Abused elders may not complain, so be proactive

LOS ANGELES – Signs of diseases common in aging populations can overlap with signs of elder abuse, but "there are certain red flags that should rise a question of mistreatment in the elderly". These red flags include certain patterns of lacerations, bruises, burns, or fractures. it is estimated that between 1 million and 4 million elderly US adults experience some form of neglect, including self-neglect or outright mistreatment, either at home or in long-term care facilities.

Signs of abuse are often not detected by medical, legal, or social service professionals, and most abuse to emergency department staff when they are injured. "Cognitive and mental health problems prevent elders from seeking help or removing themselves from abusive situations and leave them subject to exploitation by others. The AMA recommends the screening of geriatric patients for abuse if signs are present, even if the patients does not complain. According to some abused elderly patients do not complain out of fear that their caregivers will retaliate by placing them in a nursing home. For this reason, physicians should interview patients they suspect are being abused without the caregiver present.

More than one or two lacerations, especially if on the arms or legs, may signal mistreatment. Bruises related to aging, generally form on the nose, chin, cheek, arms or legs, but bruises from mistreatment tend to be on the neck, chest, trunk, buttocks, palms, and soles of feet, and may retain the pattern of a hand or a weapon. Restraints may have been needed to prevent acute harm to a patient, but bruises cause by restraints must be evaluated by a medical professional to protect the patient.

The elderly have twice the national average risk of dying from accidental burns, and 40%-70% of admissions to two US burn centers were caused by neglect. Fractures not related to abuse in the elderly tend to be located at the distal wrist, hips, or vertebrae, but fractures from abuse are found more often in the skull, spine, or trunk and tend to have a rotational or spiral component. Other signs that may indicate mistreatment include deep ulcers in multiple locations.

Malnutrition and dehydration may be caused by abuse or may be incorrectly ascribed to abuse. As patients age, they may hear poorly because of diminished senses of smell and taste, dementia, or problems with their dentures. In addition, older kidneys continue to excrete urine despite dehydration. Conversely, caregivers may withhold food and water as punishment. Clinicians should suspect malnutrition or dehydration caused by neglect in nursing home patients when staffing at a facility is inadequate to feed all the patients, if there is evidence of poor oral hygiene, or if the patient’s cultural preferences for food and beverages have been ignored. Physicians should also be alert to signs of potential sexual abuse, such as sexually transmitted diseases (including HIV), bladder infections, and behavioral changes such as fear, withdrawal, depression, anger, or increased sexuality. In discussing the medical implications of elder abuse, said about 50% of mistreatment cases are caused by neglect. About half of caregivers are well intentioned, but may lack the knowledge or resources to provide quality care or are burned out from the stress of caregiving.

In collecting evidence of possible abuse, the physician should rate the likelihood that any suspicious sign may be because of abuse, using the terms none, unlikely, possible, probable, or definite. The physician should check for bruises around the wrists or ankles that might indicate improper use of restraints and should order laboratory tests to support evidence of malnutrition, dehydration, or the possibility that prescription medications are being withheld by the caregiver. The physician should also document who is providing the care, who is the decision maker, and who is paying the bills, but should not allocate blame to a specific individual, even if there is a single caregiver. If the coroner asks outright whether neglect caused by patient’s death, the physician can reply that there were suspicious signs consistent with neglect. Note that Polaroid pictures are not stable and can’t be copied easily, so film or digital photos are needed to document injuries.