Key signs and strategies for recognizing elder abuse

Clinical question

How can I recognize elder abuse (EA) in my busy clinical practice?

Bottom line

Presentations of EA are heterogeneous and easily missed, as older adults do not always voluntarily report abuse. Owing to risks of false-positive findings, American and Canadian recommendations do not call for universal screening, but they suggest physicians be alert for evidence of EA during any clinical interaction.^1,2 Family physicians are well positioned to detect EA but may lack training and knowledge that would allow them to intervene in early stages of abuse. To enhance such skills, we have summarized key points from a Canadian Geriatrics Society Journal of CME article.²

Evidence

• The prevalence of EA in Canada ranges from 4% to 10%, but this is believed to be an underestimation as it is often underreported.³

• The 5 main types of EA are neglect and physical, psychological, sexual, and financial abuse.⁴ This article does not focus on financial abuse.

Approach

Physicians can enhance their abilities to address EA by being familiar with risk factors, precipitants, and possible signs of EA and by integrating a screening tool (eg, the Elder Abuse Suspicion Index⁵) into practice to help identify EA. They should also be familiar with the laws and reporting requirements related to EA in their provinces or territories and know the resources available in their regions to help support interventions for patients who are experiencing EA.

Implementation

Indicators from a patient’s history that may point to possible EA include unexplained injuries, history of repeated injuries, the patient being referred to as accident prone, delay between onset of medical illness or injury and seeking of medical attention, and recurrent visits to the emergency department for similar injuries.⁶

When taking a family and social history, ask about past abusive behaviour, drug or alcohol misuse, recent stressful events, and any relationship issues with the caregiver. Questions can be structured around the 5 main types of EA.⁶

During the physical examination look for signs of despair, fear, and poor eye contact. Also note the physical appearance and hygiene of the patient, including the state of nails, skin, and grooming. If injuries are noted, look at the stage of healing, the size of the bruises, and consistency of the injury with the reported mechanism, and assess for possible mimics. Physicians should try to document clinical findings suspicious of abuse using body charts and clinical photographs. Documentation should also include direct quotations and input from multiple sources, with comments about discrepancies in the history and reliability of sources. Observations about the interactions of the older adult and their caregivers should be documented.⁷ Where possible, a second staff member, preferably of the same gender as the patient, should be present for the physical examination.

Laboratory findings of dehydration, malnutrition, unexplained rhabdomyolysis, and low serum levels of prescription medications (if levels are available) should increase suspicion of neglect.⁶ Radiographic evidence of injuries suggesting high-energy mechanisms even though reports state injuries were caused by low-energy mechanisms should make one suspicious of physical abuse.⁶ For example, a fracture to the ulnar diaphysis is uncommon in accidental injuries and is more typical of trauma to a forearm raised in self defence. Injuries at multiple stages of healing, particularly in the maxillofacial area and upper limbs, are also suggestive of physical abuse.⁸

The Elder Abuse Suspicion Index (Box 1)^5,9 is a Canadian tool validated for use to screen cognitively intact patients in the primary care setting when abuse is suspected. It is a 6-item questionnaire, with 5 questions answered by the patient and 1 completed by the physician, and it takes roughly 2 minutes. One or more positive responses to questions 2 through 6 has a sensitivity of 47% and a specificity of 75% for identifying patients at risk of abuse and should warrant further evaluation.¹⁰

Box 1. Elder Abuse Suspicion Index.

Questions 1 through 5 are asked of the patient and may be answered yes, no, or did not answer. Question 6 is answered by the physician and may be answered yes, no, or did not answer. One or more positive responses to questions 2 to 6 may suggest elder abuse.*

Within the last 12 months:

1. Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?

2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids, or medical care, or from being with people you wanted to be with?

3. Have you been upset because someone talked to you in a way that made you feel shamed or threatened?

4. Has anyone tried to force you to sign papers or to use your money against your will?

5. Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

6. Doctor: Elder abuse may be associated with findings such as poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication compliance issues. Did you notice any of these today or in the last 12 months?

*Note: The Elder Abuse Suspicion Index⁵ was validated to be administered by family physicians in encounters with older persons who have Folstein Mini-Mental State Examination⁹ scores ≥24 and are seen in ambulatory care settings.

Reproduced with permission from Dr Mark J. Yaffe (mark.yaffe@mcgill.ca).⁵

There are other assessment tools available for use in the community, but better outcome measures for interventions are needed to guide their use.¹¹

There are no specific federal EA laws in Canada, but there are laws that apply to various types of abuse. The Criminal Code covers offences such as theft, fraud, extortion, misuse of power of attorney, and physical and sexual offences, as well as criminal negligence and failure to provide necessities of life.¹² Each province and territory takes a unique approach, with some having legislation that makes it an obligation to report abuse in certain environments (eg, long-term care), whereas others have mandatory reporting regardless of setting. The Canadian Centre for Elder Law has produced a practical guide about EA that outlines provincial and territorial EA and neglect laws in Canada.¹³ Consideration and assessment of capacity is important in older adults, as this will affect management approaches.

For more information on screening, assessment, and interventions see the literature review published in the Canadian Geriatrics Society Journal of CME in 2022.²

Geriatric Gems are produced in association with the Canadian Geriatrics Society Journal of CME, a free peer-reviewed journal published by the Canadian Geriatrics Society (http://www.geriatricsjournal.ca). The articles summarize evidence from review articles published in the Canadian Geriatrics Society Journal of CME and offer practical approaches for family physicians caring for elderly patients.