Elder Abuse: Systematic Review and Implications for Practice

Xin Qi Dong, MD, MPH


J Am Geriatr Soc. 2015;63(6):1214-1238. 

In This Article

Implications for Health Professionals

Health professionals are well situated to screen for elder abuse and detect vulnerabilities.[70,71] How older adults manage their daily lives can suggest predisposing factors that may impair their ability to live independently and protect themselves. Assessing functional, cognitive, and psychosocial well-being is important for understanding the predisposing and precipitating risk factors associated with elder abuse. A recent validation study of the elder abuse vulnerability index suggests that older adults with three or four vulnerability factors have almost 4 times the risk of elder abuse, whereas those with five or more factors have more than 26 times the risk.[72]

Because elder abuse victims often interact with health systems, increased screening and treatment should be instituted in healthcare settings. Primary care outpatient practices, inpatient hospitalization episodes, and discharge planning and home health could play pivotal roles in identifying potentially unsafe situations that could jeopardize the safety and well-being of older adults.[73] Early detection and interventions, such as incorporating effective treatment of underlying problems, providing community-based services, and appropriately involving family, may help delay or prevent elder abuse (Figure 2).

Figure 2.

Healthcare professional management strategies for elder abuse. APS = Adult Protective Services.

When health professionals suspect elder abuse, detailed histories should be gathered, especially psychosocial and cultural aspects. In addition, specific findings from physical examinations that may further indicate elder abuse should be documented. Moreover, health professionals should document observations of patient behavior, reactions to questions, and family dynamics and conflicts. Whenever indicated, health professionals should order laboratory tests and imaging tests. These types of documentation are critical for supporting the interdisciplinary team and APS to ameliorate elder abuse and protect vulnerable older adults. Furthermore, health professionals should devise patient-centered plans to provide support, education, and follow-up and should monitor ongoing abuse and institute safety plans.

Almost all states have mandatory reporting legislation requiring health professionals to report reasonable suspicions of elder abuse. Elder abuse reports can come from variety of sources and could be anonymous if within the authorization of the statute, but in most states, reporting of elder abuse by health professionals is not anonymous, because follow-up may be needed with the reporter to provide further evidence and assessment. When health professionals suspect elder abuse, they should contact the state office on aging, the ElderCare Locator (800–677–1116), or the National Center on Elder Abuse.

Health professionals may be reluctant to report elder abuse because of subtlety of signs, victim denial, and lack of knowledge about reporting procedures.[71] Other reasons for reluctance include concern about losing physician–patient rapport, concern over potential retaliation by perpetrators, time limitation, doubt regarding the effect of APS, and perceived contradictions between mandatory reporting and a provider's ability to act in the patient's best interests.[74] A common misconception for reporting elder abuse is that convincing evidence is needed to report. In addition, given the fear of liability, the physician may ask for proof rather than suspicion of abuse to report elder abuse.[74] On the contrary, elder abuse should be reported to APS whenever a reasonable suspicion arises.

Health professionals promote a patient's rights to autonomy and self-determination, maintain a family unit whenever possible, and provide recommendations for the least-restrictive services and safety plan. It must be presumed that an older adult has decision-making capacity (DMC) and accept the person's choices until a healthcare provider or the legal system determines that the person lacks capacity. One of the most difficult dilemmas is under what types of situations the medical community and society at large have a responsibility to override personal wishes. The presence or absence of capacity is often a determining factor in what health professionals, the community and society need to do next,[75] but capacity is not present or absent; rather it is a gradient relationship between the problems in question and an older adult's ability to make these decisions. Complex health problems require higher levels of DMC. For simpler problems, even a cognitively impaired adult could have DMC, but health providers are often forced to make gray areas black and white for purposes of guiding next steps such as guardianship or conservatorship. Commonly used brief screening tests such as the Mini-Mental State Examination are inadequate for determining capacity except at the extremes of the score. A more-useful test for assessing DMC is the Hopkins Competency Assessment Test.[76]