Clues that suggest a need for further information include reluctance on the part of the caregiver to leave the patient alone and discrepancy between objective data and what the caregiver says. Other clues include reports of frequent visits to the emergency department, clinician’s office, or hospital; seeking care from different providers; or delays in seeking medical care.12
Build from the physical examination findings. While images of major physical injury may come to mind, elder abuse symptoms often are more subtle. Challenges already exist in the physical examination of the older adult relative to age-associated physical changes and chronic illnesses; elders often present with fewer physical and psychosocial reserves. With patients who are already frail and at risk for falls and injuries, elder abuse can be masked. For all elders, a watchful, screening approach is indicated, including increased vigilance for those presenting with risk factors.
Patients who present with risk factors for abuse warrant a more focused examination. This includes a comprehensive functional approach to the examination, inquiring about social supports, specifics about the patient’s environment, and other resources, with particular attention to cognition and function or dependency.13
Physical indicators of abuse vary. Common physical symptoms that should raise suspicion include:9,12
- Repeated or unexplained injuries; evidence of old injuries not previously documented Wounds or bruises in various stages of healing or in unusual locations. Differentiating accidental bruising or tears in age-sensitive skin versus nonaccidental bruising is indicated.
- Pattern injuries indicating objects used to inflict the injuries, such as signs of cigarette burns or restraints
- Untreated health problems; poor nutrition; patients lacking necessities, such as eyeglasses, dentures, or hearing aids
- Withdrawn or passive behaviors; indicators of depression.
Document thoroughly. Clear documentation of findings provides baseline data and legally substantiates information gained.2 Documenting a thorough skin assessment is indicated, particularly in highly suspected abuse. Recommendations include taking pictures of wounds for the health record.10 Information can also be recorded from the functional assessment that includes the informal support system, environment, and social resources. Detailed documentation of follow-up plans and referrals is key.11
A more detailed assessment and further documentation of elder abuse can be gained with specific elder abuse assessment tools. These tools have been developed for both research and clinical practice. Appropriate follow-up tools depend on the population and setting. The Elder Assessment Instrument is one example; it has 41 items that further address elder abuse risk within general assessment and broad screening categories.15 These screening tools can be administered as part of office protocol, in at-risk situations, or to further process and document concerns. Selected tool summaries are provided by University of Iowa Family Medicine.
Education, communication and referral roles
PCPs can establish a practice philosophy and put in place protocols to guide all staff members in being advocates for frail elders. To enhance screening efforts, front-office staff should receive education that includes awareness of the potential for elder abuse and indicators that should raise suspicions. This includes staff members involved in admitting and fielding family/patient phone calls. As noted, watchful screening and speculation is indicated for all patients. Information acquired by office staff and their concerns can be conveyed to the provider, raising awareness that further screening is indicated.
Education. A proactive team approach to minimize risk for elder abuse includes focus on the caregiver. Information can be shared routinely with all caregivers regarding how to minimize stress and how to reach out for help when it is needed. This includes support for minimizing high-stress/abusive environments. Typically, caregivers do not receive training for this role, and assisting caregivers to access support or respite is often indicated. Many resources exist to assist in dealing with this important problem (Table 2). The resources provide helpful teaching materials for caregivers as well as office staff. Information includes access to abuse hotlines and resources for minimizing caregiving stress.
Assisting caregivers and potential victims. Communicating potential concerns or information about high-risk situations to appropriate team members is central to keeping patients safe. Interdisciplinary dialogue and referrals to appropriate teams/agencies are often indicated.16 Team members might be broadly described to include social workers and various allied health disciplines.
Some primary-care settings identify an individual to fill the role of either an informal or formal case manager for high-risk families, helping to screen for problems and identify resources. Sample approaches to support caregivers and decrease stressors leading to abuse include:
- Communicate with patients and informal caregivers regarding their stressors; seek early awareness of stressful situations.
- Provide information on caregiver support groups and resources for caregiving respite. Online support communities exist for caregivers with limited ability to leave home.
- Involve the stressed caregiver in planning, and refer to informal or formal agencies designed to support or assist in caregiving.
Sample approaches to support potential victims include:
- Develop or support team plans to keep elders socially involved. Social ties and networks can decrease isolation and create access to assistance.
- Seek telephone contact resources for homebound patients, such as volunteer programs providing daily phone checks.
- Recommend that emergency call systems be in place for urgent situations.
- Promote regular health-care checkups that also serve as contact for elder abuse risk.10
Resource protocols. Protocols can be in place not only for appropriate screening, but to refer for available community services. Informal and formal resources are available to help meet caregiver stress situations and follow up on elder abuse concerns. Community resources exist, such as senior centers, adult day-care programs, or respite services within assisted living settings. A national network of resources includes the Area Agencies on Aging at the local level. Online resources, such as Elder Locator, are identified in Table 3.
Reporting cases of suspected abuse. For potential or actual victims, the goal is patient safety. Patient follow-up by an interprofessional team is indicated in suspected abuse. An office social worker or staff designee could assist in further planning and ongoing sensitive communication needs. Team management approaches include counseling, protective services, relocation, and legal actions.16
Adult protective service agencies are mandated in all jurisdictions in the United States. In working with these agencies, the role of the PCP is to identify events and report before any events escalate. In addition to documenting findings, providers work with agencies to assist with medical issues and determine patients’ capacity for self-care and self-protection. In some cases, patient relocation or legal actions will be required.16 Elders have the right to refuse services unless they no longer have the mental capacity for making their own decisions.
All ethical codes support respect of the human condition and protecting vulnerable patients. Health-care providers have a duty to report and, in most cases, are legally required to do so. Reporting to adult protective services is indicated if there is a reasonable suspicion of elder abuse as summarized in the following:
- If there is any evidence of mistreatment without sufficient clinical explanation
- Whenever there is a subjective complaint by the elder of elder abuse
- Whenever the clinician believes there is high risk or probable abuse.15
PCPs have a screening role in identifying elder abuse as well as stressful situations that may lead to abuse. This includes knowing the risk factors for elder abuse and extending the history and physical examination as a screening tool. Opportunities exist for communicating with patients and families about elder abuse risks, as well as resources to assist in stressful situations.
Team-based strategies for supporting elders and families include needed patient referrals to social service agencies and appropriate reporting. Listening, observing and synthesizing the patient’s complex story leads to opportunities to promote patient safety.
Wanda Bonnel, PHD, GNP-BC, is an associate professor at the University of Kansas School of Nursing, Kansas City. The author has no relationships to disclose regarding the content of this article.
- Bonnie RJ, Wallace RB. “Elder mistreatment: Abuse, neglect, and exploitation in an aging America.” Panel to Review Risk and Prevalence of Elder Abuse and Neglect. Washington, DC: The National Academies Press; 2003.
- Halphen JM, Varas GM, Sadowsky JM. “Recognizing and reporting elder abuse and neglect.” Geriatrics. 2009;64:13-18.
- National Family Caregivers Association. What is family caregiving?
- National Center on Elder Abuse. What is abuse?
- Mosqueda L, Dong X. “Elder abuse and self-neglect: I don’t care anything about going to the doctor, to be honest.” JAMA. 2011;306:532-540.
- Taylor DK, Bachuwa G, Evans J, Jackson-Johnson V. “Assessing barriers to the identification of elder abuse and neglect: a communitywide survey of primary care physicians.” J Natl Med Assoc. 2006;98:403-404.
- Kennedy RD. “Elder abuse and neglect: the experience, knowledge, and attitudes of primary care physicians.” Fam Med. 2005;37:481-485.
- Wood E; for the National Center on Elder Abuse. The Availability and Utility of Interdisciplinary Data on Elder Abuse: A White Paper.
- Ahmad M, Lachs M. “Elder abuse and neglect: what physicians can and should do.” Cleve Clin J Med. 2002;69:801-808.
- Ham RJ, Sloane, PD, Warshaw GA et al. Primary Care Geriatrics: A Case-Based Approach. 5th ed. St. Louis, Mo.: Mosby; 2006.
- Lantz MS. “Domestic violence in an older couple.” Clin Geriatr. 2009;17:7-10.
- Hirsch CH, Stratton S, Loewy R. The primary care of elder mistreatment. West J Med. 1999;170:353-358.
- Bonnel W. “Screening for functional deficits in older adults.” Clinical Advisor. 2011;14:55-60.
- Reuben DB. Geriatrics at Your Fingertips 2011. 13th ed. Belle Meade, NJ: Excerpta Medica; 2011.
- Fulmer T. Elder mistreatment assessment. Best Practices in Nursing Care to Older Adults.
- Halphen JM. Geriatric gems and palliative pearls: intervention in cases of suspected elder abuse, neglect and exploitation. The University of Texas Health Science Center at Houston.
All electronic documents accessed March 8, 2012.