Elder Abuse and Neglect: Making the Diagnosis and Devising a Treatment Plan in the Emergency Department (Domestic Violence CME and Geriatrics CME)

Table of Contents

 

About This Issue

Abuse and neglect of elderly persons is increasing, due, in part, to economic and social factors. As with child abuse, recognition of risk factors and pathognomonic injury patterns, appropriate and prompt reporting, and team communication are essential. In this issue you will learn:

What the primary risk factors are for elder abuse and neglect, for both patients and caregivers.

How to differentiate non-abuse injury patterns in frail and potentially cognitively impaired elderly patients.

How to examine and interview elderly patients and their caregivers to best determine the cause for a patient’s presentation to the ED.

Reporting abuse occurring at home versus in an institution: how to contact Adult Protective Services and Long-Term Care Ombudsman

The injury patterns that are close to pathognomonic for abuse: neck, face, and arms.

The essential elements of documentation that will bolster the case for reporting.

How to employ screening tools such as the EASI^© and the ED Senior Abuse Identification Tool.

Creating a multidisciplinary team approach, including prehospital, triage, ED, imaging, and social work staff, to ensure no elderly patients are overlooked for prompt care.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Pathognomonic Injury Patterns in Elder Abuse
10. Diagnostic Studies
    1. Radiologic Studies
    2. Laboratory Studies
    3. Screening Tools
       1. The Elder Abuse Suspicion Index© (EASI©)
       2. The ED Senior AID Tool
11. Treatment
12. Disposition
13. Special Circumstances and Populations
    1. Cultural Considerations
    2. Abuse in Long-Term Care Facilities
    3. Social Isolation and the Effect of the COVID-19 Pandemic
14. Cutting Edge
    1. New Technologies With Potential for Screening for Abuse
    2. Multidisciplinary Team Collaboration
15. Risk Management Pitfalls in Emergency Department Management of Elder Abuse and Neglect
16. Case Conclusions
17. 5 Things That Will Change Your Practice
18. Summary
19. Time- and Cost-Effective Strategies
20. Clinical Pathway for the Assessment and Treatment of Elder Abuse and Neglect
21. Tables and Figures
22. References

Abstract

The prevalence of elder abuse and neglect is trending upward among American seniors, but physician reports of suspected maltreatment are not keeping pace. The most important step in management of elder abuse and neglect is making the diagnosis and reporting the suspicions to Adult Protective Services. This review presents a systematic approach for emergency department diagnosis of elder abuse and neglect, including a thorough history and physical examination combined with the use of standardized validated screening tools. To better assess and treat victims of suspected abuse, physicians can also employ a multidisciplinary team or recruit available resources in the hospital and the community, such as case managers, social workers, and primary care providers to create safety plans for at-risk elders.

Case Presentations

An 80-year-old man is brought in by EMS for high blood sugar, and you note that this is his third time presenting to the ED with this chief complaint…

• As you examine the patient, you ask him why he isn’t taking his medications, and he states that he hasn't been able to get to the pharmacy.
• On examination, the patient is ill-kempt, with poor skin turgor, long toenails, and a small wound on his left foot.
• At first, you think he’s being difficult, but then you begin to wonder whether something else could be going on...

An 84-year-old woman is brought to the ED by her adult son after a fall at home…

• The patient is taking the anticoagulant, apixaban, for atrial fibrillation. Her evaluation is significant for a laceration on her neck and bruising over her medial forearms.
• The patient has a history of cognitive impairment and cannot provide a reliable history, so her adult son provides most of the history. The nurse looks confused, because the description of the fall reported by paramedics is different from the history provided by the patient’s son.
• You consider asking the patient directly what happened and whether she was physically injured by her son, but you aren’t sure whether this is the right approach. You suspect elder abuse and wonder what other findings might help direct her care…

A 79-year-old woman is brought to the ED for vaginal itching…

• An aide at the bedside reports that the patient has a history of dementia and lives in a long-term care facility.
• A nurse helps you with a chaperoned examination, which reveals a thick, yellow-green cervical discharge that is concerning for a sexually transmitted infection.
• You wonder how best to proceed to ensure this patient’s safety…

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Clinical Pathway for the Assessment and Treatment of Elder Abuse and Neglect

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. * Makaroun LK, Beach S, Rosen T, et al. Changes in elder abuse risk factors reported by caregivers of older adults during the COVID-19 pandemic. J Am Geriatr Soc. 2021;69(3):602-603. (Cross-sectional study; 433 surveys) DOI: 10.1111/jgs.17009

5. * Rosen T, Bloemen EM, LoFaso VM, et al. Emergency department presentations for injuries in older adults independently known to be victims of elder abuse. TJ Emerg Med. 2016;50(3):518-526. (Observational study; 572 ED visits) DOI: 10.1016/j.jemermed.2015.10.037

7. * 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(2):292-297. (Observational study; 5777 participants) DOI: 10.2105/AJPH.2009.163089

13. * Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364(9441):1263-1272. (Review) DOI: 10.1016/S0140-6736(04)17144-4

14. * Rosen T, Lien C, Stern ME, et al. Emergency medical services perspectives on identifying and reporting victims of elder abuse, neglect, and self-neglect. J Emerg Med. 2017;53(4):573-582. (Qualitative, cross-sectional study; 350 paramedics) DOI: 10.1016/j.jemermed.2017.04.021

22. * Lee M, Rosen T, Murphy K, et al. A new role for imaging in the diagnosis of physical elder abuse: results of a qualitative study with radiologists and frontline providers. J Elder Abuse Negl. 2019;31(2):163-180. (Qualitative study; 25 participants) DOI: 10.1080/08946566.2019.1573160

27. * Yaffe MJ, Wolfson C, Lithwick M, et al. Development and validation of a tool to improve physician identification of elder abuse: the Elder Abuse Suspicion Index (EASI)©. J Elder Abuse Negl. 2008;20(3):276-300. (Observational study; 953 patients) DOI: 10.1080/08946560801973168

44. * Rosen T, Bao Y, Zhang Y, et al. Identifying patterns of health care utilisation among physical elder abuse victims using Medicare data and legally adjudicated cases: protocol for case-control study using data linkage and machine learning. BMJ Open. 2021;11(2):e044768. (Case control; 204 legally adjudicated cases of elder abuse) DOI: 10.1136/bmjopen-2020-044768

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Keywords: elderly, abuse, neglect, reporting, geriatric, caregiver, dependency, cognitive, social, bruise, purpura, protective, EASI, screening