What are the historical and physical examination (PE) findings that indicate abuse or neglect in elderly patients?

Historical and Physical Examination Findings Indicating Elder Abuse or Neglect

All clinicians examining elderly patients should maintain heightened vigilance for physical and behavioral signs and symptoms associated with abuse or neglect, as these cases frequently pass undetected due to victim isolation and reluctance to report. 1, 2

High-Risk Patient Characteristics

Elderly patients with the following characteristics warrant increased suspicion for abuse or neglect 1:

• Increasing age (particularly the "old-old" population)
• Functional impairment requiring assistance with activities of daily living
• Cognitive disability or dementia (particularly vulnerable as they live in care-taking environments) 1
• Low income status
• Cohabitation with caregiver (90% of perpetrators are family members, usually adult children or spouses) 1
• Substance use by patient or caregiver
• Poor emotional state, low self-esteem
• Lack of social support or social isolation

Critical Historical Findings

Patient-Caregiver Interaction Patterns

• Poor rapport between patient and caregiver during the encounter 3
• Caregiver answers all questions or prevents private conversation with patient 3
• Loss of social activities or increasing isolation 3
• Patient reluctance to discuss home situation or appears fearful 4

Medical Care Patterns

• Medical noncompliance or missed appointments 3
• Delay in seeking treatment for injuries or medical conditions 2
• Inconsistent or implausible explanations for injuries that don't match the physical findings 2
• History of repeated ED visits or hospitalizations 2

Functional Assessment Red Flags

• Recent decline in activities of daily living beyond what medical conditions would explain 3
• Instrumental activities of daily living deterioration (managing finances, medications, transportation) 3

Physical Examination Findings

Trauma and Injury Patterns

• Bruising in unusual locations (inner arms, inner thighs, torso, neck) or at different stages of healing 2, 3
• Fractures, particularly spiral fractures or multiple fractures at different stages of healing 2
• Burns or scalds with suspicious patterns or mechanisms 5
• Head trauma, facial injuries, or dental trauma 2
• Rope marks or restraint injuries on wrists or ankles 2

Signs of Neglect

• Poor general appearance and hygiene (unkempt, unwashed, soiled clothing) 3
• Malnutrition (cachexia, temporal wasting, low body mass index) 3
• Dehydration (dry mucous membranes, poor skin turgor, orthostatic hypotension) 3
• Pressure ulcers (particularly stage 3 or 4 ulcers in patients receiving home care) 2
• Untreated medical conditions (infected wounds, uncontrolled chronic diseases) 2
• Medication mismanagement (overmedication, undermedication, or medication hoarding) 3

Psychological and Behavioral Indicators

• Depression, anxiety, or fearfulness during examination 4
• Withdrawn behavior or flat affect 2
• Confusion or agitation beyond baseline cognitive status 2
• Patient flinching or cowering when approached 4

Types of Elder Abuse to Recognize

Elder mistreatment manifests in multiple forms 4:

• Physical abuse (80% of documented cases show physical maltreatment) 2
• Psychological/emotional abuse (44% of cases involve psychological components) 2
• Sexual abuse 4
• Financial exploitation 4
• Neglect by caregiver 4
• Self-neglect (64% of thermally injured elderly patients showed self-neglect) 5

Critical Pitfalls to Avoid

Do not assume caregiver stress causes abuse - this is a misconception. Abuse correlates more strongly with the emotional and financial dependence of caregivers on the elderly victim, not caregiver burden 4.

Do not dismiss injuries as "just falls" - elderly patients with cognitive impairment are particularly vulnerable and may not be able to report abuse accurately 1.

Do not screen only the patient - failure to assess caregiver risk factors (substance abuse, familial violence history, dependency needs, external stresses) results in missed cases 5.

Do not accept vague injury explanations - inconsistent histories are a hallmark finding requiring further investigation 2.

Immediate Actions When Abuse is Suspected

When abuse or neglect is suspected, clinicians must 1:

• Document thoroughly using photographs and body maps of all injuries
• Treat physical injuries immediately
• Arrange mental health counseling by skilled professionals
• Provide crisis center and shelter contact information
• Report to Adult Protective Services (mandatory in all 50 states for elder abuse) 1
• Consider hospitalization for patients in immediate danger 4

The true incidence of elder abuse is vastly underestimated because only 10% of cases are reported, and physicians infrequently report due to unfamiliarity with reporting laws, time constraints, and fear of offending patients 4. However, maintaining the diagnosis of abuse and neglect in mind for every elderly patient encounter is essential given that up to 2.5 million elderly persons are abused annually 4, 3.