II. Definitions

  1. Elder Abuse
    1. Caregiver acts via intent or neglect in a way that may harm a vulnerable adult

III. Epidemiology

  1. Prevalence: 10% of older persons experience neglect or abuse by Caregiver in the U.S. annually
    1. Acierno (2010) Am J Public Health 100(2): 292-7 [PubMed]

IV. Types

  1. Financial or material abuse
    1. Among the most common forms of Elder Abuse (estimated at $3 billion per year in U.S.)
    2. Theft of funds, resources or items
    3. Coercion of elder person to use their assets
    4. Unpaid bills (e.g. rent, utilities) or missing cash, checks or other valuables
    5. Elder's bank account with unexplained changes
    6. Unexplained change in will
    7. Suddenly unable to afford food and medications
  2. Neglect or abandonment
    1. Caregiver fails to meet elder person's needs to maintain their well being
    2. Lapses in supply of food, clothing, shelter, hygiene, medical care, social interaction
    3. May present with Malnutrition, Unintentional Weight Loss, Dehydration, Pressure Sores, poor hygiene or dirty clothes
    4. Urine burns may suggest long periods in wet clothing or adult diapers
    5. Neglect may be unintentional
  3. Physical abuse
    1. Inflicted physical injury or pain
    2. Includes slapping, hitting, kicking, striking, force-feeding, restraining or otherwise inflicting pain or injury
    3. Patients may present for fall, but may be due to Non-accidental Trauma
    4. Inflicted injuries are more extensive with larger Bruises, and often on the upper back, face and lateral right arm (defensive)
    5. Red flag findings
      1. Traumatic Alopecia
      2. Subconjunctival Hemorrhages
      3. Bruising NOT over bony prominences
      4. Bruising on the neck, ears, genitalia, buttocks, soles of feet, axilla or inner arms
      5. Hand-shaped Bruises, bites, ligature marks or imprints from shoes or belts
      6. Burn Injury with atypical patterns (e.g. Cigarette mark)
  4. Emotional or psychological abuse
    1. Verbally abusive including humiliating, intimidating, insulting or degrading statements
    2. Threats such as placing in Longterm Care facility or for social isolation
    3. Yelling, shouting or screaming
    4. Restricting access to food, water, bathroom facilities or friends
    5. At clinical encounter, patient may defer all answers to Caregiver
  5. Sexual abuse
    1. Forced sexual activity, touching or fondling a non-consenting person (includes unwanted sexual talk)
    2. May have Bruising on the genitals, thighs or Breasts
    3. Vaginal or anal tears
    4. Recurrent Urinary Tract Infections
    5. Sexually Transmitted Infection

V. Risk Factors: Victim of Abuse

  1. Age over 75 years old
  2. Shared living arrangement
  3. Cognitive Impairment
  4. Behavior Problems in Dementia
  5. Social isolation
  6. Lower socioeconomic class
  7. Caregiver mental illness or Chemical Dependency
  8. Caregiver dependency on older person (e.g. financial)
  9. Abuse in homes is far more common than abuse in institutions
    1. However neglect, and resident-to-resident abuse may occur at the Nursing Home
  10. Ethnicity
    1. African Americans have a 3-4 fold increased risk of financial and psychological abuse
    2. Chinese American elders have a 35% Prevalence of reported abuse
    3. HIspanic Americans under report abuse (only 2% report abuse, but rates of actual abuse approach 40% in some studies)

VI. Risk Factors: Perpetrator

  1. Relatives are the most common perpetrators
    1. Adult children: 40%
    2. Spouse: 15%
    3. Grandchildren: 9%
    4. Other relatives: 8%
    5. Parents: 6%
    6. Siblings: 6%
  2. Other risks
    1. Male gender
    2. Alcohol or Substance Abuse
    3. Mental health disorders
    4. Unemployment or other financial stressors
    5. Social isolation
    6. Legal difficulties

VII. Signs

  1. Atypical Bruising
    1. Bruising on lateral arms, face or back (non-bony prominence)
    2. Bruises >5 cm in diameter
  2. Atypical Burn Injury
    1. Not consistent with accidental injury
    2. Stocking or glove distribution may suggest forced immersion in hot liquid
  3. Patterned Skin Injuries
    1. Hand slap
    2. Human Bite mark
    3. Restraint marks or scars from ligature at wrists, ankles or neck
  4. Other skin findings (if not consistent with history or patient medical status)
    1. Decubitus Ulcer
    2. Traumatic Alopecia
    3. Severe diaper-rash consistent with urine burns
    4. Dirty clothing or poor hygiene
  5. Other non-skin findings suggestive of abuse or neglect
    1. Unexplained Weight Loss, Malnutrition or Dehydration
    2. Unexplained Fractures
    3. Delayed medical attention for injury or illness
    4. Medical noncompliance

VIII. Differential Diagnosis

IX. Management: Approach

  1. Step 1: Assess for level of functioning
    1. Assess for Cognitive Impairment (e.g. Mini-Cog)
    2. Assess Activities of Daily Living
  2. Step 2: Screen for Elder Abuse
    1. Elder Abuse Suspicion Index
      1. Relies on self-report
      2. Not an appropriate screening tool if Cognitive Impairment is present
  3. Step 3: Focused examination
    1. Evaluate for signs of abuse as above
  4. Step 4: Adult Protective Services Indications
    1. Immediate danger to patient or
    2. Patient without decision making capacity
  5. Step 5: Initiate safety plan
    1. See safety plan described below
    2. Coordinate resources
    3. Initiate preventive measures to reduce risk of abuse
    4. Establish a regular follow-up plan

X. Management: Safety Plan

  1. Summary
    1. Individualized plan agreed upon by patient, medical provider and trusted friend or family member
  2. Components
    1. Safe places (e.g. family or friend's home, shelter, hospital)
    2. Stategies to reduce risk of harm when in contact with potential abuser
    3. Essential item list to be stored in a safe place (to bring with them in case of emergency)
    4. Emergency phone numbers (e.g. family, friends, community resources, police, medical care)
    5. Emergency logistical planning (e.g. transportation resources)
    6. Establish regular primary care follow-up

XI. Complications

  1. Elder Abuse is associated with increased morbidity and mortality
    1. Mortality risk is increased 3 fold over control subjects (esp. after hospitalization)
    2. Increased rate of emergency department visits, hospitalizations and 30 day rehospitalization rate

XII. Resources

  1. Administration on Aging National Center on Elder Abuse
    1. http://www.ncea.aoa.gov
  2. Baylor College of Medicine - Geriatric Education Center Pocket Guide to Elder Investment Fraud and Financial Exploitation
    1. http://www.nasaa.org/wp-content/uploads/2011/08/EIFFE-Clinicians-Pocket-Guide.pdf
  3. Eldercare Locator
    1. http://www.eldercare.gov/Eldercare.NET/Public/Index.aspx

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