The role of the orthopaedist in identifying elder abuse

Child abuse and domestic or intimate partner violence are the focus of public awareness campaigns and are treated with passion and seriousness. Unfortunately, elder abuse, which is a prominent concern among the rapidly aging population of the United States, is not handled with the same sense of urgency.

The lack of heightened exigency associated with elder abuse is due, in part, to the fact that the mistreatment is not well documented. Although physicians are mandated to report cases of elder abuse, they are often unaware of its prevalence or are unsure of what to do when confronted with a possible case. Orthopaedic surgeons, in particular, are in a position to help identify possible elder abuse because many patients who have been abused or neglected may have musculoskeletal injuries.

Defining elder abuse
According to the National Center for Elder Abuse (NCEA), elder abuse includes any “intentional or neglectful acts by a caregiver or trusted individual that lead to, or may lead to, harm of a vulnerable elder.” The NCEA further defines a vulnerable elder as a person, usually older than age 60 years, who is “being mistreated or is in danger of mistreatment and who, due to age and/or disability, is unable to protect himself or herself.” The seven common types of elder abuse include physical abuse, sexual abuse, emotional abuse, financial exploitation, neglect, abandonment, and self-neglect.

The prevalence of elder abuse is not well known. Cases of abuse are grossly underreported and the lack of a standard definition makes it difficult to accumulate a national data set. The 1996 National Elder Abuse Incidence Study (NEAIS) estimated that only one in five cases of elder abuse was reported, and only 2 percent of documented cases were reported by physicians. Other studies claim that between 1 million and 2 million cases of elder abuse occur annually among noninstitutionalized elders.

Institutional cases of abuse in nursing homes and other long-term care facilities are even less well-documented. The NEAIS found that neglect was the most common type of abuse at 48.7 percent, followed by emotional abuse (35.4 percent) and physical abuse (25.6 percent). A study that investigated prosecuted cases of institutional abuse showed physical abuse to be the most prominent form of abuse.

Risk factors for elder abuse

According to the literature, risks for elder abuse include the following:

• poor health of the elder
• cognitive impairment, such as dementia
• shared living arrangements
• social isolation
• stressful factors, such as financial strain
• a history of past domestic violence

An elder is also at greater risk of abuse if the abuser is financially dependent on the elder or if the abuser has a substance abuse problem. Older elders are also at a higher risk for abuse than younger elders.

According to the NEAIS, the average age of an abuse victim is 78 years; the risk of becoming a victim increases two fold when the elder reaches age 80 years. Abusers are likely to be adult children of the victim or other family members; in cases of institutional abuse, healthcare workers may be the abusers.

Gender is not specifically a risk factor for abuse, although some studies do show females are more likely to be victims of elder abuse. According to the NEAIS, females were disproportionately represented as victims in cases of emotional, physical, and financial abuse, as well as in cases of neglect. Males were overrepresented in cases of abandonment, which was also the least prevalent form of abuse.

Orthopaedic relationship to elder abuse
As orthopaedic surgeons, we are in a unique position to identify elder abuse and should be familiar with its signs. Multiple fractures, especially those at different points in the healing process, are a common indication of abuse. Other elder abuse injuries include bruises, sprains, fractures, abrasions, and burns; often there is a delay between the occurrence of the injury and the visit to the physician. Vague explanations of the injury or disparities in the histories given by the patient and the suspected abuser may also suggest abuse.

Does the injury correspond to the mechanism of injury reported by the patient? If the stated mechanism for a musculoskeletal injury is not consistent with the actual injury, this may be a case of elder abuse and deserving of further inquiry.

Older individuals may experience “spontaneous” fractures due to osteoporosis or other conditions that may be mistaken for elder abuse. Physicians must therefore first rule out the possibility that an injury is the result of low-energy activities of daily living (such as moving a nonambulatory patient from the bed to a commode), before concluding that patient has sustained an abusive injury.

Orthopedic surgeons who suspect elder abuse should, if possible, interview the patient separately from the suspected abuser. Studies on IPV suggest that it is helpful to introduce the subject of abuse by framing it as a problem the physician has seen before. For example, the physician may say, “I have seen other patients with similar injuries who were the victims of abuse. Did someone you know give you this injury?”

Unfortunately, it may be difficult to interview the patient alone because the elder patient may be dependent on the suspected abuser for communication. Physical examinations, complemented by photo documentation, are helpful in identifying abuse. These exams and tests should be performed in addition to, or in absence of, a patient interview if abuse is suspected.

Reporting elder abuse
Although hospitals may have different protocols for reporting elder abuse, all states except Colorado and South Dakota require physicians to report cases of elder abuse. Physicians who suspect elder abuse can report it to social workers at their hospital or to an outside adult protection services (APS) agency. APS agencies are available 24/7 to take calls from mandated reporters.

The NCEA, which partners with the National Adult Protective Services Association (NAPSA) to provide protection to vulnerable elders, is a valuable resource regarding reporting elder abuse. The NCEA website (www.ncea.aoa.gov) includes state-specific abuse laws and telephone numbers to local APS agencies. Depending on the state, these agencies may provide anonymity to physicians who report cases so as not to interfere with the medical relationship between doctor and patient. The site also includes information on regional ombudsman programs that communicate between abuse agencies and elder care facilities on behalf of abuse victims.

Avery E. Michienzi attends the University of Minnesota. Julie A. Switzer, MD, is an assistant professor of orthopaedic surgery at the University of Minnesota and a member of the AAOS Women’s Health Issues Advisory Board.

Putting sex in your orthopaedic practice
This quarterly column from the AAOS Women’s Health Issues Advisory Board and the Ruth Jackson Orthopaedic Society provides important information for your practice about issues related to sex (determined by our chromosomes) and gender (how we present ourselves as male or female, which can be influenced by environment, families and peers, and social institutions). It is our mission to promote the philosophy that male and female patients experience and react to musculoskeletal conditions differently; when it comes to patient care, surgeons should not have a one-size-fits-all mentality.

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