Recognizing elder abuse

Nursing, Sep 1999 by Gray-Vickrey, Peg

Learn how to distlguish normal bumps and bruises from signs of physical abuse.

THIS YEAR over 1 million older adults in the United States could be physically abused by a caregiver. If one of them were to become your patient, could you recognize the danger signals? In this article, I'll explain how to identify signs of elder abuse, how to document your findings, and where to report your suspicions.

Why it happens

Common factors at the root of elder abuse include: a stressful caregiving situation, especially if the older person is physically or emotionally impaired family problems

isolation of the older person from friends and family

financial problems

a history of family violence or personal problems for the caregiver.

Telling behaviors

Behavior patterns reveal a lot about the relationship between your patient and his caregiver. How do they interact? Do they smile or laugh together or sit in stony silence? Is the caregiver's tone soft and soothing or loud and threatening? Does he touch the patient gently, roughly, or not at all?

Pay close attention to your patient's behavior. Anxiety, agitation, confusion, withdrawal, fearfulness, depression, aggressiveness, suspiciousness, hallucinations, or talk of suicide all may signal mistreatment.

What to look for When you assess any elderly patient, be on guard for signs of abuse or neglect. Keep in mind that aging skin is susceptible to tearing and bruising, so these aren't sure signs of abuse. The following telltale signs should arouse your suspicions: multiple injuries or fractures in various stages of healing

injuries to the trunk, abdomen, genitals, buttocks, or upper thighs bruises in clusters or regular patterns or appearing over several planes of the body, such as "wraparound" injuries that occur when someone is struck with a belt

bilateral or parallel injuries, which suggest control marks or forceful restraining. Shaking, for example, may cause bruising on both upper arms.

burns, commonly to the soles, palms, or buttocks

rope burns on the extremities, neck, or torso

injuries shaped like an object, such as a belt buckle or hand

sprains or dislocations

unusual hair loss, redness or swelling of the scalp, or hemorrhaging below the scalp line.

Neglect is also a form of abuse. Here are some indicators:

deteriorating health, cachexia, or wasting

dehydration or malnutrition

pressure ulcers or contractures

excessive dirt or odor on the body or clothing

urine burns

glasses, dentures, hearing aids, and walking devices in poor repair or missing

inappropriate dress

presence of fleas or lice

listlessness and fatigue

any indication that the patient was left unsafe or alone for long periods

overmedication or undermedication, especially oversedation.

Suspect abuse if your patient has injuries that can't be explained and aren't consistent with his history and your other assessments. Hearing conflicting stories about the injury from the patient and his caregiver is another red flag.

Asking the right questions

If your patient has an injury, ask him and his caregiver:

When and how did it happen?

How much time passed after the injury before you sought medical attention?

How often has this type of injury happened? Suspect a problem if the answers aren't consistent with the injury or if the patient or caregiver is unwilling or unable to respond.

If you believe that your patient may be a victim of abuse, settle him in a safe, private location away from his primary caregiver and ask:

Did someone hurt you?

Does anyone hit you?

Has anyone ever touched you without your consent?

Who cares for you at home?

Are you afraid of your caregiver?

Follow up immediately if the patient tells you he's been abused or if he has a suspicious history of repeated falls.

Getting down to documentation

For your patient's protection, document all the objective and subjective data you gather, including the patient's and caregiver's explanations of the injuries.

Place quotation marks around their words and note any discrepancies in their stories. Document injury sites on a body map and identify the types. Conclude with photographs of the injuries (see A Close-up on Photo Documentation).

Finally, follow your facility's policy for reporting elder abuse. A special facility response team may follow through or you may have to contact a state agency. The following agencies may be available in your area:

A close-up on photo documentation

If you suspect elder abuse, follow your facility's policy for documenting abuse. Generally, you'd ask the patient or his caregiver for signed permission to take photographs for the medical record. Here are picture-taking guidelines:

Use an instant camera and color film.

Take a full-body shot. You need at least one photo of the patient's face for identification.

Take a midrange shot to provide a frame of reference for injury locations.

Take at least two close-ups of each injury from different angles.

To indicate the injury size, inelude a ruler or coin in the picture or use grid film that's formulated to document size.

If possible, take follow-up photos 24 to 48 hours later, when bruising may be more evident.