Elder Abuse

Descriptive text is not available for this image BASICS

DESCRIPTION

Elder abuse (EA) is a public health concern (autonomy, wellbeing). Defined as: (i) intentional actions that cause harm or create a serious risk of harm to a vulnerable elder (financial, physical, emotional, impaired capacity for self-care or self-protection risk) by a caregiver or other person who stands in a trust relationship, or (ii) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm (National Academy of Sciences, 2003). In 2009, the estimated cost was approximately $2.9 billion, a 12% increase from the preceding year (National Committee for the Prevention of Elder Abuse).

EPIDEMIOLOGY

Incidence

The global incidence of EA is around 16% (World Health Organization [WHO]). In the United States, it is estimated that 10% of the population are victims of EA and as many as 5 million elders are affected each year.

Prevalence

EA in both the community and in institutions has increased during the COVID-19 pandemic (WHO). The estimated annual prevalence per 1,000 people of key forms of violence is: 22 for physical and sexual abuse, 17 for intimate partner violence, fatal suicide 0.17, nonfatal self-harm 0.27, and 9.7 to 32.6 for violence by older adults with dementia against others (1).

ETIOLOGY AND PATHOPHYSIOLOGY

The etiology of EA involves biopsychosocial factors in combination with increased dependence on the caregiver by the victim in a suboptimal environment with poor behavioral coping methods, further compounded by increased stress.

RISK FACTORS

The victim: advanced age; female gender; low socioeconomic status; exploitable resources; social isolation; lack of purpose; PTSD in veterans; poor self-perceived health; loss of sense of control; health care insecurity; prior history of abuse in life; functional dependence; cognitive impairment; mental illness or substance use; polyvictimization (victim’s perception of EA, protecting the offender, perpetrator influence on the victim). The abuser: early child abuse; history of violence; mental illness or substance use; high stress or poor coping; poor physical or cognitive health; inadequate training or supervision; poor prior relationship between the caregiver and the victim; financial dependency on the victim.

GENERAL PREVENTION

Complete annual wellness visits to discuss advanced care plan, power of attorney for health or finances, goals of care (GOC), degree of self-sufficiency, the role of the caregiver, the risk of caregiver burnout. Assess caregiver stress and burden (meet without patient). Screen for risk or presence of mood disorders (depression: PHQ-2 or PHQ-9; anxiety: General Anxiety Disorder-7 (GAD-7); loneliness: 3-item UCLA) or cognitive impairment (Folstein Mini-Mental State Examination [MMSE], Montreal Cognitive Assessment [MoCA], Saint Louis University Mental Status [SLUMS]). Encourage socialization. Refer to community programs: Department of Aging, Adult Protective Services (APS), Alzheimer’s Association.

COMMONLY ASSOCIATED CONDITIONS

Conditions commonly associated with EA can be risk factors. They include social isolation, increased dependence for activities of daily living/instrumental activities of daily living (ADLs/IADLs), depression, cognitive impairment, and aggressive behavior.

Descriptive text is not available for this image DIAGNOSIS

There is no golden standard for EA screen. The U.S. Preventive Services Task Force has not recommended screening for EA. However, when there is a high clinical suspicion, EA should be considered. Types of EA: physical or sexual, violation of personal rights, material exploitation, neglect (includes abandonment), financial, and psychological. The context can vary from self-neglect, institutional (nursing home, assisted living), or domestic (home). Most commonly, the abuser in a domestic environment is a family member. Screening tools (2),(3): (i) hospital: Elderly Indicators of Abuse (E-IOA); (ii) emergency department: Elder Abuse Instrument (EAI), ED Senior Abuse Identification (AID); (iii) nursing home: Elder Psychological Abuse Scale (EPAS); and (iv) general: Elder Abuse Suspicion Index (EASI); Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST); Vulnerability Abuse Screening Scale (VASS); Lichtenberg Financial Decision Screening Scale (LFDSS)

HISTORY

Use a culture-sensitive history with a focus on prior or current advance care plan. Do a review of living arrangements, degree of physical or cognitive function, who the caregivers are, and if there is evidence of caregiver burnout.

PHYSICAL EXAM

  • It is important to document positive and negative findings in your physical exam and to be detailed because they can be admissible in court. Assess for unexplained fractures.
  • General overall appearance: cachexia; hygiene and clothing; if bedbound, record integrity of mattress and sheets; evidence of falls, including broken eyeglasses
  • Oral exam: dentition, oral ulcers
  • Skin exam: large bruises (>5 cm) located at the face, lateral arm, back, or inner thighs
    • Patterned injury suggesting inappropriate restraint such as bite marks, ligature marks around wrists, ankles, or neck
    • Burn marks in patterns inconsistent with unintentional injury e.g., stocking and glove pattern suggesting forced immersion
    • Open wounds, cuts, punctures, untreated injuries in various stages of healing, traumatic alopecia, or scalp swelling
    • Check for pressure ulcers on the bony prominences of the patient.

DIFFERENTIAL DIAGNOSIS

  • Dementia (FAST 6 or 7), or dementia in a withdrawn or malnourished patient
  • Elderly with Alzheimer, mixed, or lewy body dementia (LBD) can present with delusions.
  • Psychosis
  • Substance use disorders
  • Parkinson disease resulting in fractures or bruises
  • Coagulopathy with advanced malignancy or other conditions
  • Antiplatelet therapy associated with bruising
  • Wasting from malignancy, infections, or chronic disease
  • Delirium due to electrolyte, trauma, infection, heart disease, urine retention, constipation, end-of-life
  • Thyroid disorder associated with altered mental status, delirium, depression, frailty, or anxiety
  • Fixed drug reaction, fragile photo-aged skin, steroid purpura, allergic reaction
  • Fracture from osteoporosis

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

CBC, CMP, UA, vitamin B12, folic acid, RPR, TSH, PT/INR (if bruising)

Follow-Up Tests & Special Considerations

  • Anemia: iron, TIBC, ferritin
  • Change in mental status: vitamin B1, vitamin B6; consider toxicology; consider encephalopathy panel.
  • Trauma: image to assess for new or old fractures. Consider CT head imaging to look for hemorrhage (e.g., subdural).

Diagnostic Procedures/Other

  • Use tools to assess for cognitive impairment such as MMSE (proprietary), MoCA (forgetfulness, MCI), SLUMS
  • Depression screening tools such as the Geriatric Depression Scale, PHQ2 or PHQ9, and GAD-7
  • Documentation
    • Can document “suspected mistreatment” but avoid making definitive diagnosis of EA (or dementia) in your initial assessment, unless it is obvious. Document the abuser’s name, relationship, and contact information.
    • Pictures need to include the patient’s name, medical number, date and time taken, a ruler (used for measurement), name of witnesses that took image. Take pictures of torn clothes.
  • Include anatomical diagrams.
  • In some states, reporting is only mandated when the patient cannot (i.e., for cognitive or physical reasons) do so. The law protects those who report in “good faith.” The identity of the reporter shall not be disclosed except with the written permission of the reporter or by order of a court.

Descriptive text is not available for this image TREATMENT

  • Most states require all health care providers to report suspected EA to a local agency such as the APS (https://www.preventfamilyviolence.org/adult-protective-services-numbers) with limited evidence on effectiveness of other interventions (4).
  • The treatment plan should be centered around action items related but not limited to: the vulnerable older adult, trusted other, or context (Abuse Intervention Model: domain I/II/III) (5).
  • Domain I—vulnerable older adult (victim): Consider virtual education interventions (Elder Abuse Training Institute Island; Ejaz et al). Consider a Family-Based Cognitive Behavioral Social Work (FBCBSW) approach to reduce emotional and financial neglect.
    • Impaired physical function: Assess need for assist devices or physical therapy.
    • Impaired cognition: Make recommendations for a healthy diet, activity, and sleep habits customized to the patient’s capabilities.
    • Emotional distress or mental illness: Assess presence of depression (PHQ-2 or PHQ-9), anxiety (GAD-7). When appropriate, use medications for mood or mental illness.
  • Domain II—trusted others (perpetrator)
    • Dependence on the vulnerable elder: Share with the perpetrator resources to support financial planning to allow mitigation of dependence on the victim.
    • Mood or substance use or pathologic personality traits: Ask the perpetrator to follow with their clinical provider. Report to law enforcement entities if the patient’s life is threatened.
  • Domain III—context of abuse (circumstances)
    • Social isolation: Provide resources to expand a patient’s social network. Can consider a trial of care at assisted living or a nursing home. Work closely with social work (clinic; home health).
    • Low-quality relationship between victim-perpetrator: Seek help from social work or psychologist.
    • Cultural norms: Address taboos related to diagnosis such as dementia in a culture-sensitive manner and customize the plan of care to the patient.

MEDICATION

None

ISSUES FOR REFERRAL

Mood or behavior concern: behavioral health services; cognitive assessment: neurocognitive specialist

ADDITIONAL THERAPIES

Physical and occupational therapy for ambulation, safety assessment, cognition assessment

COMPLEMENTARY & ALTERNATIVE MEDICINE

Relaxation or well-being techniques

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

  • Victims of abuse should not be transferred or discharged without reliable follow-up, including:
    • A home visit either by PCP or by APN, combined with home health services
    • Report to the state’s APS or a designated alternative (e.g., if patient resides in nursing home, then report to that state’s regulatory entity, public health department, and Ombudsman). With physical harm, report to local law enforcement.
    • Follow-up with appropriate mental health care
  • Manage uncontrolled chronic conditions due to neglect (i.e., wound care from ulcers or infections).
  • Hospital security may need to be notified if restricted visitor access to a patient is required.
  • Locations for disposition: friend or family member, nursing home, assisted living facility

Descriptive text is not available for this image ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Although evidence is unclear on a change in outcomes from any education intervention, information about responsibilities should be shared with the person responsible for the patient.
  • Educate caregivers on signs and effects of caregiver burnout matched with resources for home aid services.
  • Review your state requirements on reporting: http://www.napsa-now.org/wp-content/uploads/2014/11/Mandatory-Reporting-Ch....
  • Contact the APS. A helpful resource is http://www.napsa-now.org/get-help/help-in-your-area/.
  • Contact the Department of Aging to request an assessment at home including a review of services that can support the patient to be independent in the community.
  • ED providers should report to the Long-Term Care Ombudsman.

Patient Monitoring

The patient should have frequent home or clinic visits.

DIET

Mediterranean, or MIND diet

PATIENT EDUCATION

  • For EA resources in your state, https://ncea.acl.gov, or call 800-677-1166
  • Other useful resources for families

PROGNOSIS

EA and self-neglect are associated with an overall increased risk in mortality.

COMPLICATIONS

Associated outcomes: mortality; hospitalizations; functional health decline; loneliness; depression

Authors

Thomas Triantafillou, MD
Vivian Nnenna Chukwuma, MD

REFERENCES

  1. Rosen T, Makaroun LK, Conwell Y, et al. Violence in older adults: scope, impact, challenges, and strategies for prevention. Health Aff (Millwood). 2019;38(10):1630–1637.  [PMID:31589527]
  2. Van Royen K, Van Royen P, De Donder L, et al. Elder abuse assessment tools and interventions for use in the home environment: a scoping review. Clin Interv Aging. 2020;15:1793–1807.  [PMID:33061330]
  3. Ries NM, Mansfield E. Elder abuse: the role of general practitioners in community-based screening and multidisciplinary action. Aust J Gen Pract. 2018;47(4):235–238.  [PMID:29621866]
  4. Baker PRA, Francis DP, Hairi NN, et al. Interventions for preventing abuse in the elderly. Cochrane Database Syst Rev. 2016;2016(8):CD010321.  [PMID:27528431]
  5. Mosqueda L, Burnight K, Gironda MW, et al. The Abuse Intervention Model: a pragmatic approach to intervention for elder mistreatment. J Am Geriatr Soc. 2016;64(9):1879–1883.  [PMID:27550723]

ADDITIONAL READING

  • American Bar Association Commission on Law and Aging. Adult protective services reporting chart (laws current as of December 2019). https://www.americanbar.org/content/dam/aba/administrative/law_aging/2020-.... Published December 2019. Accessed January 3, 2022.
  • Cooper C, Katona C, Finne-Soveri H, et al. Indicators of elder abuse: a crossnational comparison of psychiatric morbidity and other determinants in the Ad-HOC study. Am J Geriatr Psychiatry. 2006;14(6):489–497.  [PMID:16731717]
  • Hoover RM, Polson M. Detecting elder abuse and neglect: assessment and intervention. Am Fam Physician. 2014;89(6):453–460.  [PMID:24695564]

Descriptive text is not available for this image SEE ALSO

Descriptive text is not available for this image CODES

ICD10

  • T74.11XA Adult physical abuse, confirmed, initial encounter
  • T74.21XA Adult sexual abuse, confirmed, initial encounter
  • T74.01XA Adult neglect or abandonment, confirmed, initial encounter
  • T74.91XA Unspecified adult maltreatment, confirmed, initial encounter
  • T74.31XA Adult psychological abuse, confirmed, initial encounter

SNOMED

  • 242040000 Physical abuse of elderly person
  • 444557007 Sexual abuse of adult
  • 242043003 Abandonment of elderly person
  • 95921002 elderly person maltreatment (event)
  • 242042008 Deprivation of nourishment of elderly person
  • 242041001 Emotional abuse of elderly person
  • 95929000 Psychologically abused elder

CLINICAL PEARLS

  • To reduce the risk of EA, strengthen the patients’ social support, address depression, provide the patient with assistive devices, screen for cognitive impairment with a trial of medication if possible, and identify caregiver burnout.
  • Refer to the Department of Aging for services such as home aid when ADLs or IADLs are impaired.
  • Patient with capacity: The APS cannot act if a patient has the capacity to make decisions and elects not to report the abuse. Patient with impaired capacity: A medicolegal process along with guidance from the APS can lead to guardianship.

Last Updated: 2026

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