Elder Abuse

Because older victims of abuse tend to be isolated, their interactions with physicians are important opportunities to recognize abuse and intervene. A new review article explores the manifestations of elder abuse and the role of multidisciplinary teams in its assessment and management.
Elder abuse has a range of negative sequelae that extend well beyond the obvious traumatic injury and pain to which the victims may be subjected. Studies have shown that victims of elder abuse are at increased risk for death, after adjustment for any chronic illness they may have. Elder abuse greatly increases the likelihood of placement in a nursing home and of hospitalization. Recent studies suggest that financial exploitation is emerging as the most prevalent form of abuse; by the time cases are detected, the older adult’s financial resources have often been drastically reduced - a fact that makes swift detection and intervention critical.

Clinical Pearls

How common is elder abuse?
When the available evidence is taken into consideration, an estimated overall prevalence of elder abuse of approximately 10% appears reasonable. Thus, a busy physician caring for older adults will encounter a victim of such abuse on a frequent basis, regardless of whether the physician recognizes the abuse.

What is known about elder abuse in long-term care facilities?
Although no scientific studies of the prevalence of abuse have been conducted in these settings, the available observational and clinical evidence suggests that mistreatment of residents by staff members occurs with sufficient frequency to be of concern to physicians. Studies have pointed to the very high prevalence of mistreatment of nursing home residents by other residents, in the form of physical, verbal, and sexual aggression. Physicians should be alert to this possibility when examining and treating nursing home residents, because clinically significant injuries have been found to result from resident-to-resident aggression.

Morning Report Questions

Q: What are some of the signs of elder abuse that physicians should consider?
A: With respect to physical abuse, researchers have been unable to identify injuries that are clearly diagnostic of abuse in older persons, as has been possible for child abuse. Although forensic research has demonstrated some emerging patterns of physical abuse (e.g., that older victims are more likely to have bruising on the face, lateral aspects of the right arm, and posterior torso, including back, chest, lumbar, and gluteal regions, than older adults who have bruising unrelated to abuse), these findings are useful primarily to alert the clinician to the possibility of abuse and should not be viewed as diagnostic for either medical or legal purposes without other corroborating clinical findings or historical information. Verbal and psychological abuse may be markers for other forms of abuse and may be the only form that can be observed by clinicians and office staff. The clinical manifestations of verbal and psychological abuse — depression, anxiety, and other forms of psychological distress — which may normally be amenable to pharmacologic and psychotherapeutic intervention, are not likely to remit unless the underlying abuse is detected and mitigated. Abrupt changes in either direction in the financial circumstances of the caregiver (e.g., sudden unemployment or extravagant purchases) may also herald an increased risk of financial exploitation or suggest that exploitation is already under way.

Table 1. Forms of Elder Abuse and Clinical Procedures for Assessment by the Physician.

Q: What is the role of the physician in cases of suspected or known elder abuse?
A: There have been no large, high-quality randomized, controlled studies of specific and discrete interventions in cases of elder abuse — a situation that has been identified as leading to a critical knowledge gap in the field. However, decades of clinical experience and documented best practices in the field provide guidance for practitioners in helping victims. Successful treatment rarely involves the swift and definitive extrication of the victim of abuse from his or her predicament with a single intervention. Instead, successful interventions in cases of elder abuse are typically interprofessional, ongoing, community-based, and resource-intensive. Although physicians have an important role to play in the medical components of those interventions, it will usually not be feasible for them to initiate or sustain successful interventions in cases of elder abuse on their own. Therefore, the most important tasks for the physician are to recognize and identify elder abuse, to become familiar with resources for intervention that are available in the local community, and to refer the patient to and coordinate care with those resources.

Figure 1. Recommended Strategies for Intervention by Physicians in Suspected Cases of Elder Abuse.
Table 2. Groups Involved in Interprofessional Assessment and Intervention in Cases of Suspected Elder Abuse.