How American Emergency Departments Are Missing Older Adult Abuse

A recent report in the Journal of the American Geriatric Society (JAGS) suggests that emergency departments (EDs) have opportunities to improve how they identify cases of older adult abuse and how they support these victims. The report, “Injury patterns and demographics in older adult abuse and falls: A comparative study in emergency department settings,” shares findings of an analysis of 15 years of data from the National Electronic Injury Surveillance System (NEISS) All Injury Program (2005–2019).

Researchers found an estimated 307,237 ED visits for older adult abuse and 39,477,217 ED visits for falls. They found that older adults experiencing abuse tended to be younger than those experiencing falls. They also had lower rates of admission to the hospital following their ED visits.

The study’s authors assert that the lower rates of admission indicate “the need for proactive identification and support in the emergency departments.” What’s more, they make a case that the inverse relationship between age and reporting of abuse points to complex challenges related to the disclosure and reporting of abuse.

Older Adult Abuse: Obstacles to Disclosure and Reporting

By nature, EDs tend to be chaotic environments. Levels of health literacy can vary widely among older patients, and for those with impairments in vision, hearing, and/or cognition, even basic communication can be difficult. Victims of interpersonal abuse may feel overwhelmed and afraid that reporting violence could lead to retaliation and an increasing cycle of abusive behavior. That, in turn, could decrease their willingness to be forthright about the source of their injuries.

The study’s findings suggest that there are challenges among clinicians, as well. For starters, these patients may have overlapping symptoms and co-morbidities that make it difficult to identify potential abuse. What’s more, many clinicians haven’t received specialized training about abuse of older adults—and their hospitals may not have well-defined identification protocols. Age-related biases can also come into play, with up to 60% of physicians having never asked older patients about abuse, according to the report. Even when clinicians have suspicions about what may be happening, they may be uncertain how best to handle it, choosing to focus on the most urgent injuries rather than underlying factors in a patient’s life.

Falls vs. Abuse: Understanding Injury Patterns

The study also analyzed the injuries sustained by older adults from falls as well as interpersonal violence. Those who had fallen were more likely to be admitted to the hospital and sustained the highest percentage of fractures, typically of the cervical spine as well as lower trunk.

The picture is different for abuse victims: “We found that certain injury locations (i.e., face, hand, finger, ribs) and patterns (i.e., contusions, abrasions) were more frequent among patients experiencing abuse and should therefore serve to increase clinical suspicious of older adult abuse in acute care settings.”

The Human Impacts

What follows are fictitious yet realistic ED patient scenarios that illustrate some of the dynamics the study describes:

• A 62-year-old woman arrives with bruises on her face and arms, which she says resulted from a fall at home. She reports pain in her lower legs, but an X-ray confirms there is no fracture. Clinicians dress her wounds, write a prescription to help with her pain, and discharge her.
• A caregiver brings an 87-year-old male to the ED after a fall. It’s the third time the man has fallen while in her care. Given his specific injuries, clinicians are becoming suspicious about what’s happening at home. But memory challenges make it difficult to communicate with him—so they focus on treating the patient’s immediate injuries rather than exploring possible root causes.
• A 69-year-old woman arrives at the ED with cuts and bruises on her face and chest, as well as pain in her shoulder. She starts to confide in the nurse that her significant other hurt her, but amid the noise and confusion, the patient gets flustered and shuts down. She is treated for her injuries and sent home.

Call to Action

\As the report notes, there is no standard care protocol for responding to older adult abuse in the ED. The authors laud the National Collaboratory to Address Elder Mistreatment for developing a free toolkit for hospitals. The toolkit homes in on screening and referral procedures within the ED alongside community support networks to help victims of abuse after they are discharged. 

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