Basics
Description
Elder abuse may include the following:
- Emotional abuse:
- Insults
- Humiliation
- Threats to institutionalize or abandon
- Physical and/or sexual abuse:
- Hitting
- Slapping
- Pushing
- Burning
- Inappropriate restraining
- Forced sexual activity
- Material exploitation:
- Stealing or coercion involving patient money or property
- Neglect:
- Behaviors by a patient or caregiver that compromise the patients health or safety
- Failure to provide adequate food, shelter, hygiene, and/or medical attention
Epidemiology
Incidence and Prevalence Estimates
- In the US., 1-2 million cases age 65 or older mistreated by someone on whom they depend (these numbers likely will increase in the near term as US age demographics shift):
- 55% neglect
- 14.6% physical mistreatment
- 12.3% financial exploitation
- 7.7% emotional mistreatment
- 0.3% sexual abuse
- 6.1% all other types
- 4% unknown
- Family members, including partners and adult children, are perpetrators in approximately 90% of cases
- For every case of financial exploitation reported, 25 cases likely unreported
- Elder abuse (even modest abuse) is associated with a 300% greater risk of death as well as increased rates of additional health problems such as chronic pain, bone/joint, digestive or psychological disorders (compared to the non-abused)
Etiology
- Caregiver stress, dependency, or psychopathology
- Victim dependency or diminishment of ability to perform activities of daily living
Diagnosis
Signs and Symptoms
Variable, possibly inconsistent, history or physical findings
History
- Not willing or able to obtain adequate food/clothing/shelter
- Not providing for personal hygiene/safety
- Delay in obtaining medical care/previously untreated medical condition
- Vague (or implausible/inappropriate) explanations
- Disparities between histories given by patient and caregiver
- Caregiver who insists on giving the patients history
- Medication difficulties:
- Incorrect doses
- Lost medications
- Unfilled prescriptions
- Altered interpersonal interactions:
- Withdrawn
- Indifferent
- Demoralized
- Fearful
- Substance abuse
- Caregiver with:
- Financial dependence on patient
- Substance abuse or psychiatric or violence history
- Controlling behavior (may refuse to leave elder alone with physician) or poor knowledge
- Significant life stressors
- Relationship issues
- Financial difficulties
- Legal problems
Physical Exam
- Inconsistent findings:
- Patterns or variable-age bruises, burns, lacerations/abrasions
- Unusual sites of bruising (inner arm, torso, buttocks, scalp)
- Poor hygiene (inadequate care of skin, nails, teeth)
- Unexplained injuries:
- Bruised or bleeding genital or rectal area
- Wrist or ankle lesions suggestive of restraint use
- Findings that may be consistent with neglect or delay in seeking/obtaining medical attention:
- Dehydration
- Weight loss
- Decubitus ulcer
- Malnutrition
Diagnosis Tests & Interpretation
Perform any exam and lab or radiographic studies as indicated by the patients condition.
Essential Workup
- Obtain history without family members/caregivers present:
- Abused elders may fear institutionalization if they report caregivers.
- Many may feel embarrassment and responsibility for abuse.
- Frequently will not volunteer information
- Ask patient specifically about abuse or neglect (in private)
- Patients medical condition may influence quality of history obtained
- Obtain history from caregivers/other relatives/friends/neighbors
- Document a clear and detailed description of findings including the following:
- Statements of the patient as they pertain to the abuse
- Psychosocial history:
- Family and other social relationships
- Caregiver burdens/coping mechanisms
- Drug/ethanol (Etoh) use
- Prior adult protective services reports
- Skin and other physical findings:
- Photographic documentation
- Safety assessment
Diagnosis Tests & Interpretation
As appropriate for medical condition(s)
Imaging
As appropriate for medical condition(s)
Diagnostic Procedures/Surgery
As appropriate for medical condition(s)
Differential Diagnosis
- Patient may present with any chief complaint:
- Potential differential diagnosis is nonspecific.
- Abuse best identified by asking patient directly in a setting apart from caregivers/family and correlating with risk factors and provider findings
- Differentiate findings consistent with other disease entities from abuse/neglect:
- Dehydration
- Ill-fitting dentures
- Burns
- Ecchymosis
- Insomnia
- Medication noncompliance
- Dementia
- Depression
Treatment
Pre-Hospital
Observe details of the patients environment that may not be immediately available to the hospital care team, including the following:
- Interpersonal interactions at the scene:
- Embarrassment
- Shame
- Fear of reprisal, abandonment, and/or institutionalization
- Conditions in the physical environment that present a potential danger
Initial Stabilization/Therapy
- ABCs
- Treat life-threatening medical/traumatic conditions as appropriate.
Ed Treatment/Procedures
- May require separation of the patient and the caregiver or family member
- Social work referral:
- Safety planning
- Respite planning for caregiver
- Adult protective services referral
- Competent elder patients are free to accept or decline treatment or disposition despite risks they may incur.
- General measures appropriate to the medical/traumatic conditions identified, including:
- Fluids
- Medications
- Surgery
- Diet
- Activity
- Nursing care
- Physical therapy
Follow-Up
Disposition
Admission Criteria
Disposition determined by medical condition and home environment:
- Medical condition requiring admission
- Abuse or neglect renders home conditions unsafe.
- Need for more information or time to enhance objective decision making and patient management
Discharge Criteria
- Medical condition(s) addressed
- Safe environment available
- Abuse or neglect successfully countered by social services and/or law enforcement
Issues for Referral
- Many states have mandatory reporting requirements:
- Comply with area legal requirements.
- Alcohol/drug treatment as appropriate
- Notify adult protective services.
Followup Recommendations
As appropriate for medical condition(s)
Pearls and Pitfalls
- Entertaining the possibility of abuse or neglect in an elder patient offers the best possibility of diagnosis and successful intervention.
- Only ~1/3 of healthcare providers identified a case of elder abuse in the past year.
- Current data are inconclusive about the effectiveness of interventions for diminishing recurrence of elder abuse.
- Obtain the aid of social worker, physicians trusted by the patient, even an ethics consultant, should a vulnerable competent elder seek to decline an elder abuse/neglect investigation.
Additional Reading
- Clarke ME, Pierson W. Management of elder abuse in the emergency department. Emerg Med Clin North Am. 1999;17:631-644.
- Cooper C, Selwood A, Livingston G. Knowledge, detection, and reporting of abuse by health and social care professionals: A systematic review. Am J Geriatr Psychiatry. 2009;17(10):826-838.
- http://www.ncea.aoa.gov/Resources/Publication/docs/FinalStatistics050331.pdf
- http://www.ncea.aoa.gov/Library/Data/index.aspx
- http://www.ncea.aoa.gov/Resources/Publication/docs/fact1.pdf
- Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364:1263-1272.
- Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States; prevalence estimates from a nationally representative study. J Gerontol B Psychol Sci Soc Sci. 2008;63(4):S248-S254.
- Ploeg J, Fear J, Hutchison B, et al. A systematic review of interventions for elder abuse. J Elder Abuse Negl. 2009;21(3):187-210.
Codes
ICD9
- 995.80 Adult maltreatment, unspecified
- 995.81 Adult physical abuse
- 995.82 Adult emotional/psychological abuse
- 995.83 Adult sexual abuse
- 995.84 Adult neglect (nutritional)
- 995.85 Other adult abuse and neglect
ICD10
- T74.11XA Adult physical abuse, confirmed, initial encounter
- T74.31XA Adult psychological abuse, confirmed, initial encounter
- T74.91XA Unspecified adult maltreatment, confirmed, initial encounter
- T74.21XA Adult sexual abuse, confirmed, initial encounter
- T74.01XA Adult neglect or abandonment, confirmed, initial encounter
SNOMED
- 95921002 elderly person maltreatment (event)
- 242041001 Emotional abuse of elderly person
- 242040000 Physical abuse of elderly person
- 242042008 Deprivation of nourishment of elderly person
- 242043003 Abandonment of elderly person