Clinical Features

Mistreatment and/or neglect of elderly patients may be difficult to recognize. The problem is complicated by the fact that when abuse is suspected, it may be difficult to secure confirmation from the patient. The patient may welcome and be relieved by the physician's concern and identification. However, embarrassment, fear of abandonment, fear of retaliation, and fear of nursing home placement can prompt the patient to deny the physician's concerns.

Historical information should focus on the following: (1) detecting the presence of caretaker mental illness, mental retardation, dementia, or drug or alcohol abuse: (2) family history of violence; (3) caretaker dependence on the elder patient for housing, finances, or emotional support; (4) patient isolation, as reflected by the fact that the patient does not have the opportunity to relate with people or to pursue activities and interests in a manner that the patient chooses; (5) whether the patient and suspected abuser are living together; and (6) recent occurrence of stressful life events, such as loss of job, moving, or death of a loved one for the caretaker. 5

Important historical information concerning the patient should include dependency needs. Problems such as mental confusion, immobility, and need for assistance with hygiene are most often associated with neglect, a common form of maltreatment of the elderly. Eliciting a history of cognitive impairment is essential, since abused victims have been found to have significantly greater cognitive impairment than nonabused elderly patients. Abused patients also have a greater history of problematic behavior such as incontinence, nocturnal shouting, wandering, or paranoia. 1

An important direct question to put to the patient is, "Are you happy at home, or have you experienced any recent changes in mood or sleeping or eating patterns?" Look also for the sudden onset of behavioral signs and symptoms that suggest victimization: depression, fear, withdrawal, confusion, anxiety, low self-esteem, or helplessness.

Other historical indicators of abuse or neglect include a pattern of "physician hopping," unexplained delay in seeking treatment, lack of medical care, a series of missed medical appointments, previous unexplained injuries, explanation of past injuries inconsistent with medical findings, and previous reports of similar injuries.

The physical examination begins with an observation of the interaction between the patient and accompanying caretakers. The following are findings suggestive of abuse:

1. The patient appears fearful of his or her companion.

2. There are conflicting accounts of the injury or illness between the patient and caretaker.

3. There is an absence of assistance from the caretaker.

4. The caretaker displays an attitude of indifference or anger toward the patient.

5. The caretaker is overly concerned with the costs of treatment needed by the patient.

6. The caretaker denies the patient the chance to interact privately with the physician.

The mental status examination should try to elicit signs and symptoms of confusion or disorientation. These signs and symptoms are risk factors for elder abuse or neglect. If they are present, it is important to seek an underlying cause, especially if they are new, since they may represent underlying medical disorders or may be reflective of intentional or unintentional medication abuse or misuse resulting from abuse or neglect.

The general physical examination should focus on detecting signs and symptoms of poor personal hygiene, inappropriate or soiled clothing, dehydration, malnutrition, and worsening decubiti. Specific injuries suggestive of abuse are unexplained fractures or dislocations, unexplained lacerations or abrasions, burns in unusual locations or of unusual shapes, unexplained injuries to the head or face, the presence of sexually transmitted diseases, and unexplained bruises.

For example, bilateral bruises on the upper arms may indicate holding or shaking. Bruises may be similar to the shape of an object or be clustered on the trunk, indicating striking injuries. The presence of bruises in various stages of healing is suggestive of repeated abuse. Bruises around the wrists or ankles may occur secondary to being tied down. Bruises on the inside part of the thighs or arms are highly suggestive of intentional injury, since bruises obtained from falling are usually located on the outside surfaces of the extremities.

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