Because the elderly use emergency services more frequently than younger Americans, emergency physicians are in a unique position to detect and intervene in cases of elder abuse.

You Might Also Like

• Recognize the Signs That Older Children and Adolescents Are Playing the Choking Game
• How to Recognize, Treat Victims of Sex Trafficking
• How to Recognize and Act on Risk Factors for Domestic Violence Homicide

Explore This Issue

ACEP Now: Vol 33 – No 12 – December 2014

The Case

A 75-year-old female presents to the emergency department with a chief complaint of altered mental status. You recognize her because her daughter (her full-time caregiver) frequently brings her to the ED for back pain. She has gotten multiple prescriptions for opioids but always seems to be out of her medications. Today, the patient is lethargic, and her daughter states that yesterday morning was the last time she saw the patient normal. Physical exam reveals the injury shown in Figure 1.

Elder Mistreatment

The U.S. population is aging. The 2010 US census recorded 40.3 million people age 65 and older, or 13 percent of the population.¹ It is estimated that by 2020 more than 52 million Americans will fall into this age group.² As America ages, the impact of elder mistreatment will continue to grow.

Although it is difficult to estimate the incidence of elder mistreatment, recent studies found an incidence of 7.6–10 percent among study participants.^3,4 Because the elderly use emergency services more frequently than younger Americans, emergency physicians are in a unique position to detect and intervene in cases of elder abuse.

The National Center on Elder Abuse (NCEA) defines seven types of elder abuse:⁵

1. Physical abuse: Use of physical force that may result in bodily injury, physical pain, or impairment.
2. Sexual abuse: Nonconsensual sexual contact of any kind with an elderly person.
3. Emotional abuse: Infliction of anguish, pain, or distress through verbal or nonverbal acts. May also include failure to provide social stimulation.
4. Financial/material exploitation: Illegal or improper use of an elder’s funds, property, or assets.
5. Neglect: The refusal or failure to fulfill any part of a person’s obligations or duties to an elderly person.
6. Abandonment: The desertion of an elderly person by an individual who has physical custody of the elder or by a person who has assumed responsibility for providing care to the elder.
7. 7. Self-neglect: Behaviors of an elderly person that threaten the elder’s health or safety.

Elders who experienced abuse have a 300 percent higher risk of death compared to nonabused elders.⁶ It has been estimated that the direct medical cost associated with violent injuries to older adults is more than $5.3 billion.⁷ Because victims of elder mistreatment rarely self-report, health care providers must maintain a high index of suspicion.

The size, shape, color, and location of injuries should be carefully documented using either body maps or photographs. Many electronic health records allow for photographs to be uploaded directly into a patient’s chart. Each department should have a policy regarding photographing patients and storage of images.

Figure 1. Injury on a 75-year-old female patient with lethargy and altered mental status.

If there is a suspicion of elder mistreatment, the emergency provider must take appropriate steps to ensure the patient’s safety. In some cases, the involvement of other family members may be adequate. In others, hospital admission may be required.

Reporting requirements vary among jurisdictions. In most states, the Agency on Aging or Adult Protective Services receives and investigates reports of elder abuse and neglect. It is important to know the reporting requirements and procedures for the jurisdictions in which you practice.

Case Conclusion

The patient remains lethargic during her emergency department course. Urine drug screen is negative. Head CT shows an acute on chronic subdural hematoma. When told of these results, the patient’s daughter becomes tearful and admits that she had been taking her mother’s pain medication. When the patient would not provide her daughter with the patient’s most recent prescription for pain medication, the patient’s daughter struck her in the head, knocking her to the ground.

Emergency department personnel contact the police and Adult Protective Services. The patient is admitted to the hospital for medical care pending the police investigation. With the assistance of Adult Protective Services, the patient is placed in an extended care facility following discharge from the hospital.

Dr. Rozzi is an emergency physician; director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania; and vice chair of the Forensic Section of ACEP.

References

1. Werner C. The older population: 2010 (Publication C2010BR-09). US Census Bureau. Nov. 2011.
2. 2008 national population projections. US Census Bureau website. Available at: https://www.census.gov/population/projections/data/national/2008.html. Accessed November 18, 2014.
3. Under the radar: New York State elder abuse prevalence study. May 2011. New York State Coalition on Elder Abuse website. Available at: http://www.nyselderabuse.org/prevalence-study.html. Accessed Nov. 18, 2014.
4. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the national elder mistreatment study. Am J Public Health. 2010;100:292-7.
5. What is elder abuse? National Center on Elder Abuse website. Available at: http://www.ncea.aoa.gov/faq/index.aspx. Accessed Nov. 18, 2014.
6. Lachs MS, Williams CS, O’Brien S, et al. The mortality of elder mistreatment. JAMA. 1998;280;428-32.
7. Mouton CP, Rodabough RJ, Rovi SL, et al. Prevalence and 3-year incidence of abuse among postmenopausal women. Am J Public Health. 2004;94:605-12.