CASE PRESENTATION:

As a paramedic on duty, you are called to see Mrs. P, a 74 y.o. woman, who has reportedly fallen at home. On arrival, the history is provided by Mrs. P's daughter Jane, who lives with her mother and has been caring for her mother with Parkinson's disease for 2 years. Jane reports that her mother got out of her wheelchair without waiting for assistance and had fallen. You find Mrs. P. lying on the floor incontinent of urine. She appears cachectic and unkempt. She is alert, but appears frightened, and is looking more at her daughter than at you. When you ask her what happened, she states "I fell...I'm so clumsy". Her left leg appears foreshortened and externally rotated, suggesting a hip fracture. You try to question Mrs. P. further, but Jane interrupts, stating that "Fran is confused and won't be able to answer any questions". You note multiple bruises, some purple, some greenish, and some fading. Deep pressure sores are present over both heels. In addition, there is a bony deformity of the right upper arm. When you ask about these other injuries, Jane states that "Fran is always bumping into things - she's right, you know, she's very clumsy". When you ask about how long Mrs. P. has been having difficulty, and what other medical problems she has, Jane states, "I've been trying to get her in to see the doctor, but she's stubborn, just like a child, and she just won't listen to reason."

Q: Are there some clues that elder abuse may be occurring?

Click here for answer.

Types of Abuse

Risk Factors for Abuse

• Characteristics of Patient
  • Poor health and functional impairment
  • Cognitive impairment
  • Social isolation

• Characteristics of Living Situation
  • Shared living arrangement
  • External factors causing stress
  • financial strain

• Characteristics of Abuser
  • Substance abuse or mental illness
  • Dependence of abuser on victim
  • History of violence

Presentations Suggesting Abuse or Neglect

• Delay in seeking medical attention
• Discrepancy in history between patient and possible abuser
• Vague/implausible explanations for signs/symptoms
• Frequent emergency room visits for exacerbations of disease despite adequate resources/care plan
• Functionally impaired patient presents without the primary caregiver present
• Lab findings inconsistent with history provided

Approach to Evaluation 

• Look for discrepancies in information provided by patient and caregiver
• Detailed interview of suspected abuser is best left to those with specific expertise
• Begin with general questions about patient's perceptions of safety - "do you feel safe where you live?"
• Ask about who is responsible for care
  • "who prepares your meals?"
  • "who handles your checkbook?"
• Ask specific questions about maltreatment
  • "do you often disagree with (your caregiver)?"
  • "what happens when you disagree?"
  • "are you yelled at...made to wait for food or care...slapped or hit?"
• Consider abuse whenever
  • multiple injuries in various stages of evolution
  • injuries are unexplained
  • explanations are implausible
  • evidence of gross neglect despite established caregiver, adequate resources
• Remember that abuse also occurs in institutional settings
  • nursing homes, adult family homes

Further Management

• Take suspected victims of abuse to the emergency room for further evaluation
• Mandatory reporting of suspected elder abuse to Adult Protective Services
• Report your suspicions to admitting physician in the emergency room .
• Document evidence of possible abuse or neglect

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University of Washington, Division of Gerontology and Geriatric Medicine

Copyright 1999, 2000 David A. Gruenewald, M.D. and Kayla I. Brodkin, M.D. All rights reserved.