Skip to content

Elder Abuse

BASICS

DESCRIPTION

  • Elder Abuse (EA): intentional actions causing harm or risk of harm to vulnerable elders by caregivers or trusted persons, or failure to meet elder's basic needs (National Academy of Sciences, 2003).
  • Types of harm: financial, physical, emotional, impaired self-care or self-protection risks.
  • 2009 estimated cost: $2.9 billion, 12% increase from prior year (National Committee for the Prevention of Elder Abuse).

EPIDEMIOLOGY

  • Global incidence: ~16% (WHO).
  • US prevalence: ~10% of elderly population; ~5 million elders affected yearly.
  • Increase during COVID-19 pandemic.
  • Annual prevalence per 1,000 people:
  • 22 physical/sexual abuse
  • 17 intimate partner violence
  • 0.17 fatal suicide
  • 0.27 nonfatal self-harm
  • 9.7–32.6 violence by elders with dementia against others

ETIOLOGY AND PATHOPHYSIOLOGY

  • Biopsychosocial factors + increased elder dependence + suboptimal environment + poor coping + caregiver stress.

RISK FACTORS

  • Victim:
  • Advanced age, female gender, low socioeconomic status, social isolation, lack of purpose.
  • PTSD in veterans, poor self-perceived health, loss of control, healthcare insecurity.
  • History of abuse, functional dependence, cognitive impairment, mental illness/substance use.

  • Polyvictimization: victim perception, offender protection, perpetrator influence.

  • Abuser:

  • Early child abuse, history of violence, mental illness, substance use.
  • High stress, poor coping, poor health, inadequate training/supervision.
  • Poor prior relationship with victim, financial dependency on victim.

GENERAL PREVENTION

  • Annual wellness visits: advanced care plan, power of attorney, goals of care, self-sufficiency assessment.
  • Assess caregiver stress/burden (meet without patient).
  • Screen mood disorders (PHQ-2/PHQ-9), anxiety (GAD-7), loneliness (3-item UCLA).
  • Screen cognitive impairment (MMSE, MoCA, SLUMS).
  • Encourage socialization.
  • Refer to community programs: Dept of Aging, Adult Protective Services (APS), Alzheimer's Association.

COMMONLY ASSOCIATED CONDITIONS

  • Social isolation, dependence in ADLs/IADLs, depression, cognitive impairment, aggressive behavior.

DIAGNOSIS

SCREENING

  • No gold standard or routine recommendation by USPSTF.
  • High clinical suspicion triggers evaluation.
  • Types of EA: physical/sexual abuse, violation of rights, material exploitation, neglect (including abandonment), financial, psychological.
  • Contexts: self-neglect, institutional, domestic (family member often abuser).

SCREENING TOOLS

  • Hospital: Elderly Indicators of Abuse (E-IOA)
  • Emergency Dept: Elder Abuse Instrument (EAI), ED Senior Abuse Identification (AID)
  • Nursing home: Elder Psychological Abuse Scale (EPAS)
  • General: Elder Abuse Suspicion Index (EASI), Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST), Vulnerability Abuse Screening Scale (VASS), Lichtenberg Financial Decision Screening Scale (LFDSS)

HISTORY

  • Culture-sensitive approach.
  • Assess advance care plan, living arrangements, function, caregivers, caregiver burnout.

PHYSICAL EXAM

  • Detailed documentation for legal use.
  • Look for unexplained fractures, cachexia, poor hygiene, evidence of falls (broken glasses).
  • Oral exam: dentition, ulcers.
  • Skin exam: large bruises (>5 cm), patterned injuries (bite, ligature, burn marks).
  • Open wounds, untreated injuries, alopecia, pressure ulcers.

DIFFERENTIAL DIAGNOSIS

  • Dementia (FAST 6/7), psychosis, substance use disorders, Parkinson disease, coagulopathy, malignancy-related wasting, delirium, thyroid disorders, fixed drug reaction, fragile skin, osteoporosis fractures.

DIAGNOSTIC TESTS

  • Initial labs: CBC, CMP, UA, B12, folic acid, RPR, TSH, PT/INR.
  • Follow-up: iron studies, vitamin B1/B6, toxicology, encephalopathy panel.
  • Imaging: fracture evaluation, CT head for hemorrhage.
  • Cognitive and depression screening: MMSE, MoCA, SLUMS, Geriatric Depression Scale, PHQ2/9, GAD-7.

DOCUMENTATION

  • Document "suspected mistreatment" carefully.
  • Photograph injuries with patient ID, date/time, ruler, witness info.
  • Include anatomical diagrams.
  • Reporting laws vary; reporters protected if in “good faith.”

TREATMENT

REPORTING

  • Mandatory reporting to APS or equivalent agency in most states.
  • Limited evidence on other interventions.

TREATMENT PLAN

Based on Abuse Intervention Model domains:
- Domain I – Vulnerable older adult: virtual education, Family-Based Cognitive Behavioral Social Work (FBCBSW), physical/cognitive assessments, mood evaluation and medications if indicated.
- Domain II – Trusted others (perpetrator): support financial planning, refer for mental health/substance use treatment, report threats to law enforcement.
- Domain III – Context of abuse: social network expansion, trial assisted living/nursing home, social work and psychological support, culture-sensitive care.

MEDICATION

  • None specific for EA.

ISSUES FOR REFERRAL

  • Behavioral health, neurocognitive specialists, physical/occupational therapy.

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Relaxation and well-being techniques.

ADMISSION, INPATIENT, AND NURSING

  • Do not discharge or transfer without reliable follow-up (home visit, APS report).
  • Manage neglect-related complications (e.g., wound care).
  • Notify hospital security if visitor restrictions needed.
  • Placement options: family, nursing home, assisted living.

ONGOING CARE

FOLLOW-UP

  • Educate caregivers on burnout, responsibilities, available services.
  • Review state mandatory reporting requirements.
  • Contact APS, Dept of Aging, Long-Term Care Ombudsman as appropriate.
  • Frequent patient monitoring with home or clinic visits.

DIET

  • Recommend Mediterranean or MIND diet.

PATIENT EDUCATION

  • National resources:
  • EA info: https://ncea.acl.gov, 800-677-1166
  • Eldercare Locator: 800-677-1116, https://eldercare.acl.gov
  • Alzheimer's Association: 800-272-3900
  • National Organization for Victim Assistance: https://www.trynova.org

PROGNOSIS

  • EA and self-neglect linked to increased mortality risk.

COMPLICATIONS

  • Hospitalizations, functional decline, loneliness, depression.

CLINICAL PEARLS

  • Reduce EA risk by strengthening social supports, treating depression, screening cognitive impairment, providing assistive devices, and identifying caregiver burnout.
  • Refer to Department of Aging for home aid when ADLs/IADLs impaired.
  • APS cannot intervene if patient with capacity refuses report.
  • Guardianship possible if capacity impaired, with APS guidance.

REFERENCES

  1. Rosen T, Makaroun LK, Conwell Y, et al. Violence in older adults: scope, impact, challenges, and strategies for prevention. Health Aff (Millwood). 2019;38(10):1630-1637.
  2. Van Royen K, Van Royen P, De Donder L, et al. Elder abuse assessment tools and interventions for use in the home environment: a scoping review. Clin Interv Aging. 2020;15:1793-1807.
  3. Ries NM, Mansfield E. Elder abuse: the role of general practitioners in community-based screening and multidisciplinary action. Aust J Gen Pract. 2018;47(4):235-238.
  4. Baker PRA, Francis DP, Hairi NN, et al. Interventions for preventing abuse in the elderly. Cochrane Database Syst Rev. 2016;8:CD010321.
  5. Mosqueda L, Burnight K, Gironda MW, et al. The Abuse Intervention Model: a pragmatic approach to intervention for elder mistreatment. J Am Geriatr Soc. 2016;64(9):1879-1883.

See Also

  • Tools on Elder Abuse for clinicians: https://elderabuseemergency.org/ElderWP/
  • National Council on Aging: https://www.ncoa.org

Codes

  • ICD10 T74.11XA Adult physical abuse, confirmed, initial encounter
  • ICD10 T74.21XA Adult sexual abuse, confirmed, initial encounter
  • ICD10 T74.01XA Adult neglect or abandonment, confirmed, initial encounter