Elder abuse

You are working a shift in the local emergency department. An elderly woman arrives with her son after falling at home. She has bruises on her face and back. She appears to be dehydrated and is quite thin. Upon examination, you discover that she has sustained a rib fracture.

In February 2007, a 55-year-old man in Toronto, Ont, was convicted of manslaughter for neglecting and beating his mother who had Alzheimer disease.¹ The abuse contributed substantially to her death. It was believed to be the first case in Canada in which elder abuse was declared an indirect cause of death. Did this case create or raise awareness of an ever growing problem?

The topic of elder abuse is difficult to assess and is often considered a “soft” topic by emergency physicians (ie, the literature is unclear). Soft topic was probably also used to describe “trauma X” in children, and yet here we are 30 years later, aware and on guard; there is a whole social system set up to deal with this very serious and devastating problem.

In 2002, the World Health Organization defined 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.”²

In 1997, a questionnaire was sent out to 3000 members of the American College of Emergency Physicians as part of a national survey; the results were published in the Annals of Emergency Medicine.³ The questions asked about physicians’ comfort with recognizing victims of elder abuse. The results showed that emergency doctors did not think that a clear-cut definition of abuse existed, and only 25% were able to recall educational content on this topic in residency. They also believed that there were insufficient resources available to deal with these problems.

During the past few years, the literature has grown to identify markers of abuse and neglect.³ These markers are not necessarily distinct, but they do indicate a reason to question the possibility of elder abuse.

An aging Canada

According to Statistics Canada, in 2010 the Canadian population was 34 100 000, with the median age of Canadians at 39.7 years. The youngest age group (0 to 14 years) made up 16.5% of the population, whereas those older than 65 years of age made up 14.5% of the population.⁴ By the year 2015, those aged 65 years and older will outnumber those in the 0-to-14 age group. There is no doubt that the number of Canadians older than 65 years of age will increase, and with it the stress on an already delicate balance.

Statistics Canada did a telephone survey of 5000 people on the topic of geriatric abuse and neglect. The population surveyed was a cross section of Canadians, 35% of whom were older than 65 years of age. The results were rather interesting, as 96% of participants thought that abuse and neglect were often hidden, and 22% believed they knew abused seniors. Sadly, 90% thought that abuse and neglect worsened with age and that women were more likely to be victims. Even more interesting, 12% had sought help for issues of abuse, and 20% had searched out information from various sources.⁵

There has been a push across Canada aimed at raising public awareness of this very serious problem with commercials and articles. Are emergency departments lagging behind on this problem? Are cases of abuse and neglect missed? Has there been an increased recognition of this topic?

It is safe to say that emergency departments are the pulse of a society and that any change in public health or occurrence of a new disease (eg, severe acute respiratory syndrome) is often seen there first. Are emergency staff advocates for elderly patients? We certainly expect our medical students and residents to be advocates for their patients. Evaluations in most medical schools and residency programs assess undergraduate and postgraduate trainees on this point.

Why are we missing elder abuse in our emergency departments? Trauma X victims (ie, children) share many risk factors with the victims of elder abuse and neglect. Such elderly patients are often reluctant to talk about their circumstances, as they depend on the abusers for their daily existence. Also, they are often related to the abusers, are ashamed about being victims, and might believe they somehow deserve the treatment they are receiving.

Abuse can take many forms: physical, psychological, financial, or sexual abuse or caretaker neglect. All too often, the elderly are unable to look after themselves (self-neglect) and have little or no insight into this problem. The most frequently seen types of elder abuse are self-neglect and caretaker neglect.

As aging occurs there is a tendency to fade from view. Unfortunately, victims are also often physically or cognitively impaired, making reporting difficult and often questionable.

Signs of abuse and neglect

Is a bruise just a bruise? Falls are common, but not all bruises are the result of falls. First, location and symmetry should always be noted. For example, bruising on the breasts, eyelids, neck, scrotum, abdomen, back, or shoulders is unlikely to be the result of a fall. Ask the patient how these bruises came to be, and ask the caregiver as well to see if the stories match.

In the elderly, wrist and hip fractures are common, but truncal fractures (eg, spine or ribs) can be signs of abuse. If patients with multiple ulcers on their buttocks and back have fractures, you must ask yourself how they managed to sustain them in a fall. Multiple decubiti ulcers can also be markers of abuse and neglect. Dehydration, cachexia, and weight loss must also be examined because these factors can help identify problems.⁶

Resources for patients

Seniors Canada [website]. Elder abuse—it’s time to face the reality. Ottawa, ON: Government of Canada; 2010. Available from: www.seniors.gc.ca/c.4nt.2nt3col@.jsp?cid=161.

Ministère de la famille et des aînés [website]. Elder abuse. Quebec, QC: Government of Quebec; 2010. Available from: www.aines.info.gouv.qc.ca/en/fiche.asp?sujet=76.

Caregivers are often trying desperately to cope with very difficult situations and they burn out in the process. Without identification, help, and support, such problems might escalate until neglect and abuse follow.

Questioning reveals slight discrepancies between the woman’s version of the story and her son’s version. Further questioning of the son reveals that he is at his “wits’ end” in caring for his mother. He has been increasingly frustrated by recent declines in her cognitive abilities, adding further stress to an already tenuous situation. Along with treating the woman’s injuries, you are able to connect the woman and her son with the local community care access centre, where arrangements are made to support the son in his mother’s care.

It is not currently mandatory for physicians in Canada to report elder abuse, but physicians need to be more aware of this problem and the moral obligation it entails. There is an inherent obligation for physicians to advocate for their patients.

Also, abuse increases with age and it usually occurs in the home. It has been a long-held belief that the elderly should stay in their home situations as long as possible. The important phrase is as long as possible. The risks and benefits should be weighed before returning someone to the same situation.

Emergency departments are busy places, but keeping patients safe—regardless of age—is a moral obligation. There is no doubt that there is a need for more consciousness training and recognition of forensic markers of elder mistreatment, especially for emergency department staff members who are most likely to see unrecognized cases.

BOTTOM LINE

• Is a bruise just a bruise? If an elderly patient has bruises, ask the patient and the caregiver how the bruises came to be, and see if the stories match.

• Falls are common, but not all bruises are the result of falls, especially if they are located on the breasts, eyelids, neck, scrotum, abdomen, back, or shoulders.

POINTS SAILLANTS

• Une ecchymose est-elle seulement une ecchymose? Si un patient âgé présente des ecchymoses, demandez au patient et à son aidant comment ces ecchymoses ont été causées et vérifiez si le récit des deux personnes concorde.

• Les chutes sont fréquentes, mais toutes les ecchymoses ne sont pas le résultat d’une chute, surtout si elles se trouvent sur les seins, les paupières, le cou, le scrotum, l’abdomen, le dos ou les épaules.

Emergency Files is a quarterly series in Canadian Family Physician coordinated by the members of the Emergency Medicine Committee of the College of Family Physicians of Canada. The series explores common situations experienced by family physicians doing emergency medicine as part of their primary care practice. Please send any ideas for future articles to Dr Robert Primavesi, Emergency Files Coordinator, at robert.primavesi@muhc.mcgill.ca.