Elder Maltreatment: A Review Open Access

The term geriatric refers to the aging human population, and geriatrics refers to the medical field that deals with clinical problems specific to old age (≥65 years) and the aging. Human populations continue to age at an impressive rate. In 1900, only 1% of the earth's population— 15 million—was older than 65 years.1 By 1992, 6% of the global population, or 342 million persons, were in this category. By the year 2050, these figures will have risen to 20% and 2.5 billion, respectively.2 By 2020, 22% of the US population will be older than 65 years.3 Not only do we have more elders but the life expectancy in the United States is at a record high of 77.4 years.4,5 As this segment of our population increases, we will likely be seeing more cases of elder maltreatment.

Elder maltreatment was first described in 1975 when simultaneous reports of “granny battering” appeared.6–8 The American Medical Association defines elder maltreatment as an act or omission that results in harm or threatened harm to the health or welfare of an elderly person. Elder maltreatment is seen in all races and ethnic groups, religions, educational backgrounds, and socioeconomic groups.9–19 Looking at the US population, it is estimated that up to 5% of the community-dwelling elders are victims of maltreatment; this is a group separate from those institutionalized as described later.13 The exact incidence of elder maltreatment is not known; in fact, studies have found that only 1 of every 13 or 14 cases of elder abuse is ever reported.14,15 The 2004 report of the National Center on Elder Abuse stated that 8.3 cases of abuse are reported for every 1000 elder Americans.20 Elder maltreatment can be classified into 6 categories: (1) physical abuse, (2) sexual abuse, (3) neglect, (4) psychological abuse, (5) financial and material exploitation, and (6) violation of rights.16–19 Often, several types of abuse occur simultaneously.18 For the purposes of this review, physical abuse, sexual abuse, and neglect are discussed.

Understanding the typical victim, perpetrator, and scenario is crucial to detecting and preventing elder maltreatment. The typical victim in this age group is older than 75 years, often older than 80 years.20 Although most studies have shown that men and women appear to have similar per capita rates, in 2004 the National Center on Elder Abuse found two thirds of victims to be women.20 This same study showed 77% were white. The victim is usually socially isolated and lives in close proximity to or with the perpetrator. The elder victim usually has a personal relationship with the perpetrator (eg, relative, neighbor, nurse/sitter/caregiver, family friend). Often the victim is dependent on the perpetrator. Inherent factors in the elder that appear to put him or her at risk include cognitive impairment, dementia, physical impairment, functional debility, incontinence, provocative actions of the elder, guilt, fear of nursing home placement, and a fear of retaliation.21–24 The maltreatment most often occurs at home, either the home of the victim or the perpetrator.4,16,25 The time of year is not a factor.4 

So who are the common perpetrators? Over time and generations, a type of revenge framework may be created within the family.26–28 This is often termed transgenerational violence.16,29,30 Violence is a learned behavior, an expression and/or reaction to particular experiences or difficult situations. Abused spouses later abuse their abusers; abused children later abuse their parents as well as their own children, perpetuating the cycle. Intimate violence in partnerships and intergenerational violence are definite factors in such domestic cases with elder victims and family member perpetrators.16,29 The typical perpetrator, or abuser, is a relative who lives with or near the elder.25,31 Three characteristics of the perpetrator are known risk factors: 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.14,16,23,24,26,27,32,33 Up to 35% of perpetrators have psychological disorders or are substance abusers.34 Many of them have little interest or activity outside of the home. One study showed that two thirds of elder perpetrators was the spouse, and one third was adult children of the elder.35 In 2004, it was reported that 33% of perpetrators were the adult children and also detected were other family members in addition to the spouse.20 Male victims are most often abused by their wives. Female victims are most often abused by their children; the children more likely to be male as opposed to female.26,36 Maltreatment often occurs at times of stress with the perpetrator. A family tradition of using violence in times of stress is perpetuated with the stressed caretaker abusing the elderly victim.23 

Physical abuse is an act carried out with the intention of causing physical pain or injury.18 Physical abuse is generally considered the most extreme form of elder maltreatment.16 Such physical abuse includes slapping, blunt force trauma, bites, pinching, traumatic alopecia, burns and scalds, force feeding, overmedication, undermedication, and improper medication, and improper use of physical restraints (Table 1). Physical abuse accounts for up to 14% of all elder trauma and results in death more frequently than in younger patients.37 Elders can certainly be the victims of accidental, noninflicted trauma. Such trauma includes abrasions and contusions over bony prominences and long bone and vertebral fractures. Worrisome traumatic injuries include those to areas not commonly impacted during daily activities or even secondary to accidental trauma. These include injuries to the inner thigh, top of the feet, inner ankle, inner wrists, palms and soles, pinna, posterior neck, mastoid region, and axilla. The trauma may also leave a pattern such as from a shoe or a belt or abrasions from ligatures. Injuries in various stages of evolution or healing are also suspect. The given history usually does not correlate with the physical findings, both location and severity, and/or there is a delay in seeking treatment. Head trauma is especially prominent in severe cases of physical abuse and has a high morbidity and mortality rate. Subdural hemorrhage secondary to inflicted trauma is a common cause of death in elder abuse. Any injury to the eye, nose, or mouth must be investigated as likely nonaccidental. Contusions and lacerations of the inner lips and cheeks (buccal mucosa) as well as contusions of the edentulous ridges can be secondary to blunt trauma. Fractures can occur including the orbit, nose, maxilla, and mandible. Over time, a deviated septum can result from repeated blows to the face. As with pediatric victims, inflicted contact burns and scalds can occur with elders. Patterned burns recapitulating the implement, such as a cigarette burn, or immersion lines with glove and stocking distribution can be identified. Especially with burn cases, the elder's physical and cognitive status must be assessed to substantiate the history. Hair loss from the vertex and frontotemporal regions is common in men and this same pattern may occur in woman after menopause. Also, diffuse hair loss and thinning occurs in both sexes with age. However, single or multiple patches of alopecia, with or without visible hair breakage, is worrisome for traumatic alopecia. The pattern of hair loss will be unusual because these patches will be adjacent to normal scalp. The distribution is unlike that of normal aging.30 Scalp hemorrhage or a hematoma may also result as the hairs are forcibly pulled out. The elderly often eat slowly because of decreased oromotor reflexes and xerostomia.30 A caretaker may become impatient with the amount of time needed to feed the elder and cease feeding him or her after a certain amount of mealtime. Force feeding resulting in choking is seen in cases of elder maltreatment. Improper use of restraints is another form of physical abuse resulting from inappropriate restraint type, forceful application, prolonged positioning, or the use of restraints to ensure isolation or unnecessary immobility. Findings include friction burns of the extremities, axillary abrasions, and decubitus ulcers. A different form of improper restraint is psychotropic chemical restraint. Chemical restraint is more common in elders with dementia, agitation, or combative behavior. The most common drug used is haloperidol. Sometimes a psychotropic drug is discovered that is not even prescribed to the patient. Use or overuse of these drugs can be detected by premortem or postmortem toxicology. Undermedication may also exist and is a form of medical neglect. The elder may have an exacerbation of a chronic organic disease because the caretaker refuses to provide the proper medical treatment. This refusal may have a financial purpose because the caretaker refuses to spend money on the medication. If so, the elder is a victim of financial exploitation as well as medical neglect.19 In other cases, a medication such as a narcotic is not provided because the caretaker is taking the elder's medication himself or herself.

Sexual abuse, or molestation, consists of contact with the genitalia, anus, breast, or mouth. Because sexual abuse is the most underreported type of elder maltreatment, it is difficult to assess the prevalence of a sexual assault component in elder victims. The rate of elder death investigation is low, and the inclusion of a sexual assault examination is even lower.4 Even in cases of elder homicide, sexual assault examinations are often not performed.4 

Most sexual assaults occur at home when the elder is alone.38 The victims are usually women and the perpetrators male.38,39 Most elder women will sustain anogenital injury. They are prone to vaginal injury secondary to decreased estrogen, atrophy, vaginal dryness, and a thinning wall.37,40 Vaginal or anorectal bleeding should be investigated not only to rule out organic disease but also to rule out sexual assault trauma. Spermatozoa, prostatic acid phosphatase, P30 glycoprotein, and DNA can be detected from specimens taken from an elder victim despite the changes of aging. However, with the barrier of decreased mental status, delayed reporting, defecation, urination, bathing, and/or fear of retribution, the evidence is often lacking.16,39,41,42 A significant amount of trauma can also be to the nongenital areas.39 Such trauma includes bite marks, blunt force trauma, hard and soft palate trauma, injuries secondary to restraints, and signs of asphyxia.

The most common form of elder maltreatment is neglect, the failure of a caregiver to provide basic care to a patient and to provide goods and services necessary to prevent physical harm or emotional discomfort.6,15,18,23,24,26,43 Another accepted definition is the refusal or failure to fulfill any part of a person's obligation or duties to an elder.44 Neglect can be active or passive.45,46 Active neglect is when the caregiver intentionally fails to meet his or her obligations toward the elder. With passive neglect, the failure is unintentional. Often the caretaker is uninformed, misinterprets signs and symptoms, or is distracted by an external stressor.47 A proper investigation can reveal not only inflicted trauma of physical or sexual abuse but also active or passive neglect. Findings of neglect include malnutrition, starvation, dehydration, poor hygiene, and untreated decubiti. Malnourishment encompasses starvation as well as lack of a proper diet. The diet must be well balanced and delivered in the proper form (eg, liquid, pureed, diabetic, low salt). Malnutrition is suspected in cases of decreased body mass, loss of muscle mass (sarcopenia), recurrent infection, decreased total protein, decreased albumin (<3.5 g/dL), and decreased total iron binding capacity (<250 μg/dL).30 Loss of protein may be associated with edema. Cholesterol levels are less than 160 mg/dL in cases of severe malnutrition.30 Tables for adequate elderly height and weight are not available, but a body mass index of less than 21 kg/m² is cause for concern.30 In addition to loss of weight, anemia secondary to malnutrition may be present. Dehydration is also a problem in the elderly. A caretaker may withhold water when the elder is incontinent to decrease the number of bedding and clothing changes. Compounding this, elders' thirst sensation and renal metabolism are altered with age and can predispose them to dehydration.48 On examination, one may see dry mucous membranes, dry serosal surfaces, sunken eyes, and decreased skin turgor. In the living elder, the heart rate will be elevated and the blood pressure will be low. Fecal impaction may also be evident as a result of the dehydration. Electrolytes, including postmortem vitreous, will be abnormal, in particular an elevation of sodium, chloride, creatinine, and urea nitrogen.49 The hematocrit level may also be elevated.

Decubitus ulcers are a common physical finding in the elderly and in cases of elder neglect; the pathophysiology is described later. Ulcerations in locations other than the lumbar and sacral areas may indicate unusual positioning or improper restraint use for an extended length of time. For example, an ulcer produced from the legs being crossed or an arm pressed against the thorax. Evidence that the ulcers have not been treated is further evidence of neglect. Poor hygiene, including lying in urine and feces, accelerates the skin breakdown and infection. Elders have a reduced resting anal sphincter pressure and decreased maximal sphincter pressure, which predisposes to fecal incontinence.30 Urinary incontinence affects 35% to 50%+ of all elders as the bladder capacity, contractility, and the ability to postpone voiding decline.30 With these changes are also psychiatric disorders, dementia, medications, stroke, and restricted mobility that prevent or inhibit normal voiding.30 At autopsy, decubitus ulcers should be thoroughly photographed, diagramed, and cultured, and histologic sections should be taken. If the elder is septic, correlation between the blood and exudate cultures may reveal the ulcer(s) to be the source of sepsis and positive evidence of fatal neglect. Medical neglect is when the caretaker does not seek medical treatment, delays in seeking treatment, does not provide medication, or does not care for the elder's organic diseases (eg, special diet, insulin, heart medication). Too often because of an individual's age and natural diseases, death is attributed to the natural progression of that disease. Accordingly, the autopsy rates decrease with increasing age.50 

The large majority of elder maltreatment occurs in the home. The home of the victim may be an institution such as a nursing home. A nursing home is a residential facility for people who require nursing care and related medical or psychosocial services.51 Currently, 5% to 10% of the elderly population resides in institutions.30,52 These elders comprise 90% of all nursing home residents, or 1.5 to 1.8 million people.2,52 Any of the aforementioned 6 types of elder abuse may be found in an institution. The perpetrator of abuse within an institution may be a staff member, another resident, or a visitor. One half of nursing home patients suffer from dementia and are unable to voice their abusive situation or seek help.11 As mentioned, these patients are sometimes aggressive and combative, precipitating abuse. Probably more common than in cases of homebound (noninstitutionalized) elders, improper use of restraints may occur, both physical and chemical, to control elders' behavior and make them easier for the staff to manage.11,43,53 Increasingly, institutionalization is seen as a risk factor for elder abuse and neglect although no empirical research about abuse in institutions exists.23,47 A random-sample survey of nursing home staff members in 1 state found that 10% of nurses' aides reported that they had committed at least 1 act of physical abuse in the preceding year, and 40% reported committing at least 1 act of psychological abuse.54 Another factor that impedes the understanding of such institutional elder abuse is that less than 1% of the deaths are autopsied.50 

Ancillary studies are extremely important in evaluating cases of possible elder maltreatment. Full body radiographs can detect occult fractures, healing fractures, demineralization, and osteomyelitis. Microbial cultures of blood, lung, and any wounds or exudates can be useful in cases such as sepsis secondary to decubitus ulcers. Blood or vitreous analysis (vitreous placed in a small red-top sterile tube) for electrolytes, glucose, and ketones can confirm dehydration, renal failure, or diabetic ketoacidosis.49 The hematocrit will be elevated in cases of dehydration. The aforementioned laboratory studies can be performed in suspected cases of malnutrition. At autopsy, a posterior “Y” incision and cut-downs of the buttocks and extremities are extremely helpful in evaluating blunt force trauma. In cases of suspected sexual assault, swabs from the anorectum, cervicovaginal, and mouth (especially under the tongue) should be taken. A saline mount can be prepared at the time of examination to look for motile spermatozoa. Smears should be made for Papanicolaou staining, and the swabs air-dried for other analyses such as DNA. Other ancillary studies are available, but the aforementioned are crucial in any case of elder maltreatment.

Five main areas of confusion when delineating maltreatment from organic disease are skin findings, bleeding, fractures, malnutrition, and anogenital findings (Tables 2 and 3).55,56 

Several skin changes are noted with aging: decreased elasticity, decreased collagen, decreased epidermal proliferation, flattened dermal-epidermal junction, vascular fragility, and weakened supporting structures.56,57 Photoaged skin has decreased elasticity, is fragile, and is easily traumatized.43 Senile purpura can result from the aforementioned changes even secondary to minor pressure trauma. These red-purple geographic regions are usually on the flexor surfaces of the extremities. Not uncommonly, skin lacerations will also easily occur. Steroid purpura, from long-term high doses of steroids, may be seen where the skin is thin and inelastic and on areas commonly bumped.55,56 Individuals with Cushing disease can develop purpura. The elder also has a decrease in adipose tissue and muscular atrophy. The body is less “padded” and protected as well as less insulated. These integument changes combined with the neurologic and metabolic changes predispose the elder to hypothermia and hyperthermia. Elders have decreased temperature perception, decreased ability to detect temperature changes, impaired internal temperature regulation, decreased shivering and sweating, decreased vasodilation/vasoconstriction, and a decreased metabolic rate.30,55,56 

Decubitus ulcers, usually in the lumbar and sacral areas, are a concern in the elderly population.58 The skin may break down especially when an elder is bedridden or nonambulatory, lying supine, or seated in a wheelchair. The ulcers are due to pressure pushing the blood out of the soft tissues and preventing the return of the blood supply. Peripheral vascular stiffening, a natural change of aging, results in poor perfusion. The tissues are not only under pressure but are not receiving nutrients from the bloodstream. As a result, they breakdown and ulcerate. Certain diseases can predispose to the formation and poor healing of decubitus ulcers and need to be addressed when correlating the ulcers to a neglect situation. Such diseases include diabetes mellitus, anemia, and poor circulation such as peripheral vascular disease.55,56 

Many elders have an acquired bleeding tendency.16,56 This can be due to a coagulopathy of aging, anticoagulant medications, or chronic diseases such as cirrhosis. With acquired fibrinogen defects, high levels of fibrin degradation products and prolonged prothrombin time and partial thromboplastin time may be seen. Factor assays may be performed to detect deficiencies of certain coagulations factors. Spontaneous antibodies to factor V and more often to factor VIII can result in soft tissue hematomas without apparent trauma and excessive bleeding after minor injuries.56,59 Platelet disorders cause mucous membrane bleeding and cutaneous bruising. Drugs such as aspirin, nonsteroidal anti-inflammatory drugs, quinine, quinidine, thiazide diuretics, dextran, alcohol, heparin, penicillins, certain chemotherapeutic agents, and sulfinpyrazone interfere with platelet function and/or result in thrombocytopenia. Additionally, some drugs such as cimetidine can potentiate the action of anticoagulants.30,60 Other acquired disorders resulting in bleeding tendencies include aplastic anemia, B12 and folate deficiencies, viral infections, and myelodysplastic syndromes. Testing can be performed on specimens from a living victim or on admission blood from a deceased victim.

Certain areas of the body are more prone to bleeding such as the nose. With age, the nasal mucous membrane atrophies and the blood vessel walls in the nose thin.30 As a result, epistaxis is relatively common among the elderly. Hemorrhoids, especially internal, tend to bleed and can even result in anemia. Intracranial hemorrhage can be worrisome for inflicted head trauma. Intracerebral hemorrhages are associated with hypertension, amyloid angiopathy, anticoagulation, and trauma. Hypertensive hemorrhages are usually in the basal ganglia, amyloid angiopathy hemorrhages are in the cerebral lobes, and anticoagulation-induced hemorrhages are gradual and can occur in the cerebrum and cerebellum.30 Traumatic intracerebral hemorrhages are often multiple and located on the cerebral surface, especially the frontal and temporal tips. Subarachnoid hemorrhage can be caused by vascular malformations, aneurysms, anticoagulant use, and trauma. With cerebral atrophy, the elder is more prone to subdural hemorrhage from tearing of the bridging veins. A massive subdural hemorrhage can result from an accidental fall, common in elders because of age-related decreases in proprioception and increased incidence of organic diseases (see “Fractures”). Bleeding disorders and anticoagulant use increase the frequency of subdural hemorrhage. With a decrease in alcohol dehydrogenase, the alcohol concentration remains higher per amount consumed and can promote gait and balance instability as well as increase the bleeding tendency.

Elders have a decreased bone mass. Osteopenia and osteoporosis are prevalent for various reasons. Decreased estrogen promotes bone resorption. Vitamin D production is decreased secondary to a decrease in its precursor, 7-dehydrocholesterol.56 Organic diseases such as orthostatic hypotension, diabetic neuropathy, arrhythmia, stroke, impaired gait and balance, impaired proprioception, and decreased sensory input predispose the elder to falls.57,61–64 Common sites of accidental fracture are femoral neck, proximal humerus, and vertebrae.65 Rib fractures secondary to cardiopulmonary resuscitation are common.66 

With a decreased basal metabolic rate, decreased adipose tissue, and muscular atrophy, the elder can appear cachectic and malnourished.58,63 Changes in the gastrointestinal system affect the nutrition state. A decreased sense of taste and smell, xerostomia, temporomandibular joint dysfunction, loss of teeth, and dysphagia can result in decreased food intake.67 Many medications can disrupt taste and others can cause anorexia.30 The gastric secretions, intestinal enzymes, and peristalsis are decreased, adversely affecting digestion and absorption. Organic disease such as diabetes mellitus, hypothyroidism, late-onset celiac disease, pancreatic insufficiency, and inflammatory bowel disease further inhibit absorption of nutrients.30,56 Cholelithiasis can cause early satiety.30 Hyperthyroidism can cause weight loss. Dehydration can result from a decreased thirst sensation, decreased renal water absorption, decreased concentration of urine, and diuretic use.68 Individuals on diuretic medication or nasogastric suction are at risk for dehydration. Organic diseases that predispose the elder to dehydration include chronic renal disease, diabetes, and adrenal insufficiency. Dehydration can then predispose an elder to constipation and fecal impaction.

As mentioned with sexual abuse, the changes of aging predispose the elder to anogenital injury. These same changes as well as natural diseases can affect both the man and woman and mimic inflicted trauma or neglect. In women, these include bleeding and excoriation from decreased estrogen, cystocele, uterine prolapse, weakened pelvic structures, and infection secondary to an increase in vaginal pH. Lichen sclerosis, friable and easy to bleed, can look like genital trauma.69 A fixed drug reaction, especially with tetracycline, can occur on the penis mimicking sexual abuse or a contact burn. Pathology such as inflammatory bowel disease, constipation with resultant anal fissures, and excoriations from incontinence can mimic anal injury from sexual abuse.

Life expectancy at all ages has increased dramatically.30 In the United States, the life expectancy for men is 73 years and for women is 79 years.30 Once elders reach 85 years, the difference decreases to only 1 year with men at 90 years and women at 91 years. In descending order, the leading causes of death in persons 65 years or older are heart disease, malignancy, cerebrovascular disease, and pneumonia.30 Although most elders will die of their natural disease, these individuals are also increasingly targets of violence and victims of homicide.70 By understanding the typical victim, perpetrator, scenario, and physical and laboratory findings, elder maltreatment may be accurately confirmed or ruled out. Knowledge of the pathophysiology of aging and the natural diseases seen in the geriatric population is crucial. As a society with an increasing percentage of elders, we can only expect this vulnerable group to be potential victims of maltreatment and violence. Too few government funds are devoted to geriatric forensic research. In fact, no federal statutes exist to prevent elder maltreatment as there are for child abuse and domestic violence in general.71 Only by accurate diagnosis and documentation will we be able to bring proper attention to this growing problem.