Elder Abuse: ED Presentations, Evaluation, and Management

Authors: Tara Holmes, MD, MBA (EM Resident Physician, Mount Sinai Morningside-West); Chen He, MD (EM Attending Physician and Residency Program Director, Mount Sinai Morningside-West) // Reviewed by: Joshua Lowe, MD, USAF EM Attending Physician); Alex Koyfman, MD (@EMHighAK); Brit Long, MD (@long_brit)

Case

A 68-year-old male with a past medical history significant for interstitial pulmonary fibrosis requiring home oxygen supplementation of 5L of nasal cannula at baseline presents to the ED via EMS from a nursing home after being found by staff on the ground in his room, unable to get himself up. He had become detached from his supplemental oxygen, and his initial Sp02 was 50%. Upon arrival to the ED, back on nasal cannula at 5L, his SpO2 is 99%, and he is not in any respiratory distress.

Introduction

Elder abuse refers to an action or neglect perpetrated against a vulnerable older individual, that risks or results in harm to that individual. This maltreatment is usually committed by a person with a presumed position of trust such as a caretaker.¹ There are five major categories of elder abuse including physical, sexual, emotional/psychological, financial, self-neglect, and neglect (Table 1).¹ Elder abuse has a reported prevalence of 15.6% in the general population and as high as 62.5% in the institutionalized elder care population, though this number is likely an underestimation given that elder abuse is commonly underdiagnosed and underreported.² Despite the high prevalence of elder abuse, many cases go undetected for a multitude of reasons including lack of training on and standardization of identification of abuse, lack of knowledge about the steps of intervention after abuse has been identified, and inability for this population to self-advocate.³  Emergency providers should maintain a high degree of suspicion as delays in identification and intervention can lead to increased adverse health outcomes such as dementia, depression, and increased cognitive decline.³  The victims of elder mistreatment have a three-fold increase in mortality when compared to non-victims.⁴

Compared to other age demographics, the older population (>65 years of age) is more likely to utilize the Emergency Department (ED) for medical care rather than visiting a primary care provider.³ This makes the ED an important opportunity to identify and intervene upon elder mistreatment given that ED visits are often unplanned, leaving abusers more vulnerable to exposure.³ Overcoming these barriers to intervention by ED clinicians can help increase identification of elder abuse, thereby decreasing morbidity and mortality in this population.

Table 1: Types of elder abuse and examples⁵

Presentations and Evaluation

History

Accurate medical and social history is important when evaluating possible elder mistreatment. If there is any concern for elder mistreatment, the patient and caregiver should be interviewed separately.  Additionally, sources of collateral, such as EMS or the electronic medical record, should be obtained if possible.¹ Clinicians are often trained to ask patients, “Do you feel safe at home?” to evaluate for abuse, but although it is important to ask, this one question is too broad and inadequately screens for the complexities of elder abuse.^1,6 In a fast-paced, busy environment such as the ED, a brief yet effective evaluation tool is ideal for screening. There are a variety of elder mistreatment screening tools that have been developed but only one, the Elder Abuse Suspicion Index (EASI) has been independently validated for a cognitively intact adult, age 65+, with a sensitivity of 47% and specificity of 75% in raising suspicion for elder abuse to a level that would indicate referral for possible abuse intervention (Table 2).⁷ Although sensitivity of this tool is <50%, with a specificity of 75%, the EASI can be valuable tool to rule-in elder abuse as a likely possibility.  The EASI is composed of six “yes or no” questions. If a patient answers “Yes” to any of the questions 2-6, suspicion is raised for elder mistreatment and that patient should be offered safety resources highlighted in the management section below. The EASI questionnaire has been validated for those with a mini-mental state examination score of 24 or higher.⁸ For those who are cognitively impaired, clinicians should use the physical exam to guide suspicion.

Table 2: Elder Abuse Suspicion Index (EASI)⁸

Physical Exam

Although there are no physical exam findings specific for elder mistreatment, certain findings warrant particular attention when elder abuse is suspected, especially when evaluating patients who are cognitively impaired (Table 3).⁵ Certain injury patterns such as bite marks, burns consistent with the shape of a cigarette, and ligature marks can seldom be explained by reasons other than abuse.⁸ Clinicians should evaluate further for neglect if the patient under the care of an institution/caregiver is particularly unkempt, presents with malnutrition or dehydration, or has poorly-controlled medical problems.⁸

Table 3: Physical exam findings that are more likely to indicate elder abuse⁹

Laboratory Studies

Emergency Department lab tests can help guide a clinician’s suspicion for elder mistreatment. Coagulation studies can evaluate for organic causes of abnormal bruising.⁸ Urine and serum toxicology screens can reveal the presence or absence of substances.⁸ For example, if a patient is prescribed an opiate their urine drug screen should be positive but if found to be absent, a caregiver may be withholding medications which constitutes neglect.⁸ Conversely, if there is a substance present that does not coincide with the patient’s medication list, poisoning should be considered.⁸ Although values may not result while in the ED, any prescribed medications with measurable serum levels can be checked to evaluate for withholding/failure to administer medications by a caregiver.⁸

Management

If elder abuse is strongly suspected after obtaining a history and physical, there are three major actions to take: ensure the patient’s safety, treat immediate medical/psychological concerns, report abuse to the appropriate authorities.¹¹ Since caregivers or nursing home institutions are often perpetrators of elder abuse, social admission to the hospital may be warranted if medical admission is not required.¹ It is mandatory for clinicians to report elder abuse in all fifty states, although, the definition of elder abuse, and the age which defines “elder,” varies in each state.¹⁰  Each state has a division for adult protective services (APS) where anyone can report suspected elder mistreatment.¹² APS not only investigates these allegations but can also provide resources, such as shelter placement, to ensure safety of the suspected vulnerable adult.¹² It is important to note that multiple APS reports can be filed for the same patient and that any time elder abuse is suspected, it should be reported, regardless of whether it has been reported prior. Social work, either in the ED or during hospital admission, can help facilitate reporting to APS and organize a safe disposition for the patient. Therefore, it is helpful to involve social work early in the hospital course.¹

Pearls and Pitfalls

-Elder abuse has a reported prevalence of 15.6% in the general population and as high as 62.5% in the institutionalized elder care population. Delays in identification of this mistreatment has serious detrimental health effects on the affected population.

-The Elder Abuse Suspicion Index (EASI) questionnaire is an externally validated tool clinicians can utilize in patients older than 65 who are cognitively able. It takes minutes to administer and can strengthen suspicion of elder abuse.

-There are 5 different subcategories of elder abuse: physical, sexual, emotional/psychological, financial, neglect, and each type has a screening question on the EASI questionnaire.

-When taking a history, if elder abuse is suspected, it is important to interview the caregiver and patient separately.

–Be aware of physical exam findings (see Table 2) that are more likely from abuse or mistreatment rather than a medical cause, especially in patients who have impaired cognition or cannot speak.

-It is mandatory for clinicians to report elder abuse in all 50 states. Each state has a division of Adult Protective Services (APS) to report to, which can be done in the ED or on admission with assistance from social work.

Case Resolution

The patient was sent from the nursing home without a nursing home representative. When asked if he remembers what happened that brought him to the ED, the patient becomes tearful and states, “At the nursing home, an aide is supposed to help me get around. But she tells me that if I ask her for help too much, I won’t get dinner for the night. That day, it was almost the end of her shift and she had just helped me to the bathroom. When I wanted to change my shirt, she told me I was out of favors and I was on my own. I tried to get the shirt myself and make it the short distance without my oxygen, but obviously I didn’t make it because here I am.” Physical exam demonstrated no signs of physical abuse, but the patient’s history is consistent with neglect. The nursing home was contacted, social work was consulted to assist in the APS report, and the patient was admitted to the hospital until he had a safe disposition that could also support his medical needs.

References

1. Johnson MJ, Fertel H. Elder Abuse. PubMed. Published February 20, 2023. https://www.ncbi.nlm.nih.gov/books/NBK560883/
2. Yon Y, Ramiro-Gonzalez M, Mikton CR, Huber M, Sethi D. The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis. European Journal of Public Health. 2018;29(1):58-67. doi:https://doi.org/10.1093/eurpub/cky093
3. ‌Rosen T, Zhang H, Wen K, et al. Emergency Department and Hospital Utilization Among Older Adults Before and After Identification of Elder Mistreatment. JAMA Network Open. 2023;6(2):e2255853. doi:https://doi.org/10.1001/jamanetworkopen.2022.55853
4. World Health Organization. Abuse of older people. World Health Organization. Published June 13, 2022. https://www.who.int/news-room/fact-sheets/detail/abuse-of-older-people
5. Fast Facts: Preventing Elder Abuse |Violence Prevention|Injury Center|CDC. www.cdc.gov. Published April 14, 2022. https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html#:~:text=Common%20types%20of%20elder%20abuse
6. Hoover RM, Polson M. Detecting Elder Abuse and Neglect: Assessment and Intervention. American Family Physician. 2014;89(6):453-460. https://www.aafp.org/pubs/afp/issues/2014/0315/p453.html#:~:text=THE%20ELDER%20ABUSE%20SUSPICION%20INDEX
7. Rosen T, Platts-Mills TF, Fulmer T. Screening for elder mistreatment in emergency departments: current progress and recommendations for next steps. Journal of Elder Abuse & Neglect. 2020;32(3):295-315. doi:https://doi.org/10.1080/08946566.2020.1768997
8. Aafp.org, 2024, www.aafp.org/pubs/afp/issues/2014/0315/p453/jcr:content/root/aafp-article-primary-content-container/aafp_article_main_par/aafp_figure.enlarge.html. Accessed 26 Mar. 2024.
9. Elder Mistreatment. Default. Accessed March 29, 2024. https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-geriatrics/elder-mistreatment
10. ‌Types of Abuse Defined in Adult Protective Services Statutes. American Bar Association Commission on Law and Aging. Published 2021. https://www.americanbar.org/content/dam/aba/administrative/law_aging/2020-abuse-definitions.pdf
11. Ahmad S, Rosen T. Elder Mistreatment. Default. Published September 24, 2021. https://www.saem.org/about-saem/academies-interest-groups-affiliates2/cdem/for-students/online-education/m4-curriculum/group-m4-geriatrics/elder-mistreatment
12. ‌Adult Protective Services, What You Must Know. USC Center for Elder Justice. https://eldermistreatment.usc.edu/wp-content/uploads/2023/07/APS-Fact-Sheet.pdf