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Identifying and addressing geriatric abuse

Nov. 06, 2021

During summer 2021, a Texas sheriff found a deceased 74-year-old woman with numerous maggots present, bedsores and wounds appearing overdue for treatment, including some with bone protruding from decomposing tissue, according to the Fort Worth Star-Telegram.

Daniel Stephens, M.D., a trauma surgeon at Mayo Clinic's campus in Rochester, Minnesota, says such apparent geriatric abuse — also called elder abuse — is uncommon in Mayo's trauma bay. Yet nationwide it's becoming more relevant and recognized. He emphasizes this type of abuse is crucial to be alert for and address.

The American College of Surgeons (ACS) Trauma Quality Programs (TQP) Best Practice Guidelines also prioritize detecting and dealing with geriatric abuse, including reporting.

Elder abuse types

ACS divides elder abuse into five types:

Physical abuse
Sexual abuse
Neglect
Psychological abuse
Financial exploitation

In the American Journal of Public Health, Dr. Acierno and colleagues reported elder abuse as prevalent in the U.S. Of 5,777 older adult phone survey respondents, prevalence for one year was 0.6% for sexual abuse, 1.6% for physical abuse, 4.6% for emotional abuse, 5.1% for potential neglect, and 5.2% for current financial abuse by a family member.

Elder abuse data reveals increased mortality rate, according to a 1998 article by Dr. Lachs and colleagues in JAMA. Health outcomes, especially psychological, worsened for victims compared with nonvictims, according to Dr. Dong and others in a 2013 article in the American Journal of Emergency Medicine.

Elder abuse risk factors

Elder abuse risk factor awareness is beneficial, says Dr. Stephens. The Centers for Disease Control and Prevention indicates that mental illness, substance use, physical health problems or previous disruptive behavior are among elder abuse perpetration risk factors.

Older adult victimization risk factors include poor cognition, physical dependence, developmental delay or chronic illness requiring care, according to a 2016 article by Dr. Pillemer and colleagues in The Gerontologist.

Dr. Stephens says he's seen financial incentives, jealousy, long-standing family disputes, and frustration or burnout due to care overburden contribute to elder abuse.

Distinguishing elder abuse

Dr. Stephens also indicates that differentiating elder abuse from a simple mishap is challenging. "Signs can be hard to recognize, especially with neglect and physical abuse," he says. "It's difficult to tell whether falls, for instance, are accidental or from abuse."

Abuse recognition is also complicated by older patients' tendency to neglect self-care, Dr. Stephens says. Another barrier to identifying elder abuse is the victim's desire to avoid burdening others with abuse issues. The person also may not recognize issues or want to discuss them. "Midwestern farm types don't want to impose themselves on others," says Dr. Stephens. "They want to maintain independence."

Considering challenges in pinpointing elder abuse, Dr. Stephens offers these tips:

Create a private environment to talk

Often, if providers can make time alone with an older adult patient to speak privately, the potential for candid discussion increases. He suggests careful, blunt conversation with patients, potentially using the Elder Abuse Suspicion Index as a guide as well as reviewing the patient's medical history. Dr. Stephens says that it's important for providers to set proper expectations, as patients frequently aren't open to talking initially. Repeated conversations may be necessary to establish the rapport and safety needed for abuse disclosure.

Conduct physical exam mindful of potential abuse

It's important to examine older adult patients with abuse potential in mind, taking note of bruises, burns, lacerations or broken bone indicators. Observing signs of neglect also is crucial, such as poor hygiene or ulcers. Meanwhile, providers must remember elderly patients often take anticoagulants or have frail, easily injured skin.

Observe familial interaction

Watch how older adult patients and family members interact, observing power imbalances or manipulation or control indications.

Have a discussion with caregivers

It's important to interview the older patient's family members without judgment, assess burnout and frustration levels, and then refer them to a hospital social worker, case manager, or legal or ethics professionals, if appropriate.

Neglect is especially hard to pinpoint, says Dr. Stephens, as it can be a gray area. "When it slips over the line into neglect is when older adult patients' basic needs aren't met: food, water, shelter, clothing," he says. "It starts to impact mental and physical health, leading to adverse health outcomes.

In his experience, Dr. Stephens says what often pinpoints abuse is something amiss with the patient's family: stories not matching injury or patient statements, or injury not aligning with purported injury mechanism.

Dr. Stephens explains that at times providers must determine whether a patient should be hospitalized temporarily for safety and then provide resources through social or case workers. He notes, however, that currently nursing homes staffs are stressed. People aren't getting in, and thus they're getting home health care too long.

"We have to carefully walk the line between independence and autonomy when it comes to issues such as skin infections or ulcers, or falls, or car accidents," he says. "The patient ultimately may lose some independence."

Health care providers' role with elder abuse

Providers have numerous roles related to suspected elder abuse, including reporting, patient recommendations, family resources and education:

Health care providers must report potential elder abuse incidents to Adult Protective Services.
Health care providers may offer care, protection and support guidance for older adult patients' caregivers.
Providers can help victims' families by suggesting resources, such as home health care, physical or occupational therapy, local charitable service-provided food, and psychological caregiver support.
To serve older adult patients affected by abuse, providers may familiarize themselves with the ACS TQP guidelines for geriatric abuse.