5 Things You Should Know About Elder Abuse in the ED

Studies suggest that the prevalence of elder abuse in high-income countries sits at around 7.6-10%.^​1​  As individuals age, there can be a decline in social connections and even primary care visits.  ED visits can be one of the only points of contact outside their immediate living environment, making this a crucial setting for identification of elder abuse.^​2​

It’s a statistical certainty that anyone working in health care has encountered several victims of elder abuse, particularly in the ED.  Yet, when is the last time you identified a case of elder abuse? How would you know to recognize it in the future? And what would you do about it? If you’re not happy with your answers to some of these questions, you’re not alone.  Evidence suggests ED clinicians do a poor job of recognizing and reporting elder abuse.^​3​  

In this post, we present the Top 5 Things You Should Know About Elder Abuse.  We hope it will give you the chance to be the one to break the pattern of abuse for the vulnerable patient you are certain to meet on one of your next shifts.

1. Elder abuse takes many forms.

The WHO defines elder abuse as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person”.^​4​ This broad definition encompasses many forms of abuse (see Table 1).

Significantly, neglect and abandonment are considered forms of elder abuse. In a US retrospective study, neglect and physical abuse were found to be the most commonly identified types.^​5​

Table 1

2. Elder abuse is associated with adverse health outcomes

Elder abuse isn’t just morally reprehensible.  Like all other forms of abuse, it  can cause serious harm. It is associated with adverse patient-oriented outcomes including mortality,^​6,7​ depression and PTSD.^​8​  Risk can be even higher in those patients with poorer baseline cognition and functional status.  It is also associated with a number of system-oriented outcomes including increased ED visits, hospitalizations, and use of mental health services.^​9​

3. ED visits are an opportunity to detect and act upon elder abuse.

In the ED, we are expected to consider non-accidental trauma in children, and to be alert for intimate partner violence.  Given its prevalence and consequences, we should similarly be on the lookout for elder abuse.  Elder abuse has myriad presentations and its detection can be hampered by cognitive impairment, acute medical illness, or even just the inherent limitations of the ED environment.  Fortunately, research has suggested that even those with cognitive decline can often accurately describe how their injuries were acquired.^​10​

The best strategy is to know of and regularly consider a number of red flags that should prompt further inquiry:

• The caregiver not giving your patient enough room to speak
• Apparent hostility between caregiver and patient
• A caregiver who is unaware of the patient’s medical history and needs
• Inconsistencies between your patient’s account and that of the caregiver

The patient should be interviewed alone if possible; they may be reluctant to explore this topic while their caregiver is in the room.   

One benefit of the ED is that your patient will be cared for by multiple individuals who can provide collateral information and may notice some of these red flags.  The EMS team can provide insight into the state of living the patient is coming from, as well as family dynamics observed.^​11​ As half of these patients will undergo imaging, radiologists can also point out injuries that are inconsistent with the story and other suspicious findings.^​12​ 

It has been difficult to validate a tool for identifying elder abuse in the ED due to the lack of an objective measure, or “gold standard”,  as to whether or not abuse has occurred. A recent study has suggested the ED Senior Aid Tool^​13​ which includes the following questions, alongside a mental status exam, physical exam, and judgment call by the healthcare provider:

In the last 6 months:

1. Have you needed help with bathing, dressing, shopping, banking, or meals?
   1. If yes, have you had someone who helps you with this?
   2. If yes, is this person always there when you need them?
2. Has anyone close to you called you names or put you down?
3. Has anyone told you that you give them too much trouble?
4. Has anyone close to you threatened you or made you feel bad?
5. Has anyone tried to force you to sign papers or use your money against your will?
6. Has anyone close to you tried to hurt you or harm you?

4. Certain exam findings are consistent with elder abuse

The physical exam is a useful tool as certain patterns of injury are highly suggestive of abuse. Injuries in the following areas should raise suspicion:^​4​

• Maxilofacial
• Dental
• Neck
• Left side of the face more commonly than the right side

Remember, too, that neglect is a form of elder abuse. Indicators of neglect include:^​5​

• Poor hygiene
• Elongated Toenails
• Pressure Ulcers
• Cachexia

5. You may have a duty to report

Legal requirements for reporting vary depending on which province you are working in; there is currently no federal, all-encompassing law about reporting suspected elder abuse in Canada. 

Be aware that if there is no legal requirement to report, and your patient is deemed capable and wants to return to their present living situation, reporting against their wishes likely constitutes a breach of confidentiality.

At the time of publication, in Ontario, health care providers are only required to report cases involving patients living in a Long-Term Care facility or Retirement home. These should be reported to the Director at the Ministry of Health and Long-Term Care or the Retirement Homes Regulatory Authority, respectively.

If your patient does not live in one of these settings, there is no legal requirement and so the decision to report depends on your patient’s wishes.

Once again, reporting requirements vary depending on where you are working, so make sure you are aware of the relevant guidelines.

You can help prevent future abuse!

Beyond reporting, there are other ways you can advocate for your patient. Involving allied health services such as Social Work or your department’s Geriatric Emergency Medicine Nurse can ensure that your patient and/or their caregiver has access to the resources they need and lessen the degree of isolation they experience.

Behaviour that puts elderly patients at risk is inexcusable.  That being said, neglect may signal a dedicated but overwhelmed caregiver who lacks support.  The role of a caregiver can be physically, psychologically, and financially demanding, especially when older adults are more functionally impaired. Stay focused on the patient: acknowledging burnout and providing additional support may be a better way of improving the patient’s quality of life and safety than a more punitive, judgmental approach.

At the end of the day, the reason we are on the lookout for elder abuse is because we want what is best for our patients. We need to identify the issue while also exploring any underlying contributing factors. Sometimes what is needed to break the pattern of abuse is access to resources; by connecting patients and caregivers to programs that can help relieve some of the burden, you can decrease the likelihood of further abuse.

We hope this post has given you a better understanding of what constitutes elder abuse and practical ways it can be identified. Together we can ensure that some of our most vulnerable patients are well looked after!

Copyedited by Megan Chu.

Reviewing With the Staff

Despite being someone with a particular interest in care of older ED patients, and who has done research on mistreatment of older adults, I have to confess that I find elder abuse challenging to detect clinically. Frail older adults frequently present with such a complex tangle of medical and psychosocial issues that it is easy to miss any one thread, even if it is something as egregious as abuse.

Making matters more challenging, elder abuse is itself a complex phenomenon, with risk factors including perpetrator, relationship, environment, and patient characteristics. It\'s hard to put the whole picture together in a single ED visit. As such, I\'ve moved away from the idea that elder abuse is a \"spot diagnosis,\" or that it has a phenotype. Instead, I try to force myself to look for certain red flags. Dr. Armanious\' post does a very good job of describing some of them.

Specific things I watch for include a history that doesn\'t explain the injury pattern; a caregiver who doesn\'t let the patient speak for themselves and interrupts a lot; a family member who is overly solicitous of my approval or agreement instead of focused on their loved one\'s distress; and a caregiver who expresses being overwhelmed or who is at high risk for burnout.

On this last point, the inability to provide for all of a person\'s needs isn\'t always an issue of neglect. Our study found that two-thirds of caregivers of people with dementia received fewer than 4 hours of help a week from all sources (public, non-profit, voluntary, and family) combined [1]. A struggling caregiver needs support, not punishment. Use the ED visit as an opportunity to connect them to additional resources.

Dr. Armanious also shares the results from a very interesting study showing that a few very distinctive patterns are specific for abuse: facial, dental, and neck injuries, as well as injuries to the left side of the face (which is intuitive, as most people strike with their right hands). However, do interpret these findings in context; older adults often sustain facial injuries due to falls as they often lack the strength and reflexes to break a fall.

One last point: older adults can themselves be perpetrators of intimate partner violence (IPV). People who are violent and abusive do not stop being so when they turn 65. Suspect and inquire about IPV in older patients as you would in any other age group.

Thom Ringer

Thom Ringer is an Emergency Physician at the Schwartz Reisman Emergency Medicine Institute at Sinai Health System, and at the University Health Network, both in Toronto, Canada. He is also affiliated with the Schwartz/Reisman Emergency Medicine Institute. His interests include frailty, elder mistreatment, caregivers, and the interface of law and emergency medicine.

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Miriam Armanious

Miriam Armanious is a Family Medicine resident at McMaster University (Brampton site) with an interest in Emergency Medicine. She loves making music and has watched every episode of LOST at least four times.

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• 5 Things You Should Know About Elder Abuse in the ED - March 16, 2021