Phys · geriatric
Elder Abuse and Safeguarding
Also known as elder mistreatment · elder neglect · abuse of older adults · safeguarding older people · financial exploitation of elders · carer abuse · institutional elder abuse · EASI · Elder Abuse Suspicion Index · Hwalek-Sengstock · HSEAST · adult safeguarding
Consultant-physician-depth guide to elder abuse and safeguarding for FRACP DWE and DCE — WHO definition, the six types of abuse (physical, psychological, financial, sexual, neglect, discriminatory), the 1-in-6 prevalence and severe underreporting, risk factors (dementia, carer stress, social isolation), the red flags of abuse, the EASI and Hwalek-Sengstock screening tools, the interview-alone principle, capacity assessment, mandatory reporting by jurisdiction, legal interventions (AVO, tribunal guardianship, financial management), support services, and the ethical balance of autonomy versus protection.
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Red flags
- Unexplained injuries, injuries in unusual distributions (inner thighs, axillae, neck), or injuries inconsistent with the given history — always interview the patient alone
- Delayed presentation for an injury or illness that should have been treated earlier — the carer may be concealing evidence
- A carer who refuses to leave the room during the interview, insists on answering for the patient, or displays controlling behaviour — this is itself a red flag
- Pressure injuries in a mobile patient, severe malnutrition, poor hygiene or over-sedation in a person supposedly receiving care — suggests neglect
- Sudden unexplained changes to a will, power of attorney or property title, or unexplained withdrawals — financial abuse is the most under-recognised type
- An older person with dementia who is afraid of a specific carer, flinches on examination, or becomes withdrawn and non-communicative in the carer's presence
Elder Abuse and Safeguarding
The answer first
Elder abuse is a single or repeated act — or a failure to act — within a relationship of trust, that harms an older person (WHO, Toronto Declaration 2002). The perpetrator is almost always someone the older person depends on — an adult child, a spouse, a paid carer, or a person holding a power of attorney. It is vastly under-recognised: about 1 in 6 older people in the community have experienced it, yet only an estimated 1 in 24 cases ever reaches the authorities.[1]
Four rules govern your response. First, always interview the patient alone — if the carer is in the room, the patient will not disclose, and this is the single most commonly missed step. Second, assess capacity first — a capacitous person may refuse help, however unwise that seems. Third, ensure immediate safety — admission or relocation is justified if the danger is imminent. Fourth, report and refer — know your jurisdiction, involve social work early, and document meticulously, because your notes may become the evidence.[1]
The classic trap: when asked "the most appropriate initial step in suspected elder abuse," the answer is almost always interview the patient alone and assess capacity — not "call the police" or "contact the family." A structured multidisciplinary safeguarding response follows once safety and capacity are established.[1]
References7ShowHide
- [1]Yon Y, Mikton CR, Gassoumis ZD, Wilber KH Elder abuse prevalence in community settings: a systematic review and meta-analysis Lancet Glob Health, 2017.PMID 28104184
- [2]Yaffe MJ, Wolfson C, Lithwick M, Weiss D Development and validation of a tool to improve physician identification of elder abuse: the Elder Abuse Suspicion Index (EASI) J Elder Abuse Negl, 2008.PMID 18928055
- [3]Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study Am J Public Health, 2010.PMID 20019303
- [4]Lachs MS, Williams CS, O'Brien S, Pillemer KA, Charlson ME The mortality of elder mistreatment JAMA, 1998.PMID 9701077
- [5]Pillemer K, Burnes D, Riffin C, Lachs MS Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies Gerontologist, 2016.PMID 26994260
- [6]Lachs MS, Pillemer K Elder abuse Lancet, 2004.PMID 15464188
- [7]Appelbaum PS Clinical practice. Assessment of patients' competence to consent to treatment N Engl J Med, 2007.PMID 17978292