This Policy Resource and Education Paper is an explication of the Policy Statement Management of Elder Abuse and Neglect.

January 1999

Elder abuse is a widespread problem that is often under reported. Some experts estimate that only 1 out of 14 domestic elder abuse incidents (excluding the incidents of self-neglect) come to the attention of authorities such as state adult protective service or aging agencies.

In the National Elder Abuse Incidence study, researchers found that about 450,000 elder persons were abused and/or neglected during 1996. The number increase to approximately 551,000 if self-neglect cases were included.¹

Elder abuse is often subtle and difficult to recognize. The key to recognition by emergency health care providers is an awareness of the potential for abuse and its suggestive signs and symptoms. The response to this recognition must be a timely, sensitive, and comprehensive intervention.

The purpose of this paper is to increase awareness by emergency health care providers and to provide a format for the development of individual emergency department protocols.

Definitions

Categories of elder abuse may include: (1) domestic elder abuse; (2) institutional elder abuse; and (3) self-neglect or self-abuse. State statutes usually define elder abuse using these categories.² 

Based on analyses of existing state and federal definitions of elder abuse, neglect, and exploitation conducted in 1995, the National Center on Elder Abuse (NCEA) defines seven types of elder abuse:²

1. Physical Abuse: use of physical force that may result in bodily injury, physical pain, or impairment.
2. Sexual Abuse: non-consensual sexual contact of any kind with an elderly person.
3. Emotional Abuse: infliction of anguish, pain, or distress through verbal or nonverbal acts. May also include failure to provide social stimulation.³ 
4. Financial/Material Exploitation: illegal or improper use of an elder's funds, property, or assets.
5. Neglect: the refusal or failure to fulfill any part of a person's obligations or duties to an elderly person.
6. Abandonment: the desertion of an elderly person by an individual who has physical custody of the elder or by a person who has assumed responsibility for providing care to the elder.
7. Self-Neglect: behaviors of an elderly person that threaten the elder's health or safety.

Recognition

Recognition of abuse by health care providers may allow earlier intervention with the eventual elimination of the abuse. Patients should be asked if they are happy at home, or if they have experienced any recent changes in mood, sleeping, or eating patterns.⁴ While each of the following indicators frequently occurs in the absence of elder abuse, their presence should prompt a consideration of abuse as a possible diagnosis.

Physical indicators^1,3,4

• Bruises, black eyes, welts, lacerations, and rope marks
• Bone fractures or skull fractures
• Open wounds, cuts, punctures, burns, untreated injuries in various stages of healing
• Sprains, dislocations, and internal injuries/bleeding
• Broken eyeglasses/frames, physical signs of being subjected to punishment, and signs of being restrained
• Laboratory findings of medication overdose or under- utilization of prescribed drugs
• Dehydration and/or diarrhea
• Fecal impaction
• Malnutrition
• Urine burns or excoriations
• Incontinence with poor personal hygiene, excessive dirt, foul odors, lice or fleas
• Alcohol and/or substance abuse
• Inadequate or inappropriate clothing
• Absence of eyeglasses, hearing aids, prostheses
• Repetitive hospital admissions or emergency department visits
• Unexplained injuries or explanation inconsistent with medical findings
• Torn, stained or bloody underclothing
• Difficulty in walking or sitting
• Pain, itching, bruising or bleeding in anal or genital area
• Unexplained venereal disease or genital infections
• An elder's report of being hit, slapped, kicked, or mistreated
• An elder's report of being sexually assaulted or raped
• Untreated bed sores or decubiti

Behavioral indicators:^1,3,4

• Being emotionally upset or agitated
• Being extremely withdrawn and non-communicative or non-responsive
• An elder's sudden change in behavior
• Fear or hesitancy to talk
• Depression and/or anger
• Disorientation or confusion
• Change in appetite or weight
• Isolation and/or resignation
• Implausible stories
• An elder's report of being verbally or emotionally mistreated.

Other indicators:^1,3,4

• Unexplained inability to pay bills, purchase food or personal items
• Disparity between income and assets and lifestyle
• Lack of receptivity by family members or elder person to any necessary assistance requiring money
• History of alcoholism, drug abuse, mental illness or past abuse in either patient or primary caregiver
• The elder may not be allowed to speak for himself or be interviewed without the presence of the caretaker
• Family member or caregiver "blames" the elder, e.g., accusation that incontinence is a deliberate act
• Previous history of abuse by a family member or caretaker to others
• Obvious absence of assistance, indifference or anger by the caretaker toward the elder person
• Aggressive behavior (threats, insults, harassment) toward the elder
• Unwillingness or reluctance of family members or caretaker to comply with service providers in planning for care and implementation
• Conflicting accounts of incidents by the family, caretaker, and victim
• The caregiver's refusal to allow visitors to see an elder alone
• Unexplained delays in seeking treatment or a series of missed medical appointments.
• Desertion of an elder at a hospital, nursing facility, or public location such as a shopping center.

Adult Protective Services

In most jurisdictions, either Adult Protective Services (APS), the Area Agency on Aging, or the county Department of Social Services is designated as the agency to receive and investigate allegations of elder abuse and neglect. If abuse or neglect is found, the investigator makes arrangements for services to help protect the victim. Many states have instituted a confidential 24-hour toll-free number for receiving reports of abuse.^1,3

Interventions

Intervention is best accomplished by using a team approach. This involves the medical profession, social services, mental health, and legal professionals.

Emergency health care providers must be aware and comply with their state regulations on reporting suspected cases. Emergency departments should develop protocols and guidelines for suspected elder abuse cases.

An elder who may have been abused should be talked with in a caring, nonjudgmental manner and be apprised that assistance is available. If the elder is competent, they may refuse any intervention.

Possible interventions include:^3,4,5 

• Linkages with appropriate resources, such as home health services, adult day care, or respite care
• Referral to counseling and interdisciplinary support groups
• Case management when indicated
• Dietary assistance
• Guardianship of the person
• Financial or legal assistance
• Assistance with development of informal support systems
• Counseling the abuser
• Housing assistance
• Placement in a convalescent home
• Emergency responses for housing, food, physical/mental health
• Resolution of disposition problems resulting from caregiver exhaustion.

Prevention

Prevention is the best intervention. This can be accomplished by increasing public/physician awareness through education. The elderly need to know their rights and be encouraged not to tolerate abuse. Identification of those elders at risk may lead to early prevention.

References

1. The National Elder Abuse Incidence Study; Final Report September 1998. The National Center on Elder Abuse at the American Public Human Services Association. 
2. The National Center on Elder Abuse. What is Elder Abuse? Washington, DC. www.gwjapan.com/NCEA.
3. American Medical Association. Diagnostic and Treatment Guidelines on Elder Abuse and Neglect. Chicago Illinois. 1992.
4. Taliaferro, Ellen and Patricia Salber. Abuse in the Elderly and Impaired in Emergency Medicine A Comprehensive Study 4th edition. Tintinalli, Judith, Ernest Ruiz and Ronald L. Krome (eds.). 1996 (1377-1379).
5. Wisconsin Coalition Against Domestic Violence and the Wisconsin Bureau of Aging and Long Term Care Resources. Elder Abuse, Neglect and Family Violence: A Guide for Health Care Professionals. 1997 (PSL-3077) 608-266-2568

Developed by the Emergency Medicine Practice Committee

Stephen J. Groth, MD, FACEP, Chair
J. Andrew Sumner, MD, FACEP, Subcommittee Member

ACEP's Emergency Medicine Practice Management Committee has developed this document as supplemental information to the College's policy statement on "Management of Elder Abuse and Neglect."