Elder Abuse: Groundbreaking Research Identifies Suspicious Injury Patterns

Injuries to the head and neck in absence of injury to other parts of the body can be suspicious injury patterns in older adults.

Elder abuse is difficult to identify, but recent research shows injury patterns that are indicative of elder abuse rather than unintentional injury.

Elder abuse from violence is difficult to detect because seniors have thin skin and take medications such as blood thinners that lead to easy bruising, and they can have osteopenia or osteoporosis that increase the risk of broken bones. Elder abuse has serious health consequences, including depression, anxiety, post-traumatic stress disorder, and significant trauma injuries. And it is not well recognized in the clinical setting.

The lead author of the recent research, which was published in Annals of Emergency Medicine, told HealthLeaders that clinicians play a unique and vital role in the detection of elder abuse.

"Elder abuse is dramatically underrecognized and underreported. One of the reasons for that is many older adults do not come into contact with other folks. In fact, contact with a medical professional might be the only time that an older adult leaves their home. As a result, physicians—particularly emergency room clinicians—have an opportunity and responsibility to identify elder abuse, neglect, and exploitation," said Tony Rosen, MD, MPH, and assistant professor of emergency medicine in the Department of Emergency Medicine at Weill Cornell Medicine and New York Presbyterian Hospital in New York.

The research is based on medical, police, and legal records collected from 78 successfully prosecuted elder abuse cases with physical injury from 2001 to 2014. There was a control group of 78 patients who suffered injuries in unintentional falls.

The study features several key data points.

• Compared to older adults who experienced unintentional falls, elder abuse victims were more likely to have bruising, 78% vs. 54%
   
• Compared to older adults with unintentional falls, abuse victims were more likely to have injuries on the maxillofacial, dental, and neck area, 67% versus 28%
   
• Compared to older adults with unintentional falls, elder abuse victimes were more likely to have maxillofacial, dental, or neck injuries in the absence of upper and lower extremity injuries, 50% vs. 8%
   
• Compared to older adults with unintentional falls, seniors who were victims of physical abuse were more likely to have injuries to the left cheek or zygoma (22% vs. 3%), neck (15% vs. 0%), or ear (6% vs. 0%)

The head and face are a primary target for elder abuse perpetrators, Rosen said. "When you are angry at someone, you lunge for things that are exposed and things that are symbolic of the person you are angry at. Ultimately, the face is an attractive target to an assailant. According to the literature on younger age groups, the face is a common place to be injured in an assault."

Injuries to the face in the absence of injuries to other parts of the body should raise suspicion of elder abuse, he said. "If someone is prone to bruising, they should be covered with bruises in an accidental fall. So, the presence of bruising in the face combined with the absence of bruising in places where people get bruised more often—like the shins or the knees—is more concerning."

Neck injuries are particularly suspicious, Rosen said. "We found injuries to the neck were most consistent with elder abuse. When you fall, the neck is protected by the face and the shoulders. So, it is hard to injure your neck in a fall, unless you fall against the edge of a table or refrigerator. As a result, we think injuries to the neck are particularly concerning."

The study's data indicate exploration of elder abuse is appropriate for a small but significant percentage of fall patients, he said. "We recognize that no matter how good of a job we do identifying elder abuse, falls and other unintentional injuries are still going to be more common. So, the first thing we can do with these findings is to keep in mind that every single fall is not necessarily a fall. There ought to be characteristics about the injury pattern that ought to make us question whether injuries really occurred from a fall."

Addressing suspicion of elder abuse

In most states, clinicians are mandatory reporters of elder abuse, and most cases are reported to adult protective services.

When elder abuse is suspected, the first step for clinicians is to interview the patient with no home caregivers or family members present, Rosen says. "The second thing is you want to make sure that you conduct interviews in a supportive and nonjudgmental manner while ensuring privacy. You need to build a therapeutic alliance with the patient and the family."

Patients should be treated sensitively because they are potentially trauma survivors, he says. "Providing trauma-informed care is important for these patients and their families. Trauma-informed care includes being sensitive to the profound impact of traumatic and stressful life experiences on a patient's physical and mental health. Previous and even remote traumatic experiences can cause depression, anxiety, or post-traumatic stress disorder."