Detecting Elder Abuse and Neglect: Assessment and Intervention



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Am Fam Physician. 2014 Mar 15;89(6):453-460.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See CME Quiz Questions.

Author disclosure: No relevant financial affiliations.

Elder mistreatment includes intentional or neglectful acts by a caregiver or trusted person that harm a vulnerable older person. It can occur in a variety of settings. One out of 10 older adults experiences some form of abuse or neglect by a caregiver each year, and the incidence is expected to increase. Although the U.S. Preventive Services Task Force found insufficient evidence that screening for elder abuse reduces harm, physicians in most states have professional and legal obligations to appropriately diagnose, report, and refer persons who have been abused. Screening or systematic inquiry can detect abuse. A detailed medical evaluation of patients suspected of being abused is necessary because medical and psychiatric conditions can mimic abuse. Signs of abuse may include specific patterns of injury. Interviewing patients and caregivers separately is helpful. Evaluation for possible abuse should include assessment of cognitive function. The Elder Abuse Suspicion Index is validated to screen for abuse in cognitively intact patients. A more detailed two-step process is used to screen patients with cognitive impairment. The National Center on Elder Abuse website provides detailed, state-specific reporting and resource information for family physicians.

The National Center on Elder Abuse defines elder abuse as “intentional or neglectful acts by a caregiver or ‘trusted’ individual that lead to, or may lead to, harm of a vulnerable elder.”1  Although some authors draw distinctions among mistreatment, abuse, and neglect, this article uses the terms inclusively and interchangeably. The major manifestations of elder abuse are described in Table 1.2

Abuse appears to occur most often in domestic home situations, and may be perpetrated by adult caregivers, family members, or other persons.3 It may also occur in institutional settings such as long-term care facilities, nursing homes, or hospice.4,5 Older patients (older than 75 years) tend to have more risk factors (i.e., shared living arrangements, cognitive impairment with disruptive behaviors, social isolation from family and friends, caregiver mental illness [e.g., major depression], alcohol misuse, and caregiver dependency on the older person [e.g., financial]).6 These same risk factors can be barriers to detection of abuse. Not all patients who experience abuse readily demonstrate or express risk factors, and, conversely, many patients with risk factors are not being mistreated.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comments

Physicians should routinely inquire about risk factors for elder abuse.

C

2022

Consensus

The Elder Abuse Suspicion Index can be used to assess for risk of and suspected elder abuse.

C

23

Screening for cognitive impairment should be performed before screening for abuse in older persons.

C

24, 26, 34

Physicians should be aware of medical conditions and medication effects that can mimic abuse in older persons.

C

28, 29

Disease-oriented evidence

Patients and caregivers should be interviewed separately when screening for elder abuse.

C

21

Usual practice

Specific patterns of injury are more suspicious for intentional injury in older persons.

C

2833

Disease-oriented evidence


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References Comments

Physicians should routinely inquire about risk factors for elder abuse.

C

2022

Consensus

The Elder Abuse Suspicion Index can be used to assess for risk of and suspected elder abuse.

C

23

Screening for cognitive impairment should be performed before screening for abuse in older persons.

C

24, 26, 34

Physicians should be aware of medical conditions and medication effects that can mimic abuse in older persons.

C

28, 29

Disease-oriented evidence

Patients and caregivers should be interviewed separately when screening for elder abuse.

C

21

Usual practice

Specific patterns of injury are more suspicious for intentional injury in older persons.

C

2833

Disease-oriented evidence


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Table 1.

Types of Elder Abuse

Types of abuse Characteristics Examples

Financial or material

Illegal or improper use of funds or resources, exploitation

Theft of debit or credit cards, coercion to deprive the

The Authors

ROBERT M. HOOVER, MD, FAAFP, is an assistant professor in the Department of Family Medicine at the University of Tennessee Health Science Center College of Medicine in Memphis.

MICHOL POLSON, PhD, is an assistant professor of behavioral medicine in the Cascades East Family Medicine Residency Program at the Oregon Health and Sciences University in Klamath Falls. At the time this article was written, he was an assistant professor in the Department of Family Medicine at the University of Tennessee Health Science Center College of Medicine in Memphis. He was also the director of behavioral science for the Family Medicine Residency Program at the University of Tennessee Health Science Center in Jackson, and in the St. Francis Family Medicine Residency Program in Memphis.

Address correspondence to Michol Polson, PhD, Cascades East Family Medicine, 2801 Daggett Ave., Klamath Falls, OR 97601 (e-mail: polson@ohsu.edu). Reprints are not available from the authors.

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