Elder Abuse: How to Diagnose it and What to do Next

Elder abuse is common, underrecognized, and associated with a roughly 300% higher risk of death in older adults. In the emergency department, the challenge is separating abuse, neglect, and self-neglect from falls, frailty, dementia, and complicated caregiver dynamics.

Recognizing Elder Abuse in the ED

• High-risk patient groups: Older adults with dementia are at especially high risk, with abuse reported in up to half of patients living with cognitive impairment, particularly when the patient is physically or verbally aggressive.
• Suspicious injury patterns: Posterior rib fractures, distal ulnar shaft injuries, traumatic alopecia, and zygomatic bruising are red flags when the reported mechanism sounds like a simple fall.
• Bruising and story mismatch: Large bruises, injuries in different stages of healing, and discrepancies between exam findings and the caregiver's story should raise concern for inflicted trauma.
• Neglect and self-neglect: Missed appointments, absent medications, poor hygiene, malnutrition, and untreated sacral ulcers point toward neglect; self-neglect alone accounts for 42% of APS reports.
• Financial exploitation clues: Forced signatures, unexplained money loss, and confusion about paperwork suggest financial abuse, a problem estimated to cost billions of dollars annually in the US.

Evaluation and Immediate Next Steps

• Separate patient and caregiver: Interviewing the older adult and caregiver apart is a basic diagnostic move, especially when fear, dependence, or loyalty may keep the patient from disclosing abuse.
• Specific screening questions: Direct questions about being hit, kicked, punched, pushed, denied medications, or pressured to sign documents uncover abuse more reliably than broad questions about safety.
• Home environment collateral: EMS observations about food access, hygiene, medications, and the living situation can reveal neglect that is easy to miss once the patient is cleaned up in the ED.
• Acute safety disposition: If there is an immediate safety threat, admission is the safest default while social work, case management, and follow-up resources are mobilized. We get into the disposition nuances in the episode.
• Mandatory reporting laws: Reporting requirements are state-specific, but cognitive impairment commonly triggers mandatory reporting, so emergency clinicians need to know their local Adult Protective Services rules.

References

1. Bond MC, Butler KH. Elder abuse and neglect: definitions, epidemiology, and approaches to emergency department screening. Clin Geriatr Med. 2013;29(1):257-273. PMID: 23177610
2. Rosen T, LoFaso VM, Bloemen EM, et al. Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases. Ann Emerg Med. 2020;76(3):266-276. PMID: 32534832
3. Murphy K, Waa S, Jaffer H, Sauter A, Chan A. A literature review of findings in physical elder abuse. Can Assoc Radiol J. 2013;64(1):10-14. PMID: 23351969
4. LoFaso VM, Rosen T. Medical and laboratory indicators of elder abuse and neglect. Clin Geriatr Med. 2014;30(4):713-728. PMID: 25439637