Elder abuse increasing — Can you recognize it?

Do you consider that abuse or neglect may be occurring when you care for elderly patients in your ED? According to a new report from the Centers for Disease Control and Prevention, 33,000 patients older than the age of 60 were treated in EDs over a four-year period for assault-related injuries from elder abuse.1

Elder abuse is a growing problem in EDs, and numbers will continue to increase, warns Kathleen Loeffler, RN, research nurse at Harborview Medical Center in Seattle.

"As ED nurses, it is imperative for us to be able to recognize, report, and intervene in this burgeoning epidemic," she says.

To improve your assessment and intervention of elder abuse, do the following:

• Recognize risk factors for abuse.

Risk factors associated with elder abuse include age older than 75, dependence on the caregiver, alcohol or substance use in the elder or caregiver, caregiver inexperience or mental illness, financial problems, lack of help or support systems, cramped living conditions, and recent change in the elder’s level of functioning, according to Loeffler.

To assess elders for abuse, what you observe is critical, says Loeffler. Address the following questions, she advises:

— How do the elder and caregiver interact?

— How is the patient’s mental status and mood? Does the patient seem fearful, agitated, passive, or compliant?

— What is the elder’s overall condition, including hygiene and nutritional status?

— Are there overt signs of trauma? Does the history match the injury?

— Did someone else besides a family member or caregiver bring in the patient for treatment? Was there a delay in seeking care?

Obtain the history from several sources if possible, and be sure to interview the patient and caregiver separately, says Loeffler. "Using a nonjudgmental attitude with open-ended questions is an effective method to gain trust and maximum information," she suggests.

• Identify signs of abuse or neglect.

Physical signs for elder abuse include old and new bruises, burns, fractures, alopecia due to hair pulling, pattern injury from being struck by cords or objects, cigarette burns, eye trauma, whiplash injury, and patients who are over- or undermedicated, says Loeffler. Your first priority is treatment of acute injuries and protecting the elder from further harm, she says.

Elder neglect is the most common form of elder abuse, says Loeffler. Signs include dehydration, malnutrition, decubitus ulcers, poor hygiene, and noncompliance with medications, she says.

"Psychological maltreatment will reveal an elder who is verbally berated, harassed, or intimidated, treated like an infant, socially isolated, ignored, denied companionship, or threatened with punishment or deprivation," she says.

• Give patients choices whenever possible.

To explore a variety of options for an abused elder, ask the following questions, she says:

— Could you stay temporarily with other relatives, friends, or church members?

— Is assisted living or an adult family home an acceptable alternative?

— Are there funds for home health or respite services to relieve the caregiver?

Elders may fear intervention of any kind because they don’t want to be left homeless or alone, says Linda Hutson, RN, SANE, assistant nurse manager in the ED at Mercy Hospital Anderson in Cincinnati. "They may fear reporting a spouse or family member because they may be financially dependent on the family member committing the abuse," she notes.

This may make it difficult to obtain a clear history of abuse, so when in doubt, investigate further by interviewing family members or friends, suggest Hutson. "Exhaust all resources before you risk discharging the elderly patient back to an abusive environment," she says.

• Consider the possibility of sexual abuse.

After the ED at Mercy Anderson began universal screening of women for domestic violence, nurses discovered a significant number of elders were abused, reports Hutson.

"We also realized that when we asked elderly women about violence in their homes, we rarely asked about sexual abuse because the thought was culturally repulsive," she says.

However, about 20% of the elder abuse that is seen in the ED includes sexual assault, estimates Hutson. Recently, she cared for a 70-year-old woman who was brought to the ED from her nursing home because her caregiver found blood in her undergarments. The patient was found to have multiple bruises and tears with bleeding in the genital area, she reports.

"We collected forensic evidence and took photographs of the injuries for the police and prosecutors," says Hutson. "A caregiver at the nursing home was arrested and prosecuted for abuse in this case."

Do a complete physical examination if you suspect sexual abuse, says Hutson. "However, remember that the elderly may have special needs and concerns about privacy and modesty," she cautions.

If sexual abuse is occurring, you must obtain permission to collect forensic evidence for law enforcement, says Hutson. "If you suspect abuse, be aware that you are obligated legally and morally to report to your local adult protective services agency," she says. "If physical abuse is present, always consider that sexual abuse may also be occurring."


1. Centers for Disease Control and Prevention. Public health and aging: Nonfatal physical assault-related injuries among persons aged > 60 years treated in hospital emergency departments — United States, 2001. MMWR 2003; 52:812-816.


For more information about elder abuse, contact:

  • Linda A. Hutson, RN, SANE, Assistant Nurse Manager, Emergency Department, Mercy Hospital Anderson, 7500 State Road, Cincinnati, OH 45255. Telephone: (513) 624-4032. E-mail: sanenurse@lycos.com.
  • Kathleen Loeffler, RN, Trauma Registry, Harborview Medical Center, 325 Ninth Ave., Box 359731, Trauma Registry, Seattle WA 98104. Telephone: (206) 341-4327. E-mail: loeff@u.washington.edu.