Geriatric abuse victims can be men or women, and abuse rate differences are not clear in available research.14 Abusers can be anyone who has a relationship with the victim, but are almost always a family member.7 Abusers can be a spouse, partner, adult child or grandchild, another relative or a caregiver. Abusers are typically male, and sexual abusers are almost exclusively men.15 In one study of sexual abuse, more than 90% of the victims were women and more than 90% of the abusers were men.16 Abusers typically have a dependency relationship with the victim, which may include dependence for money, food, housing and/or transportation.15 Abusers typically have problems of their own, including substance abuse, mental illness like depression, and cognitive impairment.15
The incidence of elder abuse has increased with the rapid aging of the American population. One author noted that although elder abuse is under-reported, the incidence had increased 150% from 1986 to 1996.7 A 1998 study found that more than a half-million Americans older than age 60 were victims of domestic abuse. As many as two million adults older than 65 are estimated to have been "injured, exploited, or otherwise mistreated" by their caregivers.11,17 More than 80% of incidents of elder abuse go unreported.17
Why Abuse Happens
Researcher Bonnie Brandl reviewed 13 published articles that attempted to answer why abuse happens to elders.18 The review of research challenged some commonly held assumptions about abuse and some potential situations that can increase the chance of abuse.
Elder cognitive impairment, chronic disease and depression along with caregiver stress were not found to increase the likelihood of abuse,18 while financial and housing dependence of an adult child on his or her mother is associated with abuse and neglect. As previously noted, abusers are also likely to have a history as an abuse victim, substance abuse and/ or addiction problem, mental illness or cognitive impairment.18
Abuse can happen anywhere. In the home, the abuser may be a spouse, partner, adult child or caregiver who visits the patient at home. Since the great majority of elders live in their own home or the home of a family member, most abuse happens inside the home and is perpetrated by a family member.19
In a residential setting, like an assisted living center or skilled nursing facility, abuse can be perpetrated by staff, vendors and even other residents. Although it does happen, abuse inside a nursing home or other type of residential facility is relatively rare. Only 4% of older adults live in nursing homes.19
Our assessment of an elderly male "fall victim" began in the doorway. The apartment was clean. The patient's spouse carefully explained her husband's middle-of-the-night fall, her inability to lift him, and her hesitancy to call for an ambulance until morning. My partner and I carefully listened for clues about the consistency of the mechanism with our exam findings, the patient's own report of the incident and previous medical problems.
EMS professionals use the patient assessment to determine the nature and extent of injuries, but can also use it as a means to look for clues of elder abuse. In this case, all signs pointed toward a fall, need for immediate lift assistance, and conversation with the wife about the need for in-home care assistance as her husband's dementia and chronic illnesses worsened. Can you think of some ways this scenario could be only subtly different and show signs of abuse?
Use the scene size-up to look for clues about the mechanism of injury, as well as the need for additional resources like law enforcement or adult protective services. During the initial assessment, assess for and treat immediate life threats with the tools and training you have.
EMS professionals are most likely to find clues of elder abuse while conducting the secondary assessment. Note any injuries that seem incongruous with the complaint and/or mechanism of injury found with the focused or detailed head-to-toe physical examination. Like patients of other ages, some potential signs of physical abuse include:
- Musculoskeletal injuries like sprains, strains, fractures and dislocations
- Bruises in unusual areas like the inner arm or inner thigh
- Burns from hot water or cigarettes
- Wounds (bruises, burns, abrasions) in various stages of healing
- Abrasions and/or bruises from being firmly held, pulled or restrained
- Recurring injuries to the same area of the face, neck or upper extremities
- Unusual markings from hand grips, bites, ropes or other restraints.4,19,20
PreventElderAbuse.org explains that the following injuries are "rarely accidental":
- Bilateral arm bruising from being grabbed, pulled, shaken or restrained
- Circumferential arm and/or leg bruising from being restrained
- Traumatic hair and tooth loss.4