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Drugs & Diseases > Emergency Medicine

ELDER ABUSE

Updated: Nov 12, 2019
* Author: Trevor John Mills, MD, MPH; Chief Editor: Barry E Brenner, MD, PhD,
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Sections
Elder Abuse

* Sections Elder Abuse
* Overview

* Background
* Epidemiology
* Show All
* Presentation

* History
* Physical
* Causes
* Show All
* DDx
* Workup

* Laboratory Studies
* Imaging Studies
* Procedures
* Show All
* Treatment

* Emergency Department Care
* Consultations
* Show All
* Medication
* Follow-up

* Further Outpatient Care
* Patient Education
* Show All
* References

Overview

BACKGROUND

Over the past 35 years, tremendous strides have been made in identifying and
increasing awareness about patterns of abusive relationships. Child abuse and
intimate partner violence have received significantly more recognition than
elder abuse and continue to receive more attention in both public and medical
domains.

With current medical advances and the adoption of healthier lifestyles, people
are living longer. Older Americans now comprise the fastest growing segment of
the United States population. The 2010 US Census recorded 40.3 million people
aged 65 years or older as comprising 13% of the population. [1] By the year
2020, this group will increase by 5.5%, and by 2050, older Americans are
projected to account for 25% of the population. [2]

As a result of the number of older Americans, the number of elder abuse cases
will increase, and the impact of elder abuse as a public health issue will grow.
[3] Victims of violence have twice as many physician visits compared with the
general US population, allowing opportunities for discovery and intervention.
Due to the relative isolation of many elders who are mistreated, an unexpected
visit to the emergency department may be the only opportunity for detection.
Emergency physicians are in a unique position to identify, advocate for, and
help manage this vulnerable population.

Elder mistreatment is a multidimensional phenomenon that encompasses a broad
range of behaviors, events, and circumstances. Unlike random acts of violence or
exploitation, elder abuse is often perpetrated by person(s) known to the victim,
and usually consists of repetitive instances of misconduct. It encompasses any
act of commission or omission that results in harm or threatened harm to the
health and welfare of an older adult.

The US National Academy of Sciences defines elder abuse as follows:

* Intentional actions that cause harm or create a serious risk of harm (whether
or not harm is intended), to a vulnerable elder by a caregiver or other
person who stands in a trusted relationship to the elder

* Failure by a caregiver to satisfy the elder's basic needs or to protect the
elder from harm.

From the legal system through the lay press to the medical literature, the
terminology used to describe elder abuse is not consistent. Terms vary among
researchers, and usage is not consistent in the laws of different states. Even
the age at which a person is considered elderly, usually 60 or 65 years, is
debated. Seven categories of elder abuse have been described by the National
Center on Elder Abuse (NCEA). [4] Categories include the following:

* Physical abuse - Any act of violence that causes pain, injury, impairment, or
disease, including striking, pushing, force-feeding, and improper use of
physical restraints or medication

* Emotional or psychological abuse - Conduct that causes mental anguish
including threats, verbal or nonverbal insults, isolation, and humiliation.
Some legal definitions require identification of at least 10 episodes of this
type of behavior within a single year to constitute abuse.

* Financial or material exploitation - Misuse of an elderly person's money or
assets for personal gain. Acts such as stealing (money, social security
checks, possessions) or coercion (changing a will, assuming power of
attorney) constitute financial abuse.

* Neglect - Failure of a caretaker to provide for the patient's basic needs. As
in the previous examples of abuse, neglect can be physical, emotional, or
financial. Physical neglect is failure to provide eyeglasses or dentures,
preventive health care, safety precautions, or hygiene. Emotional neglect
includes failure to provide social stimulation (leaving an older person alone
for extended periods). Financial neglect involves failure to use the
resources available to restore or maintain the well-being of the aging adult.

* Sexual abuse - Nonconsensual intimate contact or exposure or any similar
activity when the patient is incapable of giving consent. Family members,
friends, institutional employees, and fellow patients can commit sexual
abuse. [5]

* Self-neglect - Behavior in which seniors compromise their own health and
safety, as when an aging adult refuses needed help with various daily
activities. When the patient is deemed competent, many ethical questions
arise regarding the patient's right of autonomy and the physician's oath of
beneficence.

* Abandonment - The desertion of an elderly person by an individual who has
assumed responsibility for providing care for an elder, or by a person with
physical custody of an elder.

Further training is needed for physicians regarding elder abuse. [6]

Next: Epidemiology

EPIDEMIOLOGY

FREQUENCY

Due to the inconsistencies in the working definitions of elder abuse,
differences in sampling and survey methods, and underreporting of cases,
obtaining accurate information on the incidence of elder abuse and neglect is
difficult. A 2017 study based on the best available evidence from 52 studies in
28 countries from diverse regions, including 12 low- and middle-income
countries, estimated that, over the past year, 15.7% of people aged 60 years and
older were subjected to some form of abuse. [7] Regarding elder abuse in
institutions, a meta-analysis of 9 studies in 6 countries based on staff
self-reports on perpetrating abuse found that 64.2% of staff perpetrated some
form of abuse in the past year. [8]

Many factors play a role in the underestimation of the number of abused elders.
Patient factors include fear, shame, guilt, or ignorance. Healthcare providers
underestimate and underreport elder abuse due to decreased recognition of the
problem, lack of awareness of reporting requirements, including who to report
to, and concerns about physician-patient confidentiality.

In addition, many studies routinely exclude certain populations such as persons
unable to respond to a survey, speakers of languages other than English, and
persons with mental illness, further complicating accurate tallies of the number
of older persons who are abused. Despite difficulty in identifying the exact
frequency of elder abuse, the occurrence is common enough to be encountered
regularly in daily clinical practice. As a result, healthcare providers must
maintain a high index of suspicion.

MORTALITY/MORBIDITY

Elders who are victim to physical abuse, caregiver neglect, or self-neglect have
triple the mortality of those never reported as abused. Early detection and
intervention by healthcare professionals in elder abuse cases may lead to
decreased morbidity and mortality. Healthcare provider involvement is paramount,
as studies have shown that only 1 in 6 victims are likely to self-report
mistreatment to the appropriate legal authorities.

RACE

Elder abuse occurs among members of all racial, socioeconomic, and religious
backgrounds. The NCEA found the following racial and ethnic distribution among
older persons who had been abused: [9]

* White, non-Hispanic – 66.4%

* Black – 18.7%

* Hispanic – 10%

* Other – 4.9%

SEX

Women are believed to be the most common victims of abuse, perhaps because they
report abuse at higher rates or because the severity of injury in women
typically is greater than in men. Numerous studies, however, have found no
differences based on sex.

AGE

By definition, elder abuse occurs in the elderly, although there is no
universally accepted definition of when old age begins. Typically, 60 or 65
years is considered the threshold of old age.

Clinical Presentation

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CONTRIBUTOR INFORMATION AND DISCLOSURES

Author

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs
Northern California Health Care System; Professor of Emergency Medicine,
Department of Emergency Medicine, University of California, Davis, School of
Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies:
American Academy of Emergency Medicine, American College of Emergency Physicians