Up to 1 in 10 elders experience abuse, but most cases are missed during visits to the ED.
Chloe Sidley, MD and Lauren T. Southerland, MD
Emergency departments are exceptional at detecting child abuse and they’ve trained SANE forensic nurses to assist with sexual abuse cases. So why aren’t we better at detecting elder abuse?
During a shift on a bitterly cold winter day, a 76-year-old man is brought in by paramedics. He is disheveled and the medic team says that the home health aide found him in a freezing apartment with the heat off. The home health aide called 911 because the patient was confused and “not acting right.” The patient is not oriented to time or place, but says his name is Frank. He has a temperature of 93 degrees Fahrenheit, pulse 52, BP 138/88, and is oxygenating 95% on room air. When the nursing staff undresses the patient to put him into a gown, you note that he is very thin and is in mismatched clothing. Thankfully, the patient’s electronic medical record has a number for an emergency contact. His son, Bob, answers the phone and you inform him that his father is in the ED. Bob says that his father has a home health aide visit three times per week to take care of him, and to ask the aide about his father’s medical needs. You inform Bob that his father will be admitted to the hospital for continued care and likely will need a better living arrangement. When you go back to check on the patient, he is covered in warm blankets and eating a turkey sandwich. Frank’s mental status has improved and he informs you that his heat was shut off last week. Frank told his son who said he was taking care of it.
The questions are piling up. Is this abuse? Does this need to be reported to Adult Protective Services? Or can we just “admit and forget”?
Your next patient is a pleasant 83-year-old women presenting with arm pain. On first impression, Mabel is dressed appropriately in clean clothes with her lipstick on and is accompanied by her daughter and son-in-law. She has an obvious deformity to her right arm. Her daughter informs you that her mother tripped and fell on her outstretched right arm. Her mother has become very clumsy and is falling all the time because she refuses to use her walker. While the daughter is talking, the patient looks down. You let the daughter finish up and say that you are going to escort the patient to x-ray. You get Mabel into a wheelchair and take her down the hall to radiology. Once there, you sit down next to her and ask her to share her story about what happened. Mabel says, “Just like my daughter said, I tripped and fell on my arm.” Based on her countenance, and your gestalt, you are suspecting that this may not be the whole truth, so you add, “I have seen patients with similar injuries and they were victims of abuse. Has anyone been harming you?” At that point, Mabel opens up about living with her daughter. She is fearful of being put in a nursing home and is in tears saying that her daughter really does take good care of her, but sometimes her daughter gets frustrated with how slow she is and how much help she needs. She doesn’t think her daughter meant to push her, but she was moving slowly with her walker and she did fall. You reassure the patient that she is not necessarily going to be removed from the home, but that we will need to have a longer discussion with social workers and possibly with Adult Protective Services to determine if her daughter’s caregiver stress has resulted in elder mistreatment.
Emergency physicians are at the front line to detect elder mistreatment, but they receive minimal training on this during residency. One in 10 older adults experiences abuse,1 and the majority of abuse/neglect cases are missed. In fact, victims of elder mistreatment visit the ED twice a year on average, and have over twice the relative risk of hospitalization.2,3 There are the obvious cases, such as Frank’s, where we know not to send someone back into a dangerous situation. But what about Mabel? Her humeral fracture does not require admission to the hospital. Does your hospital have a standardized medical work up for patients with concern for abuse or neglect? How would you and your ED social work team handle her situation? All too often in our busy EDs, Mabel would get an x-ray, a sling, and discharge paperwork without someone taking the extra time to discover her true situation. Once she reveals that her injury is not entirely accidental, are there other questions you should be asking?
There are multiple types of elder mistreatment, and many patients suffer from more than one type at a time. Neglect, emotional, and financial abuse make up the vast majority of elder abuse cases reported (see more examples in table 1). In large surveys, financial abuse has been seen to be prevalent in 4.7% of elders.5 One myth about elder abuse is that it typically happens at the hands of a non-related caregiver. However, surveys show that most perpetrators of elder abuse are actually immediate family members and relatives, and most often, adult children or spouses. The risk of elder abuse increases if the elder has dementia and, not surprisingly, if family caregivers abuse alcohol or drugs. Over half of caregivers of older adults with dementia report being verbally abusive, 5-10% report physical abuse, and 14% report neglecting their patient or family member.4
Any older adult who is dependent on others for care needs is at risk for elder mistreatment. The Elder Abuse Suspicion Index (EASI) tool can help physicians recognize elder abuse in the ED (Table 2).7 If you are suspicious of abuse, go through the five questions with the patient and complete the 6th one on your own. It might help to make a smart phrase for the EASI tool in your EMR, or train the nurses and radiology techs to look for signs. Detecting elder abuse as a multidisciplinary team in the ED increases the chance of finding it.
Most states have mandatory reporting laws (find yours at the National Center for Elder Abuse web site), yet a 2004 survey showed that only 1.4% of elder abuse cases were reported by physicians. A suspicion for elder abuse is all that is needed to initiate a report.6 The ED is a unique place to begin the investigation because the patient can be admitted while Adult Protective Services, social work, and potentially law enforcement investigates the situation. If an APS report does not turn up intentional abuse or neglect, it can help identify resources for the patient and their family that they may not have known about before, such as caregiver respite programs. Additionally, there are other community services which can help in a situation with concern for elder mistreatment. Your local Area Agency on Aging can follow the patient with a case manager and do home safety checks. There are a wide variety of hospital-based interventions to assist with identification, referral, and monitoring.9
Incidence of elder abuse in the ED is going to increase with the aging of the baby boomer population. Currently, it is estimated to affect 700,000 to 1.2 million elders per year. The eight types of elder abuse should be on every emergency department provider’s radar. You may be the one to discover not only the neglect in Frank’s case, but also the financial abuse that resulted in him being unable to pay his heating bills.Or you may be the astute provider who detect’s Mabel’s daughter’s caregiver stress, contacts your social work team, and provides her and her family with the appropriate counseling, home health aide, and caregiver respite care. These vulnerable patients are not going to openly admit their difficulties, so please take the extra moment to assess for elder mistreatment and educate your ED staff so the entire team is looking out for these patients.
REFERENCES available online at epmonthly.com
Chloe Sidley, MD is a Resident in the Department of Emergency Medicine at The Ohio State University
Lauren T. Southerland, MD is the Director of Geriatric Emergency Care in the Department of Emergency Medicine at The Ohio State University