++
An awareness of risk factors is important for the recognition
of potential victims of elder abuse or neglect. Risks factors can
be divided into two categories: factors associated with the elders
and factors associated with the perpetrators (Table
293-2).
++
++
Patient characteristics associated with a higher risk for elder
mistreatment are cognitive impairment, physical dependency, lack
of social support, alcohol abuse, female sex, and a history of domestic
violence.4 In addition, developmental disabilities,
special medical or psychiatric needs, and difficult behavior (such
as aggression or verbal outbursts) also increase the risk for abuse.
Individuals with limited experience in managing finances are at
increased risk for financial or material exploitation. Although
elder abuse is more common in residential than institutional settings,
institutionalization is also recognized as a risk factor for neglect
and abuse.14,19
++
Three characteristics of perpetrators have been identified as
risk factors: a history of mental illness and/or substance
abuse, excessive dependence on the elder for financial support,
and a history of violence within or outside of the family.20 Abusers
are most often the primary caregiver. Adult children tend to be
more inclined to abuse than are spouses, and males
engage in abuse more often than females.18 Caregivers
may be well intentioned but simply overwhelmed by the amount of
care required. They may themselves be impaired by mental or physical
problems that serve as barriers to the provision of adequate care.
++
The approach to the patient interview is important.
Potential sufferers of abuse should be interviewed in private. The
presence of caregivers, family, or friends may cause the patient
to feel intimidated or embarrassed, which limits the amount and
accuracy of information obtained. The clinician should try to put
the patient at ease by making the assessment seem like a routine
part of the evaluation.2 Other individuals accompanying
the patient should be interviewed separately. Screening tools
are available to aid in the detection of elder abuse.21–23 The
use of lengthier tools is not feasible in a busy ED, but the American
Medical Association has proposed a list of nine screening questions
that may be more practical to implement (Table 293-3). An affirmative answer to any of the questions
in this screening tool raises concern and mandates further exploration.
++
++
During the interview, the physician should also
be prepared to recognize behavioral signs and symptoms that suggest
elder abuse. These include depression, fear, withdrawal, confusion,
anxiety, low self-esteem, and helplessness. Other history-related
indicators that suggest abuse or neglect include a pattern of physician
shopping, unexplained delay in seeking treatment, lack of medical
care, a series of missed medical appointments, previous unexplained
injuries, explanation of injuries inconsistent with medical findings,
and recurrent visits for similar injuries. Additional history taking
should explore risk factors for abuse as outlined above in Risk
Factors.
++
Information can be obtained by the physician prior to conducting
the private interview or by other members of the health care team,
such as nurses, who are likely to have more frequent interaction with the patient and caregivers.
Observing the interaction between the patient and accompanying individuals
can yield valuable clues (Table 293-4).
++
++
Physical examination findings range from subtle and nondiagnostic
to highly suspicious. Abuse is often detected when examination findings prompt
further history taking with results suggesting elder mistreatment.
Psychological and financial abuse are especially hard to diagnose in
the ED setting because physical examination findings are less common.
Nonetheless, it is important to perform a detailed evaluation, including
obtaining adequate exposure of the body to evaluate for trauma and
pressure ulcers. Common physical findings in sufferers of elder abuse
are bruising or trauma, poor general appearance and hygiene, malnutrition,
and dehydration.22
++
Although not the most common form of elder abuse, physical abuse
is the most easily recognized. Evidence of injury to normally protected
areas of the body is highly suspicious for physical abuse.4 Examples
include contusions or lacerations on the inner arms or inner thighs,
and injury to the mastoid area. It is important to expose these
areas when examining the patient to avoid missing significant findings.
Contusions on the palms, soles of the feet, and buttocks also raise
concern for elder abuse.4 Multiple injuries in
various stages of healing can suggest abuse, but may also be seen
in patients with recurrent falls. Taking a thorough history is especially
important in differentiating these two causes. Although older patients
may sustain burns through accidental injury (such as coming too
close to an open flame while cooking), unusual burns or multiple burns
in various stages of healing should also raise concern. Traumatic
alopecia is highly suspicious, although not necessarily diagnostic (because
it may be seen in patients with some psychiatric conditions). Rope
or restraint marks on wrists or ankles18 occur
when elders are inappropriately restrained. Midshaft ulnar fractures
(nightstick fractures) can occur from attempts to shield blows by
raising the forearm. Fractures of the head, spine, and trunk may
be more indicative of abuse, although these can occur by other mechanisms.24 Spiral
fractures of long bones and fractures with rotational components
also raise suspicion of abuse.24
++
Findings resulting from caregiver neglect or self-neglect
are less specific. Perhaps the most identifiable finding is that
of multiple or deep pressure ulcers. Ulcers that are uncared for
(such as open ulcers lacking appropriate dressings or packing) or
those not in lumbar or sacral areas raise suspicion even further. Incapacitated
patients should be turned as part of the examination to evaluate
for skin breakdown. Poor personal hygiene, inappropriate
or soiled clothing, dehydration, malnutrition, contractures, fecal
impaction, and excoriations suggest neglect.15
++
Sexually transmitted diseases or findings of genital trauma,
especially in an incapacitated patient, should raise concern for
sexual abuse. Patients may complain of genital or anal pain, itching,
bruising, or bleeding. Torn or stained underwear, with unexplained
difficulty walking or sitting, may be present. Oral trauma can also
be a manifestation of sexual abuse.
++
Depression, anxiety, and fear can be manifestations of psychological abuse,
although they are nondiagnostic. Observation of interactions with caregivers
and companions can provide further important clues to this type
of abuse.
++
Although elder abuse is widely underrecognized and underreported, the
physician must remember that underlying medical disorders are often
associated with findings that could otherwise be identified with abuse. Advanced
neurologic disorders such as multiple sclerosis, amyotrophic lateral
sclerosis, and Parkinson’s disease may lead to immobilization
and severe disability. Individuals with such conditions are at risk for
pressure ulcers, pneumonia, or venous thromboembolism, even with adequate
care.18