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4-6% of elderly are abused, with ~2 million elderly persons experiencing abuse and/or neglect each year. In 90% of cases, the perpetrator is a family member.
Elder abuse is any form of mistreatment that results in harm or loss to an older person; may include physical, sexual, emotional, financial abuse, and/or neglect.
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Pediatric Considerations
>3 million children aged 3 to 17 years are at risk of witnessing acts of DV.
~1 million abused children are identified in the United States each year.
Children living in violent homes are at increased risk of physical, sexual, and/or emotional abuse; anxiety and depression; decreased self-esteem; emotional, behavioral, social, and/or physical disturbances; and lifelong poor health.
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Pregnancy Considerations
DV occurs during 7-20% of pregnancies. Women with unintended pregnancy are at 3 times greater risk of DV. 25% of abused women report exacerbation of abuse during pregnancy. There is a positive correlation between DV and postpartum depression.
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RISK FACTORS
- Patient/victim risk factors
- Substance abuse
- Poverty/financial stressors/unemployment
- Recent loss of social support
- Family disruption and life cycle changes
- History of abusive relationships or witness to abuse as child
- Mental or physical disability in family
- Social isolation
- Pregnancy
- Attempting to leave the relationship
- Abuser risk factors
- Substance abuse (e.g., PCP, cocaine, amphetamines, alcohol)
- Young age
- Unemployment
- Low academic achievement
- Witnessing or experiencing violence as child
- Depression
- Personality disorders
- Threatening to self or others
- Violence to children or violence outside the home
- Relational risk factors
- Marital conflict
- Marital instability
- Economic stress
- Traditional gender role norms
- Poor family functioning
- Obsessive, controlling relationship
Geriatric Considerations
Factors associated with the abuse of older adults include increasing age, nonwhite race, low-income status, functional impairment, cognitive disability, substance use, poor emotional state, low self-esteem, cohabitation, and lack of social support.
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Pediatric Considerations
Factors associated with child abuse or neglect include low-income status, low maternal education, nonwhite race, large family size, young maternal age, single-parent household, parental psychiatric disturbances, and presence of a stepfather.
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DIAGNOSIS
- DV is often underdiagnosed, with only 10-12% of physicians conducting routine screening.
- Although prevalence of DV in primary care settings is 7-50%, <15% are screened.
- Pregnancy increases risk.
- Barriers to screening: time constraints, discomfort with the subject, fear of offending the patient, and lack of perceived skills and resources to manage DV
- Abused patients may refuse to disclose abuse for many reasons, which includes the following:
- Not feeling emotionally ready to admit the reality of the situation
- Shame and self-blame
- Feelings of failure if abuse is admitted
- Fear of rejection by the physician
- Fear of retribution from abuser
- Belief that abuse will not happen again
- Belief that no alternatives or available resources exist
HISTORY
- Physicians should introduce the subject of DV in a general way (i.e., "I routinely ask all patients about domestic violence. Have you ever been in a relationship where you were afraid?"�).
- How to screen
- Screen patient alone, without partner or others present.
- Ask screening questions in patient's primary language; do not use children or other family members as interpreters.
- Partner violence screen (sensitivity 35-71%; specificity 80-94%)
- "Have you ever been hit, kicked, punched, or otherwise, hurt by someone within the past year? If so, by whom?"�
- "Do you feel safe in your current relationship?"�
- "Is there a partner from a previous relationship who is making you feel unsafe now?"�
- CDC-recommended RADAR system
- R: Routinely screen every patient; make screening a part of everyday practice in prenatal, postnatal, routine gynecologic visits, and annual health screenings.
- A: Ask questions directly, kindly, and be nonjudgmental.
- D: Document findings in the patient's chart using the patient's own words, with details. Use body maps and photographs as necessary.
- A: Assess the patient's safety and see if the patient has a safety plan.
- R: Review options for dealing with DV with the patient and provide referrals.
- SAFE questions
- Stress/safety: "Do you feel safe in your relationship?"�
- Afraid/abused: "Have you ever been in a relationship where you were threatened, hurt, or afraid?"�
- Friends/family: "Are your friends or family aware that you have been hurt? Could you tell them, and would they be able to give you support?"�
- Emergency plan: "Do you have a safe place to go and the resources you need in an emergency?"�
- "How often does your partner: physically hurt you? insult or talk down to you? threaten you with harm? scream or curse at you?"�
- Assess pregnancy difficulties such as poor/late prenatal care, low-birth weight babies, and perinatal deaths.
- Pelvic and abdominal pain, chronic without demonstrable pathology
- Headaches, back pain
- Gynecologic disorders
- Sexually transmitted infections (STIs) including HIV/AIDS
- Depression, suicidal ideation, anxiety, fatigue
- Substance abuse
- Eating disorders
- Overuse of health services/frequent emergency room visits
- Noncompliance
PHYSICAL EXAM
- Clinical presentation/psychological signs and symptoms
- Delay in seeking treatment
- Inconsistent explanation of injuries
- Reluctance to undress
- Signs of battered woman syndrome and/or posttraumatic stress disorder (PTSD) (flat affect/avoidance of eye contact, evasiveness, heightened startle response, sleep disturbance, traumatic flashbacks)
- Depression, anxiety, chronic fatigue, substance abuse
- Suspicious partner accompaniment at appointment; overly solicitous partner and/or refusal to leave exam room
- Physical signs and symptoms
- Tympanic membrane rupture
- Rectal or genital injury (centrally located injuries with bathing-suit pattern of distribution-concealable by clothing)
- Head and neck injuries (site of 50% of abusive injuries)
- Facial scrapes, loose or broken tooth, bruises, cuts, or fractures to face or body
- Knife wounds, cigarette burns, bite marks, welts with outline of weapon (such as belt buckle)
- Broken bones
- Defensive posture injuries
- Injuries inconsistent with the explanation given
- Injuries in various stages of healing
DIAGNOSTIC TESTS & INTERPRETATION
- The U.S. Preventive Services Task Force (USPSTF) in 2013 issued guidelines recommending that clinicians screen all women of childbearing age (14 to 46 years old) for DV and provide or refer women to intervention services when appropriate (1)[B].
- Other recommendations
- American College of Physicians (ACP) recommends routine screening for DV for all women in primary care settings at periodic intervals and when women present for emergency care with traumatic injuries.
- The American Medical Association (AMA) recommends that all patients be routinely screened for DV with inquiry into history of family violence.
- The World Health Organization (WHO) recommends against DV screening or routine inquiry about exposure to DV; however, they recommend asking about exposure to DV when assessing conditions that may be caused or complicated by abuse (2)[B].
- U.S. Surgeon General and American Association of Family Practitioners recommend that physicians consider the possibility of DV as a cause of illness and injury.
- The Partner Violence Screen is a 3-question screening tool with a high specificity.
- There is no evidence of harm in screening for DV.
Pediatric Considerations
American Academy of Pediatrics (AAP) and AMA recommend that physicians remain alert for signs and symptoms of child physical and sexual abuse in the routine exam.
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Pregnancy Considerations
American Congress of Obstetrics and Gynecologists (ACOG) and AMA guidelines on DV recommend that physicians routinely assess all pregnant women for DV. ACOG recommends periodic screening throughout obstetric care (at the first prenatal visit, at least once per trimester, at the postpartum checkup).
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Initial Tests (lab, imaging)
Liver function tests (LFTs), amylase, lipase if abdominal trauma is suspected �
TREATMENT
- Treatment includes initial diagnosis; ongoing medical care; emotional support, counseling, and patient education regarding the DV cycle; referrals to community and supportive services as needed.
- On diagnosis, use the SOS-DoC intervention:
- S: Offer Support and assess Safety
- Support: "You are not to blame. I am sorry this is happening to you. There is no excuse for DV."�
- Remind patient of your commitment to confidential communication.
- Safety: Listen and respond to safety issues for the patient: "Do you feel safe going home?"�; "Are your children safe?"�
- O: Discuss Options, including safety planning and follow-up.
- Provide information about DV and help when needed. Make referrals to local resources:
- "Do you need or want to access a safety shelter or DV service agency?"�
- "Do you want police intervention and if so, would you like me to call the police so they can make a report with you?"�
- Offer numbers to local resources and National DV Hotline: 1-800-799-SAFE (open 24/7; can provide physicians in every state with information on local resources).
- S: Validate patient's Strengths:
- "It took courage for you to talk with me today. You have shown great strength in very difficult circumstances."�
- Do:Document observations, assessment, and plans:
- Use patient's own words regarding injury and abuse.
- Legibly document injuries: Use a body map.
- If possible, take instant photographs of patient's injuries if given patient consent.
- Make patient safety plan. Prepare patient to get away in an emergency:
- Encourage patient to keep the following items in a safe place: keys (house and car); important papers (Social Security card, birth certificates, photo ID/driver's license, passport, green card); cash, food stamps, credit cards; medication for self and children; children's immunization records; important phone numbers/addresses (friends, family, local shelters); personal care items (e.g., extra glasses)
- Encourage patient to arrange a signal with someone to let that person know when she or he needs help.
- C: Offer Continuity:
- Offer a follow-up appointment and assess barriers to access.
GENERAL MEASURES
- Reporting child and elder abuse to protective services is mandatory in most states. Several states have laws requiring mandatory reporting of IPV.
- Contact the local DV program to find out about laws and community resources before they are needed.
- Display resource materials (National DV Hotline: 1-800-799-SAFE) in the office, all exam rooms, and restrooms.
ADDITIONAL THERAPIES
- National DV Hotline: 1-800-799-SAFE (7233)
- Post in all exam rooms posters in both English and Spanish; available at http://www.thehotline.org/resources/download-materials/
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Schedule prompt follow-up appointment.
- Inquire about what has happened since last visit.
- Review medical records and ask about past episodes to convey concern for the patient and a willingness to address this health issue openly.
- DV often requires multiple interventions over time before it is resolved.
PATIENT EDUCATION
- Counsel patients about nonviolent ways to resolve conflict.
- Educate patients about the cycle of violence.
- Counsel parents about developmentally appropriate ways to discipline their children.
- Educate parents about the negative consequences of arguments on children and each other.
- National Coalition Against Domestic Violence: http://www.ncadv.org/
- CDC: http://www.cdc.gov/violenceprevention/
PROGNOSIS
Most DV perpetrators do not voluntarily seek therapy unless pressured by partners or upon legal mandate. Current evidence is insufficient on effectiveness of therapy for perpetrators. �
REFERENCES
11 U.S. Preventive Services Task Force. Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults. Rockville, MD: Agency for Healthcare Research and Quality; 2013.22 Feder �G, Wathen �CN, MacMillan �HL. An evidence-based response to intimate partner violence: WHO guidelines. JAMA. 2013;310(5):479-480.
ADDITIONAL READING
- Cronholm �PF, Fogarty �CT, Ambuel �B, et al. Intimate partner violence. Am Fam Physician. 2011;83(10):1165-1172.
- Hegarty �K, O'Doherty �L, Taft �A, et al. Screening and counselling in the primary care setting for women who have experienced intimate partner violence (WEAVE): a cluster randomised controlled trial. Lancet. 2013;382(9888):249-258.
- Wu �Q, Chen �HL, Xu �XJ. Violence as a risk factor for postpartum depression in mothers: a meta-analysis. Arch Womens Ment Health. 2012;15(2):107-114.
CODES
ICD10
- T74.91XA Unspecified adult maltreatment, confirmed, initial encounter
- T74.11XA Adult physical abuse, confirmed, initial encounter
- T74.31XA Adult psychological abuse, confirmed, initial encounter
- T74.21XA Adult sexual abuse, confirmed, initial encounter
ICD9
- 995.80 Adult maltreatment, unspecified
- 995.81 Adult physical abuse
- 995.82 Adult emotional/psychological abuse
- 995.83 Adult sexual abuse
- 995.85 Other adult abuse and neglect
SNOMED
- 406138006 Domestic abuse of adult
- 371778002 Physical abuse of adult
- 371774000 Emotional abuse of adult
- 432527004 Domestic sexual abuse of adult
- 242039002 Abuse of partner
CLINICAL PEARLS
- Display resource materials in the office (e.g., posting abuse awareness posters/National DV Hotline, 1-800-799-SAFE, in both English and Spanish, in all exam rooms and restrooms).
- Given the high prevalence of DV and the lack of harm and potential benefits of screening, routine screening is recommended.
- For those who screened positive, offer resources, reassure confidentiality, and provide close follow-up.