Approach

Abuse of older adults is often an ongoing process. If the diagnosis is missed, individuals may go on to suffer more serious abuse, which may be fatal. Both medical and psychosocial problems may be present, and so the condition requires a comprehensive and multi-faceted evaluation.[36]​ Some of the difficulties with identifying older adult abuse stems from variations in its definition.[37]

The presence of risk factors combined with a detailed history and physical examination should determine if there is a need for using additional screening tools. Several assessment tools are available to screen potential victims of abuse.[37][38][39]

History

The American Medical Association (AMA) recommends that doctors routinely ask geriatric patients about abuse, even if signs are absent. Key risk factors for older adult abuse include: age >75 years; dementia; dependence on a carer for personal care; depression or other mental illness in the carer; substance misuse in the older adult or carer; and financial dependence of the carer on the older adult.

Unexplained fear, withdrawn attitude, failure to make any eye contact, presence of agitation, or behaviour not appropriate for the level of dementia or depression can sometimes be a sign of abuse in older adults.[40] Patients should be asked whether they are happy at home and whether they have experienced any recent changes in mood, sleeping, or eating patterns. Social isolation is a risk factor for self-inflicted abuse. The evaluation should include a detailed social history, the functional ability of the older adult, living arrangement, and social support. Given the time constraints in many primary care practices, this could be achieved during the annual wellness visit or by using allied health care professionals to update this information on a regular basis. Refusal of the carer to let the patient answer any of the questions during an interview, or refusal of the carer to let the older patient be interviewed separately, can indicate abuse. Inconsistencies in patient history, either between patient and carer or between carers, should alert suspicion of older adult abuse. Likewise, inconsistencies between history and physical findings, medical regimen, laboratory values, or living conditions are causes for concern.

Any report of abuse by the older person should be considered accurate and should be investigated as such. A detailed history should include explanations for any injuries present.

The prevalence of older adult abuse is high and cannot be easily discerned from other medical issues, so the AMA recommends a series of screening questions.[37] A positive response to any of these questions should prompt further evaluation.

  • Has anyone ever touched you without your consent?

  • Has anyone ever made you do things you didn't want to do?

  • Has anyone taken anything that was yours without asking?

  • Has anyone ever hurt you?

  • Has anyone ever scolded or threatened you?

  • Have you ever signed any documents you didn't understand?

  • Are you afraid of anyone at home?

  • Are you alone a lot?

  • Has anyone ever failed to help you take care of yourself when you needed help?

A number of screening measures have been developed and tested in different settings, including the accident and emergency department, clinics, and at home.[41]​ If screening tests do not indicate abuse, then no immediate action is required.[37][42][43][44][45]​​ However, owing to the low sensitivity of some screening tests, continued monitoring is advised. Conversely, a positive screen does not necessarily mean abuse is happening, but guides the need for further evaluation.

See Screening.

Physical examination

If abuse is suspected, then the patient should be examined thoroughly. The size, shape, and location of any injury should be recorded. Any injuries should be photographed. A number of clinical findings make older adult abuse a strong possibility, but are not necessarily confirmatory. These include:[5][24][46]​​

  • Unexplained injuries.

  • Delay in seeking treatment.

  • Injuries inconsistent with history.

  • Contradictory explanations given by the patient and carer.

  • Bruises, welts, lacerations, rope marks, burns.

  • Venereal disease or genital infections.

  • Volume depletion, malnutrition, pressure sores, poor hygiene.

  • Changes in sleeping patterns or eating habits.

  • Signs of withdrawal, depression, agitation, infantile behaviour.

Investigations

The presence of volume depletion, electrolyte abnormalities, malnutrition, improper medicine administration, and substance misuse should be assessed.

Initial investigations in all patients:

  • Full blood count with platelet count and a clotting profile, particularly if the older adult has bruises or evidence of bleeding.

  • Clinical photograph: it is important that appropriate clinical photographs are taken of bruises and wounds.

Suspected head injuries:

  • CT brain can identify subdural haemorrhage, with or without subarachnoid haemorrhage or (rarely) extra-dural haemorrhage.

  • Parenchymal injury with or without cerebral oedema may also be present.

  • CT brain should be considered in adults with neurological symptoms or signs, and in all those with head injury.

Suspected skeletal injury:

  • X-rays should be taken to detect any fractures.

Abdominal injuries:

  • Liver function tests and serum amylase.

  • CT abdomen should be considered if there is abusive abdominal injury. It delineates any hollow organ rupture and detects sub-capsular haematomas, ruptures of liver or spleen, and renal injury.

Poisoning:

  • A toxicology screen can reveal the presence of substances that the patient has not been prescribed or absence of medicines that the patient is receiving, both indications of abuse.[39]

Use of this content is subject to our disclaimer