How to Identify and Intervene in Cases of Elder Abuse
With Dr. Tony Rosen
Elder abuse is a common and under-recognized problem among older adults. In the Emergency Department, we are uniquely positioned to identify patients who may be at risk. In this episode, Tony Rosen, an Emergency Physician and researcher with fellowship training in Geriatric Emergency Medicine, who works at Cornell in NYC discusses what constitutes elder abuse, its prevalence, how to identify it, and what to do when you suspect it.View Responsibilities by State
What is “elder abuse?”
- Action or negligence against a vulnerable older adult that causes harm or risk of harm either:
- committed by a person in a relationship with an expectation of trustor
- when the older adult is targeted based on age or disability
- This mistreatment may include physical abuse, sexual abuse, neglect, psychological abuse, or financial exploitation, and many victims suffer from multiple types of abuse at the same time
How common is elder abuse?
- 5-10% of community dwelling older adults are victimized each year
- More common in nursing homes, though the perpetrators are not typically staff, as you might think, but rather other resident – recent research suggests that more than 20% of nursing home residents suffer from mistreatment each month
- Psychological abuse, neglect, financial exploitation more common
- Physical abuse, sexual abuse less common – but they do occur!
Are there medical consequences to elder abuse?
- Associated with3X greater mortality and increased morbidity including: higher rates of depression, hospitalization, nursing home placement, and – emergency department visits
- Medical costs associated with elder abuse are likely many billions of dollars annually
Who is at greatest risk?
- Research is conflicting and hasn’t yet clearly defined risk factors, but we think that cognitively impaired older adults may be at much greater risk
- We also think that: poor physical health, poor mental health, low income / socio-economic status, socialisolation / low social support, history of family violence, previous traumatic event exposure, and substance abuse may increase risk
Who are the perpetrators?
- Often a family member such as a spouse, boyfriend/girlfriend, or adult child – but also may be a paid caregiver
- Risk factors for perpetrating elder abuse include: Mental illness, substance abuse, financial dependence on an older adult,or caregiver stress (particularly with an older adult who has behavioral issues)
How often is elder abuse identified?
- Unfortunately, research suggests 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 this delay in identification and intervention.
Why does the ED need to focus on this?
- An emergency department (ED) visit provides a unique opportunity to identify elder abuse, which has high morbidity and mortality
- Medical assessment for injury or illness may be the only time a victimized older adult leaves their home.
- Available evidence indicates that victims of elder abuse are less likely to receive routine care from a primary provider than other older adults but receive emergency care more frequently
- Further, the potential for identifying elder abuse in the ED may be higher than in other healthcare settings because ED visits are unplanned, leaving perpetrators and victims little or no time to align histories or suppress evidence of abuse
- Also, despite our best efforts, ED visits are typically prolonged, with many providers able to observe, examine, and interact with a patient
- Despite this, emergency providers seldom recognize or report, due to several factors:
- Lack of formal training in identifying signs of abuse
- Uncertainty about the appropriate steps to take after identification
- Doubts about the effectiveness of interventions
- ED plays a central role in child abuse detection, suggesting the potential for a similar approach to assist this other vulnerable population
How could an ED physician screen for elder abuse if he or she wanted to?
- Though several tools to screen for elder abuse have been described in the literature, none of these tools are specifically designed for the ED.
- A brief, accurate screening protocol to assess all older adults for abuse would be valuable, but whether this can be achieved and if the best place to conduct the screen is at or after triage is unknown.
- Additional research on ED screening for elder abuse is ongoing.
- The Elder Abuse Suspicion Index (EASI) is a short screening instrument that is easy to use in the Emergency Department and has been validated for cognitively intact patients in family practice and ambulatory care settings. This will be available as an additional resource.
- Therefore, a physician should look for clues in the history and physical that suggest potential mistreatment, many of which are similar to other types of family violence that we see as ED providers.
- Historical cluse include: poorliving conditions according to paramedics or others, unexplained injuries, past history of frequent injuries, delay between onset of medical illness or injury and seeking of medical attention, recurrent visits to the emergency department for similar injuries, using multiple physicians and emergency departments for care rather than one primary care physician (“doctor hopping or shopping”)
- Also, physical findingsmay suggest mistreatment. These serve as a reminder that, though it may be difficult in a busy ED, head-to-toe examination of older adult patients is critical to providing optimal care:
- PHYSICAL ABUSE: bruising in atypical locations (not over bony prominences / on lateral arms, back, face, ears, or neck), patterned injuries (bite marks or injury consistent with the shape of a belt buckle, fingertip, or other object, wrist or ankle lesions or scars (suggesting inappropriate restraint), burns (particularly stocking / glove pattern suggesting forced immersion or cigarette pattern), multiple fractures or bruises of different ages, traumatic alopecia or scalp hematomas, subconjunctival, vitreous or retinal ophthalmic hemorrhages, intraoral soft tissue injuries
- SEXUAL ABUSE: genital, rectal, or oral trauma (including erythema, bruising, lacerations), evidence of sexually-transmitted disease
- NEGLECT: cachexia / malnutrition, dehydration, pressure sores / decubitus ulcers, poor body hygiene, unchanged diaper, dirty, severely worn clothing, elongated toenails, poor oral hygiene
What can we do if we suspect or confirm it?
- 3 things: treat acute medical and psychological issues, ensure patient safety, and report to the authorities
- Traumatic injuries and metabolic abnormalities including dehydration are common and should be stabilized and treated. Also, management of worsening chronic medical conditions may be required due to an abuser’s failure to provide appropriate care. In some circumstances, hospitalization may be necessary to provide extended treatment and observation.
- If a mistreatment victim is in immediate danger, the patient should be prevented from having any contact with the suspected abuser. (This may be challenging, as, in some cases, the suspected abuser may be the patient’s official health care proxy!) In extreme cases, this may require security watch for the patient and even having the abuser removed from the Emergency Department and law enforcement, hospital social workers and administrators should be alerted. Alternate living arrangements may need to be arranged for the patient. It not possible, the patient may require hospital admission to ensure safety.
- If the patient refuses intervention, you must determine whether the patient has the capacity to make this decision. A psychiatric consultation (if available!) may be helpful. The wishes of an older adult with decision-making capacity who desires to return to an abusive situation must be respected, as in cases of intimate partner violence among younger adults. If possible, the emergency provider should educate the patient about the potential for escalation in violence and abuse and provide appropriate referral materials for future use.
- In suspected cases of elder mistreatment without an imminent threat to a patient’s safety, interventions may be individualized. If the patient wants to return home and may be safely discharged, the emergency provider should coordinate with the patient’s primary care physician to ensure an appropriate longitudinal follow-up plan. Social workers may be able to offer resources to both the patient and the caregiver, including: senior centers, medical transportation services, Meals-on-Wheels, adult day care, respite care, and substance abuse treatment.
- Reporting to the authorities typically requires contacting your local or state Adult Protective Services, but – please keep in mind – different than Child Protective Services, they are not going to come to hospital or even open an investigation until a patient is discharged. Therefore, if you’re concerned about a patient’s safety and/or you think a crime has been committed, you should consider calling the police.
What are we or aren’t we legally required to do, and does it vary by state, and where can we find out what our state’s rules are?
- In most but not all states, ED providers are mandatory reporters for elder abuse. I recommend you check your state Department of Health website to see what the requirements are in your state.
What do you think are the next steps in improving identification and intervention of elder abuse in the ED?
- Many areas where research is ongoing that will hopefully have an impact on our clinical practice:
- Improved screening tools
- Clinical prediction rules to identify injury patterns or other features of common presentations such as falls that should raise suspicion of elder mistreatment
- Multi-disciplinary ED based interventions to optimize care for and protect these vulnerable patients, similar to the child protection teams that exist in many EDs
- Another important way that care may improve is developing a team-based approach to detection (elder mistreatment is hard, but very important, to identify) so we need to empower all members of the ED team to watch for clues: emergency medical service (EMS) providers, triage providers, nurses, radiologists, radiology technicians, social workers, and case managers
- Lachs MS, Teresi JA, Ramirez M, et al. The prevalence of resident-to-resident elder mistreatment in nursing homes. Ann Intern Med. 2016;165(4):229-236. doi: 10.7326/M15-1209 http://www.ncbi.nlm.nih.gov/pubmed/27295575
- Rosen T, Hargarten S, Flomenbaum NE, Platts-Mills TF. Identifying elder abuse in the emergency department: Toward a multidisciplinary team-based approach. Ann Emerg Med. 2016. http://www.ncbi.nlm.nih.gov/pubmed/27005448
- Lachs MS, Pillemer KA. Elder abuse. N Engl J Med. 2015;373(20):1947-1956. http://www.ncbi.nlm.nih.gov/pubmed/26559573
- Dong XQ. Elder abuse: Systematic review and implications for practice. J Am Geriatr Soc. 2015;63(6):1214-1238. http://www.ncbi.nlm.nih.gov/pubmed/26096395
- Gibbs LM. Understanding the medical markers of elder abuse and neglect: Physical examination findings. Clin Geriatr Med. 2014;30(4):687-712. http://www.ncbi.nlm.nih.gov/pubmed/25439636
- Stevens TB, Richmond NL, Pereira GF, Shenvi CL, Platts-Mills TF. Prevalence of nonmedical problems among older adults presenting to the emergency department. Acad Emerg Med. 2014;21(6):651-658. http://www.ncbi.nlm.nih.gov/pubmed/25039549
- Hoover RM, Polson M. Detecting elder abuse and neglect: Assessment and intervention. Am Fam Physician. 2014;89(6):453-460. http://www.ncbi.nlm.nih.gov/pubmed/24695564
- Yaffe MJ, Wolfson C, Lithwick M, Weiss D. Development and validation of a tool to improve physician identification of elder abuse: The elder abuse suspicion index (EASI). J Elder Abuse Negl. 2008;20(3):276-300. http://www.ncbi.nlm.nih.gov/pubmed/18928055
- Geroff AJ, Olshaker JS. Elder abuse. Emerg Med Clin North Am. 2006;24(2):491-505, ix. http://www.ncbi.nlm.nih.gov/pubmed/16584968
- Elder Justice Roadmap https://www.justice.gov/elderjustice/research/resources/EJRP_Roadmap.pdf
- Shenvi, CL on ALiEM https://www.aliem.com/2013/elder-abuse-and-neglect-what-to-do-in-the-emergency-department/
- State by State Responsibilities for Mandatory Reporting http://www.napsa-now.org/wp-content/uploads/2014/11/Mandatory-Reporting-Chart-Updated-FINAL.pdf
Dr. Christina Shenvi is an associate professor of Emergency Medicine at the University of North Carolina. She is fellowship-trained in Geriatric Emergency Medicine and is the founder of GEMCast. She is the director of the UNC Office of Academic Excellence, president of the Association of Professional Women in Medical Sciences, co-directs the ACEP/CORD Teaching Fellowship, is on the Annals of EM editorial board, is on the Geriatric ED Accreditation board of governors, and she teaches and writes about time management at timeforyourlife.org.