Expert Urges Providers to Remain Vigilant When Evaluating Geriatric Patients for Signs of Physical and Sexual Abuse

Abuse of any kind can do irreparable harm to a patient's physical and psychological health, destroy social and family ties and lead to devastating financial loss. Older victims, in particular, have been shown to die earlier than those who have not been abused. The following article is the first in a series of stories designed to shed light on the escalating and often-overlooked global issue of elder abuse and neglect — physical, sexual, emotional and financial. Our aim is to increase provider awareness and improve the detection and management of at-risk geriatric patients.

Even experienced clinicians may assume that bruises on an older patient’s arms or legs are the result a fall – an accepted risk of normal aging. But by blindly attributing such complaints to a simple mishap, providers run the risk of missing a far riskier etiology: physical abuse.

The World Health Organization estimates that 1 in 6 older adults are regularly subjected to some form of maltreatment – yet despite its prevalence, elder abuse can be challenging to recognize and differentiate from more benign culprits, says Cleveland Clinic geriatrician Ronan Factora, MD.

Because physical abuse can have particularly devastating consequences for older victims, Dr. Factora urges providers to remain alert to even the subtlest warning signs when evaluating any geriatric patient.

“Clinicians can play a crucial role in protecting older adults by identifying potential abuse and intervening before they can be harmed again,” he says. “With careful screening and the right care, we can help improve the lives and outcomes of even our most vulnerable patients.”

Spot red flags

Although it’s not uncommon for older adults to suffer bumps and bruises, several specific injury patterns should be cause for concern, Dr. Factora says. For example, bruises or welts on the face or neck, particularly near the eye or cheek, warrant further investigation. Unexplained injuries, including burns, to the chest, back, inner arms and legs, or abdomen should also raise suspicion.

In addition, the frequency of injuries should be considered when evaluating any older patient, Dr. Factora says. “Patients who present multiple times with similar injury patterns should always be assessed for abuse,” he explains. “Furthermore, bruising that is associated with concomitant injuries like missing teeth or broken bones warrants investigation, as does any mark that resembles the shape of a weapon or object.” A bruise that wraps around a patient’s torso or leg, for example, may indicate a strike with a rope or belt.

Forced confinement, another form of physical abuse, is equally dangerous but often less obvious, he says. Although physical signs of restraint, including rope marks on the wrists or ankles, are blatant red flags, social isolation is often the first indication of confinement. To better catch the warning signs, Dr. Factora encourages providers to routinely ask geriatric patients about their daily activities, including where they go, if they have visitors and whether they have regular contact with family members who live outside the home.

“If isolation is a concern, it’s a good idea to ask the patient if that is their choice,” he says. “If the patient expresses a desire to be more engaged and you can’t identify barriers that explain their isolation, consider probing further."

Sexual abuse can be equally difficult to spot because it may not result in visible wounds and can be especially painful for patients to disclose. Symptoms like vaginal bleeding, recurrent urinary tract infections and sexually transmitted infections can be red flags; however, Dr. Factora cautions that any unwanted sexual behavior constitutes abuse, including inappropriate touching and forcing the victim to view pornography.

Behavioral symptoms like sudden-onset anxiety, fearfulness and withdrawal can also be potential warning signs. Because abuse is typically carried out by a relative, caregiver or someone else they know and trust, patients may be reluctant to report mistreatment out of embarrassment or retaliation, he says. To mitigate this risk, Dr. Factora urges providers to speak privately to any patient at risk.

He adds that clinicians should also be attuned to factors that elevate a patient’s risk for abuse. Older age, the presence of multiple comorbidities, limited mobility, cognitive impairment or dementia, social isolation and dependence on family members for daily activities has been shown to increase the danger of abuse. Although older women are more likely to be victimized than their male counterparts, Dr. Factora emphasizes that virtually any patient can be targeted.

Trust your instincts

Above all, Dr. Factora stresses the importance of follow up when managing any patient in whom physical or sexual abuse is suspected. “Proof is not required; suspicion is enough to justify additional questions,” he says. “It is critical for clinicians to trust their instincts when evaluating for signs of abuse, even those that are ambiguous or could be attributed to other, nonviolent causes.”

When abuse is suspected, Dr. Factora says providers should start by documenting the patient’s complaints and injuries thoroughly. The victim’s statements should be registered in the medical record in as much detail as possible (ideally, using direct quotes), and any injuries should be photographed.

He also urges providers to seek additional support from hospital social workers, a local adult services office or a Sexual Assault Nurse Investigator – all of whom should be capable of initiating appropriate interventions and contacting the proper authorities.

“Understand that you can’t tackle a case like this by yourself,” he says. “For the patient’s protection – and your own – it is imperative to seek the advice and support of experts in the field.”

Offer protection

Dr. Factora recalls treating a woman in her 80s whose behavior raised red flags. After noticing the patient appeared to cower in the presence of her family member, he pulled her aside for a private conversation. When interviewed separately, the patient became upset and disclosed that she had been hit.

After examining the injury, which was evidenced by a handprint, Dr. Factora carefully documented the case. The bruise was photographed, and a social worker was brought in to help move the patient to a safe location away from her family member.

“Fortunately, we were able to help this woman achieve an ideal outcome,” he says. “She is now safe and can live out the rest of her life without fear. After all, that’s what every patient deserves.”