ED providers should carefully observe the patient-caregiver interaction, looking for any suggestions of a strained relationship.
Observations that should increase concern for elder abuse or neglect include:
- Older adult and caregiver provide conflicting accounts of events
- Caregiver interrupts/answers for the older adult
- Older adult seems fearful of or hostile towards caregiver
- Caregiver appears unengaged/inattentive in caring for the older adult
- Caregiver appears frustrated, tired, angry, or burdened by the older adult
- Caregiver appears overwhelmed by the older adult
- Caregiver appears to lack knowledge of the patient’s care needs
- Evidence that the caregiver and/or older adult may be abusing alcohol or illicit drugs
Obtaining a complete and accurate medical history is critical to evaluate for abuse or neglect. An ED provider should take the medical history from the patient alone without caregivers or family present. The provider should assure the patient of privacy and confidentiality and keep in mind that many victims will be reluctant to report abuse or neglect because of guilt, shame, or fear of reprisal. If a language barrier exists, a professional translator or telephone service should be used. Don’t use caregivers or family members as interpreters, even if they are not suspected to be abusers.
When obtaining the history, providers should explore in detail how any injuries occurred and consider asking directly about physical abuse if suspicion exists.
In addition, the provider should explore the patient’s care needs, functional status, cognition, and safety of the home environment and may ask whether the patient feels socially isolated.
Indicators from the medical history that may suggest the possibility of elder abuse or neglect are:
- Unexplained injuries
- Past history of frequent injuries
- Elderly patient referred to as “accident prone”
- Delay between onset of medical illness or injury and seeking of medical attention
- Recurrent visits to the emergency department for similar injuries
- Using multiple physicians and emergency departments for care rather than one primary care physician (“doctor hopping or shopping”)
- Noncompliance with medications, appointments, or physician directions
Even though it may be difficult to perform in a busy ED, a comprehensive head-to-toe exam is essential to adequately evaluate a patient for abuse and neglect. Providers should focus particularly on a full skin examination, including fingernails and toenails. An intra-oral examination is also helpful.
Providers should always consider whether the physical findings are consistent with the reported injury mechanism. A patient sustaining five upper rib fractures after reportedly rolling off a bed two feet above the ground would indicate incongruency.
When sexual abuse is reported or suspected – particularly if evidence of trauma or vaginal bleeding exists on genitourinary examination – an ED provider should conduct a complete sexual assault examination, just as one would with younger victims. If the patient consents, this evaluation should include evidence collection by a trained sexual assault forensic examiner.
When concerns exist after the physical exam, follow up with questions about specific types of abuse or neglect. For patients presenting with injuries, questions should focus on how the injuries occurred, including asking directly about whether anyone has hit, punched, tripped, or kicked the patient.
Radiologists have played a critical role in the detection of child abuse in the ED for decades, identifying imaging strongly suggestive of abuse. Unfortunately, only very limited radiology literature exists describing potential imaging that correlates with elder abuse, and diagnostic radiologists typically do not receive any training in elder abuse detection.
Still, potentially suggestive findings exist, such as co-occurring old and new fractures, high-energy fractures despite low-energy mechanism, distal ulnar diaphyseal fractures, and small bowel hematomas. The ED provider should communicate any suspicion for elder abuse or neglect to the radiologist and ask him/her to focus on whether the imaging findings are consistent with the purported mechanism.
Providers may also consider additional screening imaging tests, including a maxillofacial CT scan and chest X-ray to evaluate for acute and chronic fractures. This is analogous to the skeletal survey routinely performed in potential victims of child abuse.
Examples of Suspected Elder Abuse Imaging
No laboratory test can definitively detect abuse, but lab tests may suggest potential malnutrition, dehydration, anemia, hypothermia/ hyperthermia, or rhabdomyolysis.
Blood or urine tests can detect medication levels, drugs, or toxins. A low or undetectable medication level may suggest intentional or neglectful withholding or diversion.
An elevated medication level may suggest intentional or unintentional overdose.
The presence of toxin or medication that has not been prescribed may indicate poisoning.
More information is available from:
LoFaso VM, Rosen T. Medical and laboratory indicators of elder abuse and neglect.
Clin Geriatr Med. 2014 Nov;30(4):713-28.