspected or if the patient reports a sexual assault, a forensic examination should be performed by an appropriately trained physician. When documenting the proposed mechanism of injury, clinicians should consider this central question to distinguish intentional injury from unintentional[13]:
"Is the provided explanation reasonable and befitting of the physical findings?"
In cases of suspected elder financial abuse, document the type and approximate value of the assets taken from the senior, and the date(s) and location of the incident(s).[20]
Image courtesy of the CDC.[20]
A unique distinction between the management of child abuse and elder abuse is that elders can refuse treatment and intervention if they have decision-making capacity. In most states, any physician can legally assess capacity; however, a psychiatrist or geriatrician can be of great help in determining if the patient can make his/her own decisions.
Frequent causes of loss of decision-making capacity include dementia and delirium. Seniors who lack such capacity will likely need a guardian to help make healthcare choices and other decisions on the patient's behalf. It is the clinician's duty to participate in guardianship proceedings to prevent an offender from gaining guardianship of a suspected victim of elder abuse.
Image courtesy of Pixabay/geralt.
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