Browse the corpus

1974 SECTION 25: Abuse and Assault Obtain relevant forensic evidence, and follow the appropriate chain of custody of evidence. If sexual assault has occurred, document ED testing and treatment; arrange for a sexual assault nurse examiner exam, if locally available. See Chapter 293, “Female and Male Sexual Assault, ” for detailed discussion. Record safety assessment and planning. A safety assessment form or referral notes from an expert are helpful adjuncts.  LEGAL CONSIDERATIONS Most states in the United States have laws that require healthcare providers to report specified injuries, wounds, or crimes. Intimate personal violence is a crime in all 50 states. 13 Four states have exceptions to mandatory reporting for injuries related to domestic violence. The specifics of the reporting requirements vary from state to state, and the adequacy of response by the police to reporting varies by jurisdiction. Inadequate or inappropriate response to the reports (e.g., informing the perpetrator of the report without providing for the safety of the abused individual) can increase the risk of harm to the abused. Inform the victim if there is an obligation to make a police report and explain possible ramifications. SPECIAL POPULATIONS  PREGNANCY Prevalence of intimate partner violence during pregnancy ranges from 6% to 22%. 4,8 Women who report intimate partner violence and abuse during pregnancy are at increased risk of postnatal abuse. Women assaulted during pregnancy are three times more likely to be admitted to the hospital than nonpregnant women.  IMMIGRANT POPULATIONS Overall, prevalence of intimate partner violence is lower in people born outside of the United States. However, certain immigrant populations have rates far higher than U.S. natives. 1,14 Moreover, the burden of intimate partner violence can be much higher in these populations as victims may be socially and linguistically isolated and perpetrators can use threats of deportation to restrain victims from seeking help. 14 The federal Violence Against Women Act establishes protection that may protect undocumented persons from deportation if they have been a victim of crime, including intimate partner violence.  LGBTQ PERSONS Intimate partner violence occurs in same sex relationships at rates gen erally similar to opposite sex relationships. Bisexual women and men, however, report substantially higher rates of intimate partner physical violence overall. 1 Transgender women and gender nonconforming persons also experience intimate partner violence at higher rates. Lesbian, gay, bisexual, transgender, and queer persons may not report to police or seek advocacy services for fear of discrimination. Acknowledgment: The authors gratefully acknowledge the contri butions of Mary Hancock, the author of this chapter in the previous edition. REFERENCES The complete reference list is available online at www.TintinalliEM.com. TABLE 294-6 Hotlines for Patients National Domestic Violence Hotline: 24 h; links caller to help in her (or his) area—emergency shelter, domestic violence shelters, legal advocacy and assistance programs, social services 800-799-SAFE (7233) 800-787-3224 (TTY) Rape, Abuse, and Incest National Network: 24 h; automatically transfers caller to nearest rape crisis center anywhere in the nation 800-656-HOPE (4673) http://www.rainn.org Abuse of the Elderly and Impaired Jonathan Glauser Frederic M.

cacy and assistance programs, social services 800-799-SAFE (7233) 800-787-3224 (TTY) Rape, Abuse, and Incest National Network: 24 h; automatically transfers caller to nearest rape crisis center anywhere in the nation 800-656-HOPE (4673) http://www.rainn.org Abuse of the Elderly and Impaired Jonathan Glauser Frederic M. Hustey INTRODUCTION Elder abuse is an act or omission resulting in harm to the health or welfare of an elderly person. Three key groups have published definitions of elder abuse. 1-3 Although the incidence of elder neglect and abuse is unknown and widely felt to be underreported, the rate of different types of abuse among the elderly has been estimated to be in the mid-single digits up to 10% of persons age >65 years, 4 or between 500,000 and 1 million U.S. adults. 5,6 One meta-analysis identified the pooled preva lence of elder abuse overall in geographically diverse countries to be 15.7%. 7 Alternatively, a clinician seeing between 20 and 40 adults over age 60 per day could encounter more than one victim of elder mistreat ment on a daily basis. 8 Table 295-1 summarizes the categories of elder abuse. CLINICAL FEATURES  PHYSICAL ABUSE Physical abuse is the most easily recognized form of elder abuse. It is defined as the use of physical force that might result in bodily injury, physical pain, or impairment. Pushing, slapping, burning, striking with objects, and improper use of restraint are all examples of physical abuse. Chemical restraint (such as intentional overmedication or administra tion of tranquilizers) is a more subtle form. Regardless of mechanism, physical abuse is carried out with the intention of causing suffering, pain, or other physical impairment to the abused person.  CAREGIVER NEGLECT Elder neglect is the most common form of elder maltreatment, accounting for more than half of all elder maltreatment cases reported to adult protective services agencies annually. 9 Elder neglect is defined as the failure of a caregiver to meet basic needs for a person or to provide goods and services necessary to prevent physical harm or emotional CHAPTER TABLE 295-1 Categories of Elder Abuse Categories of Abuse Example Physical abuse Pushing, slapping, burning, striking with objects, improper use of restraint (physical or chemical) Caregiver neglect Deprivation of food, clothing, hygiene, medical care, shelter, or supervision Sexual abuse Unwanted touching, indecent exposure, unwanted innuendo, rape Financial or material exploitation Forcible transfer of property or other assets, including changing elderly person’s will Emotional or psychological abuse Verbal threats (such as threats of violence, institutionalization, or deprivation), humiliation, intimidation, harassment, social neglect, and isolation Abandonment Desertion of an elder in the home or a hospital, nursing facility, shopping mall, or other public location by a caregiver or caretaker Self-neglect Failure or unwillingness to provide adequate food, clothing, shelter, medical care, hygiene, or social stimulation to self in individuals with diminished capacity to perform essential self-care tasks Source: Reproduced from U.S. Department of Health and Human Services, Administration on Aging and Administration for Children and Families: The National Elder Abuse Incidence Study. Washington, DC: National Center on Elder Abuse, 1998. Tintinalli_Sec25_p1967-1978.indd 1974 8/2/19 1:50 PM

rform essential self-care tasks Source: Reproduced from U.S. Department of Health and Human Services, Administration on Aging and Administration for Children and Families: The National Elder Abuse Incidence Study. Washington, DC: National Center on Elder Abuse, 1998. Tintinalli_Sec25_p1967-1978.indd 1974 8/2/19 1:50 PM CHAPTER 295:  Abuse of the Elderly and Impaired      1975 discomfort.10,11 Examples of neglect include deprivation of food, cloth ing, hygiene, medical care, shelter, or supervision that a prudent person would consider essential for the well-being of another.10,11 Elder neglect is both underrecognized and potentially lethal. It likely accounts for the majority of cases of unreported abuse. 12 It is also an independent risk factor for mortality, even taking into account that the deaths themselves may not be immediately ascribed to injury. neglect may be difficult to diagnose. Although some cases may be obvi ous (such as in a patient with multiple deep pressure ulcers), neglect is often more subtle and difficult to detect.  SEXUAL ABUSE Sexual abuse is broadly defined as nonconsensual sexual contact of any kind with an elderly person. The spectrum of sexual abuse ranges from unwanted touching, indecent exposure, or unwanted innuendo, to rape itself. Although sexual abuse is underreported across all age groups, in the elderly, sexual abuse is even less likely to be reported. Fear of retaliation and shame on the part of patients, as well as stereotyping of older patients as asexual or not sexually desirable by clinicians, police, and others, may be factors in underrecognition and underreporting of sexual abuse.  FINANCIAL OR MATERIAL EXPLOITATION Financial abuse is estimated to be the second most common form of elder abuse, accounting for approximately 20% to 30% of abuse cases. Financial or material exploitation is the illegal or improper use of an elder’s funds, property, or assets. 15 It occurs when family members, caregivers, or friends take control of the elder person’s resources. Coercion or outright theft may occur, with or without the awareness of the elder person experiencing abuse. An elderly person may unwittingly sign over access to savings accounts and other assets when he or she is in an incapacitated state. Social Security checks or pensions may be used by caregivers for personal gain. Theft may be blatant or coerced, with forcible transfer of property, including changing of the elder’s will. Anticonstitutional abuse is a term coined to describe violation of constitutionally guaranteed human rights, such as theft of identity papers, coercion, or false pretense resulting in the surrender of rights. 16 Abuse may result in a decrease in the standard of living and an inability to pay bills, purchase food, or obtain medications.  EMOTIONAL OR PSYCHOLOGICAL ABUSE Emotional or psychological abuse is defined as the infliction of anguish, emotional pain, or distress. Examples of psychological and emotional abuse include verbal threats (such as threats of violence, institution alization, or deprivation), humiliation, intimidation, and harassment. Social neglect and isolation are also forms of abuse. Psychological and emotional abuse can contribute to the development and worsening of mental health problems such as depression, which is common in many older victims.  ABANDONMENT Abandonment constitutes the desertion of an elderly person by an individual who is that person’s custodian or who has assumed responsibility for providing care to the elder. Desertion of an elder in the home, hos pital, nursing facility, shopping mall, or other public location may occur.  SELF-NEGLECT Self-neglect includes those behaviors of an elderly person that threaten his or her own safety.

is that person’s custodian or who has assumed responsibility for providing care to the elder. Desertion of an elder in the home, hos pital, nursing facility, shopping mall, or other public location may occur.  SELF-NEGLECT Self-neglect includes those behaviors of an elderly person that threaten his or her own safety. Such behaviors include failure or unwillingness to provide adequate food, clothing, shelter, medical care, hygiene, or social stimulation for oneself. It is the result of an adult’s inability, due to diminished capacity, to perform essential self-care tasks. By defini tion, this applies to one who understands the consequences of his or her choices and makes a conscious decision to engage in acts that threaten his or her own health or safety. 17 Patients who have cognitive impair ment or who are living in poverty are at greater risk of self-neglect and may have increased mortality. TABLE 295-2 Risk Factors for the Occurrence of Elder Abuse Risk Factors for Elders Risk Factors for Perpetrators Cognitive impairment Physical dependency Lack of social support Alcohol abuse History of domestic violence Female gender Developmental disability Difficult behavior (such as aggression or verbal outbursts) Special medical or psychiatric needs Limited experience managing finances Institutionalization History of mental illness History of substance abuse Excessive dependence on elder for financial support History of violence within or outside the family Unemployed History of financial difficulties DIAGNOSIS  RISK FACTORS An awareness of risk factors is important for the recognition of potential victims of elder abuse or neglect. Risk factors can be divided into two categories: factors associated with the elders and factors associated with the perpetrators (Table 295-2). 10,17-21 Patient characteristics associated with a higher risk for elder mistreatment are cognitive impairment, physical dependency, lack of social support, alcohol abuse, female sex, and a history of domestic violence. In addition, developmental disabilities, special medical or psychiatric needs, and difficult behavior (such as aggression or verbal outbursts) also increase the risk for abuse. Individuals with limited experience in managing finances are at increased risk for financial or material exploi tation. Although elder abuse is more common in residential than insti tutional settings, institutionalization is also recognized as a risk factor for neglect and abuse. 10,20 Three characteristics of perpetrators have been identified as risk fac tors: a history of mental illness and/or substance abuse, excessive dependence on the elder for financial support, and a history of violence within or outside of the family. 21 Abusers are most often the primary caregiver. Adult children tend to be more inclined to abuse than are spouses, and males engage in abuse more often than females. 17 Caregivers may be well intentioned but simply overwhelmed by the amount of care required. They may themselves be impaired by mental or physical problems that serve as barriers to the provision of adequate care.  HISTORY The approach to the patient interview is important. Potential sufferers of abuse should be interviewed in private. The presence of caregivers, family, or friends may cause the patient to feel intimidated or embarrassed, which limits the amount and accuracy of information obtained. Try to put the patient at ease by making the assessment seem like a routine part of the evaluation. 15 Separately interview individuals accompanying the patient. Screening tools are available to aid in the detection of elder abuse.

ntimidated or embarrassed, which limits the amount and accuracy of information obtained. Try to put the patient at ease by making the assessment seem like a routine part of the evaluation. 15 Separately interview individuals accompanying the patient. Screening tools are available to aid in the detection of elder abuse. 22-24 The use of lengthier tools is not feasible in a busy ED, but the American Medical Association has proposed a list of nine screening questions that may be more practical to implement ( Table 295-3). An affirmative answer to any of the questions in this screening tool raises concern and mandates further exploration. During the interview, be prepared to recognize behavioral signs and symptoms that suggest elder abuse. These include depression, fear, withdrawal, confusion, anxiety, low self-esteem, and helplessness. Other history-related indicators that suggest abuse or neglect include a pattern of “physician shopping, ” unexplained injuries inconsistent with medical findings, and recurrent visits for similar injuries. Additional history taking should explore risk factors for abuse as outlined earlier in “Risk Factors. ” Tintinalli_Sec25_p1967-1978.indd 1975 8/2/19 1:50 PM

st abuse or neglect include a pattern of “physician shopping, ” unexplained injuries inconsistent with medical findings, and recurrent visits for similar injuries. Additional history taking should explore risk factors for abuse as outlined earlier in “Risk Factors. ” Tintinalli_Sec25_p1967-1978.indd 1975 8/2/19 1:50 PM 1976 SECTION 25: Abuse and Assault TABLE 295-3 Screening Questions for Elder Abuse •   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? TABLE 295-4 Clues During the Medical Interview That May Suggest Elder Abuse •   The patient appears fearful of his or her companion. •   There are conflicting accounts of an injury or illness from the patient and caregiver. •   The caregiver displays an attitude of indifference or anger toward the patient. •   The caregiver is overly concerned with the costs of treatment needed by the patient. •   The caregiver denies the patient the chance to interact privately with the physician. •   The caregiver appears overly concerned and attentive. Information can be obtained by the physician prior to conducting the private interview or by other members of the healthcare team, such as nurses, who are likely to have more frequent interaction with the patient and caregivers. Observing the interaction between the accompanying individuals can yield valuable clues (Table 295-4).  PHYSICAL EXAMINATION Physical examination findings range from subtle and nondiagnostic to highly suspicious. Abuse is often detected when examination findings prompt further history taking with results suggesting elder mistreat ment. Psychological abuse and financial abuse are especially hard to diagnose in the ED setting because physical examination findings are uncommon. Nonetheless, it is important to perform a detailed evalu ation, including obtaining adequate exposure of the body to evaluate for trauma and pressure ulcers. Common physical findings in sufferers of elder abuse are bruising or trauma, poor general appearance and hygiene, malnutrition, and dehydration. Although not the most common form of elder abuse, physical abuse is the most easily recognized. Evidence of injury to normally protected areas of the body is highly suspicious for physical abuse. 18 Examples include contusions or lacerations on the inner arms or inner thighs and injury to the mastoid area. It is important to expose these areas when examining the patient to avoid missing significant findings. Contusions on the palms, soles of the feet, and buttocks also raise concern for elder abuse. 18 Multiple injuries in various stages of healing can suggest abuse but may also be seen in patients with recurrent falls. Taking a thorough history is especially important in differentiating these two causes. Although older patients may sustain burns through accidental injury (such as coming too close to an open flame while cooking), unusual burns or multiple burns in various stages of healing should also raise concern. Traumatic alopecia is highly suspicious, although not necessarily diagnostic (because it may be seen in patients with some psychiatric conditions). Rope or restraint marks on wrists or ankles 17 occur when elders are inappropriately restrained. Midshaft ulnar fractures (nightstick fractures) can occur from attempts to shield blows by raising the forearm.

ous, although not necessarily diagnostic (because it may be seen in patients with some psychiatric conditions). Rope or restraint marks on wrists or ankles 17 occur when elders are inappropriately restrained. Midshaft ulnar fractures (nightstick fractures) can occur from attempts to shield blows by raising the forearm. Fractures of the head, spine, and trunk may be more indica tive of abuse, although these can occur by other mechanisms. More recently, the radiologic literature has investigated specific findings that may be suggestive of elder abuse, although so far these are not consid ered pathognomonic; examples include upper, posterior, or multiple rib fractures; multiple subdural hematomas; small bowel hematomas; and injuries inconsistent with reported mechanism. Spiral fractures of long bones and fractures with rotational components also raise suspicion of abuse. 25,26 Findings resulting from caregiver neglect or self-neglect are less specific. Perhaps the most identifiable finding is that of multiple or deep pressure ulcers. Ulcers that are uncared for (such as open ulcers lacking appropriate dressings or packing) or those not in lumbar or sacral areas raise suspicion even further. Incapacitated patients should be turned as part of the examination to evaluate for skin breakdown. Poor personal hygiene, inappropriate or soiled clothing, dehydration, malnutrition, contractures, fecal impaction, and excoriations suggest neglect. Sexually transmitted diseases or findings of genital trauma, especially in an incapacitated patient, raise concern for sexual abuse. Patients may complain of genital or anal pain, itching, bruising, or bleeding. Torn or stained underwear, with unexplained difficulty walking or sitting, may be present. Oral trauma can also be a manifestation of sexual abuse. Depression, anxiety, and fear can be manifestations of psychological abuse, although they are nondiagnostic. Observation of interactions with caregivers and companions can provide further important clues to this type of abuse. Although elder abuse is widely underrecognized and underreported, remember that underlying medical disorders are often associated with findings that could otherwise be identified with abuse. Advanced neurologic disorders such as multiple sclerosis, amyotrophic lateral sclerosis, and Parkinson’s disease may lead to immobilization and severe disability. Individuals with such conditions are at risk for pressure ulcers, pneumonia, or venous thromboembolism, even with adequate care. TREATMENT, DISPOSITION, AND FOLLOW-UP Treatment of elder abuse in the ED involves three key components: • Addressing associated medical and psychological needs • Ensuring patient safety • Complying with local reporting requirements (https://ncea.acl.gov/) Medical problems, including injuries, should be stabilized and treated and may be best managed through hospital admission. In addition to physical injury, metabolic derangements may be present. Patients with dehydration or malnutrition can have a variety of electrolyte abnormalities and may also have coexisting renal failure. Elders left in the same position for an extended period of time may be at risk for rhabdomy olysis. Additional problems may exist due to failure to administer usual medications at home. These issues should all be addressed during the ED visit, including the ability to conduct activities of daily living, such as meal preparation, housework, bathing, dressing oneself, toileting, and managing finances. Psychological problems brought on by abuse, as well as preexisting psychiatric conditions and substance abuse, should also be addressed. The severity of the problem and planned disposition can affect the extent to which treatment is completed in the ED.

work, bathing, dressing oneself, toileting, and managing finances. Psychological problems brought on by abuse, as well as preexisting psychiatric conditions and substance abuse, should also be addressed. The severity of the problem and planned disposition can affect the extent to which treatment is completed in the ED. For patients requir ing hospitalization, concerns and findings should be communicated to the admitting service and documented in the medical record. For patients who are discharged to home, arrangements should be made for appropriate follow-up. Follow-up must be arranged for the patient’s medical and psychiatric needs, and arrangements must also be made for monitoring and assessment of home safety and assessment of caregiver stress or substance abuse. A variety of resources are available to assist with these issues (Table 295-5). Social work consultation can be helpful in finding local resources. Patients in immediate danger should be hospitalized, transferred to the care of a friend or reliable family member, or placed in an emer gency shelter. Suspected abuse should be reported to the appropriate state agency (https://ncea.acl.gov/) or local adult protective services agency in order to ensure a follow-up investigation and a thorough long-term assessment. Adult protective services is the federal program that receives mandatory reports of suspected abuse, typically leading to a home visit and further investigation. Although all 50 states have adult protective services and long-term care ombudsman programs, reporting is not mandated by law in every state. Elderly who live in the community are protected in all states by adult protective services agen cies. Elders in institutional settings are protected in all states by longterm care ombudsman programs. Violations specific to nursing home Tintinalli_Sec25_p1967-1978.indd 1976 8/2/19 1:50 PM

mandated by law in every state. Elderly who live in the community are protected in all states by adult protective services agen cies. Elders in institutional settings are protected in all states by longterm care ombudsman programs. Violations specific to nursing home Tintinalli_Sec25_p1967-1978.indd 1976 8/2/19 1:50 PM CHAPTER 295:  Abuse of the Elderly and Impaired      1977 TABLE 295-5 Resources for Elder Abuse Who to Contact Services Provided Who to Contact Services Provided Clinical Justice Services Public Policy Institute American Association of Retired Persons 601 E St., NW Washington, DC 20049 202-434-2222 Provides self-instruction training program, pamphlets, and brochures on elder abuse prevention. National Center on Elder Abuse 1201 15th Street, NW, Suite 350 Washington, DC 20005 202-898-2586 Email: ncea@nasua.org https://www.elderabusecenter.org/ One of the main information sites for elder abuse; provides a variety of resources, both nationally and by state. Also provides link to Training Library for Adult Protective Services and Elder Abuse. National Adult Protective Services Association (NAPSA) PO Box 96503 PMB 74669 Washington, DC 20090 202-370-6292 http://www.napsa-now.org/ Provides a variety of resources for elder abuse, both nationally and by state and county. Family Caregiver Alliance 235 Montgomery Street, Suite 950 San Francisco, CA 94104 415-434-3388 or 800-445-8106 http://www.caregiver.org AARP 601 E St., NW Washington, DC 20049 888-OUR-AARP http://www.aarp.org Other resources: Administration on Aging 330 Independence Ave., SW Washington, DC 29201 202-245-0641 https://www.acl.gov/about-acl/ administration-aging National Committee for the Prevention of Elder Abuse 1730 Rhode Island Ave., NW, Suite 1200 Washington, DC 20036 202-464-9481 http://www.preventelderabuse.org National Committee for the Prevention of Elder Abuse c/o Institute on Aging 119 Belmont St. Worcester, MA 01605 508-793-6166 Elder Care Locator U.S. Administration on Aging 800-677-1116 https://eldercare.acl.gov/Public/Index.aspx Lead agency in CareJourney, a program designed to provide Internet services to caregivers of adults with cognitive impairments. Leading organization representing people over age 50. Provides publications on caregiving issues, financial planning, durable power of attorney, trusts, and insurance.

cl.gov/Public/Index.aspx Lead agency in CareJourney, a program designed to provide Internet services to caregivers of adults with cognitive impairments. Leading organization representing people over age 50. Provides publications on caregiving issues, financial planning, durable power of attorney, trusts, and insurance. Nationwide service connecting older Americans and caregivers with local support resources. National Center on Elder Abuse c/o University of Southern California Keck School of Medicine Department of Family Medicine and Geriatrics 1000 South Fremont Avenue, Unit 22, Building A-6 Alhambra, CA 91803 855-500-3537 http://ncea.acl.gov/ One of the main information sites for elder abuse; provides a variety of resources, both nationally and by state. National Organization for Victim Assistance 510 King St., Suite 424 Alexandria, VA 22314 800-TRY-NOVA or 703-535-6682 http://www.trynova.org Provides referrals, resources in every state. National Coalition Against Domestic Violence One Broadway, Suite B210 Denver, CO 80203 303-839-1852 http://www.ncadv.org Provides  training  and education  on domestic  violence,  publications,  and programs. National Domestic Violence Hotline Toll free: 800-799-SAFE TTY: 800-787-3224 (for hearing impaired) http://www.thehotline.org/ Provides intervention;  cannot take reports; confidential;  available 24 h via phone. Live chat service available via website 19 h/day. National Long-Term Care Ombudsman Resource Center http://www.ltcombudsman.org Provides information on support, technical assistance as well as information on local long-term care ombudsman resources by state. National Council on Aging 251 18th Street South, Suite 500 Arlington, VA 22202 571-527-3900 http://www.ncoa.org Addresses many aging issues through various programs. Commission on Law and Aging American Bar Association 321 North Clark Street Chicago, IL 60654 312-988-5000 http://www.abanet.org/aging Provides information on laws pertinent to elders; has contact information by state and other law-related services for legal assistance providers; provides mandatory reporting requirements for each state. Makes available Domestic Violence and Sexual Assault in Later Life, a resource packet of information and materials accessible online. residents might include the following: failure to respond to calls for help, unattended symptoms, injury of unknown origin or falls, physical abuse, poor staff attitudes related to respect or dignity, inappropriate medica tions or dosages, stolen or lost property, or abuse by other residents. Much long-term facility abuse occurs between residents; many facilities have younger psychiatric patients who are more mobile and aggressive than the older debilitated residents. 27 Become familiar with requirements pertaining to your own practice area (https://ncea.acl.gov/). Tintinalli_Sec25_p1967-1978.indd 1977 8/2/19 1:50 PM

term facility abuse occurs between residents; many facilities have younger psychiatric patients who are more mobile and aggressive than the older debilitated residents. 27 Become familiar with requirements pertaining to your own practice area (https://ncea.acl.gov/). Tintinalli_Sec25_p1967-1978.indd 1977 8/2/19 1:50 PM 1978 SECTION 25: Abuse and Assault In cases of unintentional neglect, education of the caregiver may be the only intervention necessary. Other support options include home health aide visits, respite services, day programs, accessible transporta tion, support groups, adult day care, and church activities or pastoral visitations. 20,28 When mistreatment results because the caregiver is overburdened, interventions to decrease stress and anxiety may be welcomed by all parties. Spouses are most likely to be primary caregivers; most of these are women. Lack of sleep and inadequate exercise and nutrition are commonly expressed by caregivers, perhaps leading to anger and risk of abuse. Services for caregivers may be publicly funded or community based with support groups. Some programs provide home-delivered meals, respite care, counseling, and assistance with advance directives and estate planning. If available, medical case management teams can provide consultation and support by assisting in the multidisciplinary evaluation of suspected abuse cases and developing treatment plans. Team members gener ally are composed of a physician, nurses, and social workers. 30 Teams may make house calls, arrange physical and occupational therapy, and provide for nutritional improvement and management of disease states. Legal intervention teams can also be used to address financial manage ment, probate and guardianships, and other legal and housing issues. Civil courts can issue protective orders, create guardianships, and issue emergency removal orders. Recommendations for ED management of cases of elder abuse and neglect are provided in Table 295-6. SPECIAL CONSIDERATIONS  BARRIERS TO THE DETECTION OF ELDER ABUSE Sufferers of elder abuse often have low self-esteem and may blame themselves for the abuse. They may not want to admit vulnerabilities and feel disgraced for having raised a child who would betray them. 28,32 Elder abuse victims may also be unwilling to press charges against a family member. Abused older adults are frequently unaware of available resources. 32 In addition, they may harbor a fear of being removed from the home or placed in a long-term care facility, of implicating family mem bers, or of experiencing further abuse in retaliation for having divulged information. They may worry about not being believed. Victims may be unable to articulate their circumstances due to cognitive impairment. Abusers may control access to others and prevent encounters with out siders to ensure that secrecy is maintained. There may also be differing perceptions as to what constitutes abuse based on cultural background. Physicians may fail to report abuse for a variety of reasons. They may not be familiar with reporting laws or adequately understand reporting mechanisms. 5 They may fear offending patients or their family members. Time constraints in the ED can also be a barrier to recognition and reporting. There are no published studies of physical markers of mis treatment to distinguish preventable injury from intentional, inflicted, or avoidable trauma. 34 In addition, some physicians may have the misper ception that the law requires them to obtain the patient’s permission before reporting suspected abuse. 35 Hospitals may also lack protocols for identifying or addressing elder abuse. It has been noted that screening for elder abuse and neglect has not been recommended by the U.S. Preventive Services Task Force for some of the aforementioned reasons.

em to obtain the patient’s permission before reporting suspected abuse. 35 Hospitals may also lack protocols for identifying or addressing elder abuse. It has been noted that screening for elder abuse and neglect has not been recommended by the U.S. Preventive Services Task Force for some of the aforementioned reasons.  ABUSE IN LONG-TERM CARE FACILITIES Approximately 1.4 million Americans lived in nursing homes on any given day in 2012. 36 Elder abuse in nursing homes is well documented. In one study, 36% of nurses and nursing aides working in long-term care facilities reported witnessing at least one act of physical abuse in the previous year. 37 A study of 2400 deaths in Arkansas nursing homes found 50 cases of suspected abuse or neglect, which indicates that forensic studies need to play a larger role in the investigation of unexplained deaths of older adults in long-term care facilities. 38 Abuse in institutional settings manifests in similar ways to abuse in residential settings: theft of money or personal property, unsanitary conditions, poor personal hygiene, sexual assault, physical abuse or unexplained injury, bed sores, physical or chemical restraint, and malnutrition and dehydration. Perpetrators appear to be evenly divided between residents of the facility and staff members involved in the direct care of the victim. 36 Nursing homes participating in Medicare and Medicaid programs must comply with certain quality-of-care requirements. 39 Suspicion of abuse or neglect among patients in nursing homes should be reported to the state nursing home ombudsman program (http://www.ltcombudsman.org) or to an adult protective services agency.  LEGAL CONSIDERATIONS Circumstances may occur in which hospital admission is advised, but the patient refuses. If the patient is competent, his or her wishes must be honored, even if those wishes do not appear to be in the patient’s best self-interest. Decisional capacity by the patient depends on his or her ability to understand all of the relevant information in order to make a choice, to communicate that choice, and to appreciate the current situation and treatment options. Therefore, it is especially important to interview the patient alone and to explain in detail the concerns of the healthcare provider. The physician should also attempt to explore reasons for the patient’s reluctance to stay. Patients who refuse admission but who lack decision-making capac ity should not be discharged back to an unsafe environment. Contact with an adult protective services agency should be initiated. ED social workers can help locate contact information for the local adult protec tive services agency. If the agency determines that the victim of abuse lacks decision-making capacity, an emergency court order for protective services may be necessary. REFERENCES The complete reference list is available online at www.TintinalliEM.com. TABLE 295-6 American College of Emergency Physicians Policy on Domestic Family Violence31 •   Emergency personnel assess patients for intimate partner violence, child and elder maltreatment, and neglect. •   Emergency physicians are familiar with signs and symptoms of intimate partner violence, child and elder maltreatment, and neglect. •   Emergency medical services, medical schools, and emergency medicine residency curricula should include education and training in recognition, assessment, and interventions in intimate partner violence, child and elder maltreatment, and neglect. •   Hospitals and EDs encourage clinical and epidemiologic research regarding the incidence and prevalence of family violence as well as best practice approaches to detection, assessment, and intervention for victims of family violence.

erventions in intimate partner violence, child and elder maltreatment, and neglect. •   Hospitals and EDs encourage clinical and epidemiologic research regarding the incidence and prevalence of family violence as well as best practice approaches to detection, assessment, and intervention for victims of family violence. •   Hospitals  and EDs are encouraged  to participate  in collaborative  interdisciplinary approaches for the recognition, assessment, and intervention of victims of family violence. These approaches include the development of policies, protocols, and relationships with outside agencies that oversee the management and investigation of family violence. •   Hospitals and EDs should maintain appropriate education regarding state legal requirements for reporting intimate partner violence and child and elder maltreatment. Tintinalli_Sec25_p1967-1978.indd 1978 8/2/19 1:50 PM