Physical abuse is the most easily recognized form of elder abuse. It is defined as the use of physical force that might result in bodily injury, physical pain, or impairment. Pushing, slapping, burning, striking with objects, and improper use of restraint are all examples of physical abuse. Chemical restraint (such as intentional overmedication or administration of tranquilizers) is a more subtle form. Regardless of mechanism, physical abuse is carried out with the intention of causing suffering, pain, or other physical impairment to the abused person.


Elder neglect is the most common form of elder maltreatment, accounting for more than half of all elder maltreatment cases reported to adult protective services agencies annually.6 Elder neglect is defined as 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.7,8 Examples of neglect include deprivation of food, clothing, hygiene, medical care, shelter, or supervision that a prudent person would consider essential for the well-being of another.7,8

Elder neglect is both underrecognized and potentially lethal. It likely accounts for the majority of cases of unreported abuse.9 It is also an independent risk factor for mortality, even taking into account that the deaths themselves may not be immediately ascribed to injury.6 Elder neglect may be difficult to diagnose. Although some cases may be obvious (such as in a patient with multiple deep pressure ulcers), it is often more subtle and difficult to detect.


Sexual abuse is broadly defined as nonconsensual sexual contact of any kind with an elderly person. The spectrum of sexual abuse ranges from unwanted touching, indecent exposure, or unwanted innuendo, to rape itself. Although sexual abuse is underreported across all age groups, in the elderly, sexual abuse is even less likely to be reported. Fear of retaliation and shame on the part of patients, as well as stereotyping of older patients as asexual or not sexually desirable by clinicians, police, and others, may be factors in underrecognition and underreporting of sexual abuse.10


Financial abuse is estimated to be the second most common form of elder abuse, accounting for approximately 20% to 30% of abuse cases.11 Financial or material exploitation is the illegal or improper use of an elder's funds, property, or assets.12 It occurs when family members, caregivers, or friends take control of the elder person's resources. Coercion or outright theft may occur, with or without the awareness of the elder person experiencing abuse. An elderly person may unwittingly sign over access to savings accounts and other assets when he or she is in an incapacitated state. Social Security checks or pensions may be used by caregivers for personal gain. Theft may be blatant or coerced, with forcible transfer of property, including changing of the elder's will. Abuse may result in a decrease in the standard of living and an inability to pay bills, purchase food, or obtain medications.


Emotional or psychological abuse is defined as the infliction of anguish, emotional pain, or distress. Examples of psychological and emotional abuse include verbal threats (such as threats of violence, institutionalization, or deprivation), humiliation, intimidation, and harassment. Social neglect and isolation are also forms of abuse. Psychological and emotional abuse can contribute to the development and worsening of mental health problems such as depression, which is common in many older victims.12


Abandonment constitutes the desertion of an elderly person by an individual who is that person's custodian or who has assumed responsibility for providing care to the elder. Desertion of an elder in the home, hospital, nursing facility, shopping mall, or other public location may occur.


Self-neglect include failure or unwillingness to provide adequate food, clothing, shelter, medical care, hygiene, or social stimulation for oneself. It is the result of an adult's inability, due to diminished capacity, to perform essential self-care tasks. By definition, this applies to one who understands the consequences of his or her choices and makes a conscious decision to engage in acts that threaten his or her own health or safety.

13Patients who have cognitive impairment or who are living in poverty are at greater risk of self-neglect and may have increased mortality.9


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three key components:

  1. Addressing associated medical and psychological needs

  2. Ensuring patient safety

  3. Complying with local reporting requirements

Medical problems, including injuries, should be stabilized and treated, and may be best managed through hospital admission.

In addition to physical injury, metabolic derangements may be present. Patients with dehydration or malnutrition can have a variety of electrolyte abnormalities and may also have coexisting renal failure.

Elders left in the same position for an extended period of time may be at risk for rhabdomyolysis. Additional problems may exist due to failure to administer usual medications at home. These issues should all be addressed during the ED visit, including the ability to conduct activities of daily living, such as meal preparation, housework, bathing, dressing oneself, toileting, and managing finances.

Psychological problems brought on by abuse, as well as preexisting psychiatric conditions and substance abuse, should also be addressed. The severity of the problem and planned disposition can affect the extent to which treatment is completed in the ED. For patients requiring hospitalization, concerns and findings should be communicated to the admitting service and documented in the medical record. For patients who are discharged to home, arrangements should be made for appropriate follow-up. Follow-up must be arranged for the patient's medical and psychiatric needs, and arrangements must also be made for monitoring and assessment of home safety and assessment of caregiver stress or substance abuse. A variety of resources are available to assist with these issues (Table 295-5). Social work consultation can be helpful in finding local resources.


Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.


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Question 1 of 1

A 42-year-old African-American man has been diagnosed with hypertension for the past 10 years and treated with medication. One morning, he is found unresponsive by his wife. He is taken to the emergency department and pronounced dead by the physician. An autopsy revealed cardiac hypertrophy and a narrowing of the aorta just distal to the ligamentum arteriosum, with dilation of the intercostal artery's ostia. How could the death have possibly been prevented?



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