Emergency physicians (EPs) are trained to recognize and treat conditions that most severely affect patients at the extremes of age. For decades, the recognition and management of child neglect and abuse has been part of emergency medicine (EM) residency training and most states now require physicians to complete a child abuse course for licensing. In this issue, “Recognizing and Managing Elder Abuse in the Emergency Department” by Rosen et al describes abuse at the other age extreme. The thorough discussion following an illustrative case presentation raises serious concerns that the occurrence of elder neglect and abuse may be increasing in frequency in a rapidly aging population.
Child abuse and elder abuse share several common features along with some notable differences. When a member of either age group presents to the ED with fractures and/or soft tissue injuries, EPs must maintain a high index of suspicion for abuse, obtain a carefully directed history, and be able to recognize the characteristic patterns of injury. Hallmarks of both child abuse and elder abuse include a history provided by the caregiver that is not consistent with the actual injuries; an often-unobtainable independent history from an infant or baby not yet able to speak or an older adult with dementia; and a physical exam revealing bruises in areas that are not over bony prominences. A radiographic skeletal survey may show multiple fractures in various stages of healing, and laboratory testing may reveal nutritional evidence of neglect, medication over- or underdosing, or the presence of medications that have not been prescribed for the patient.
Patterns of abuse injuries in the two age groups differ. As noted by Colbourne and Clarke in Tintinalli’s Emergency Medicine (8th ed, p. 1001), nonaccidental bruises in children are more common on the torso, neck, ears, cheeks, buttocks, and back; appear in clusters; are frequently symmetrical; and tend to be larger and more numerous than accidental injuries. Hand or implement patterns on the skin may be observed. Rib and metaphyseal fractures are unusual in children, as are all fractures at a very young age.
In the midst of an epidemic of elderly fall injuries, abuse injuries, as described in the pages ahead, most commonly occur on the head, neck, and upper extremities, and include large bruises on the face, lateral arm, or posterior torso. Based on preliminary results from an ongoing study, left periorbital, neck, and ulnar forearm injuries appear to be particularly indicative of abuse rather than accidental. An elderly person may be abused by an adult-child or relative living in the same household attempting to gain control over the victim’s wealth or residence.
Interventional resources required for both types of abuse, as well as for intimate partner abuse, are also similar and include safe facilities for extended treatment and separation from a suspected abuser; hospital security, legal, and administrative support; social services; law enforcement; psychiatric evaluation of adult capacity; and child or adult protective services, which, as Rosen et al note, operate very differently from one another. All states, except one, now require reporting of both child abuse and elder abuse.*
None of these comparisons of child abuse and elder abuse are meant to suggest equivalency—moral or otherwise. Children are not “little adults,” and the frail elderly are not truly “child-like.” Each incident of a child “slipping through the cracks” of the protective measures currently in place underscores the need for sufficient resources to deal with child abuse alone, and an increasing number of elder abuse cases should not compete with these needs. But implementing greater awareness, preventive measures, and physical and human resources to address these problems at both extremes of age cannot be put off for the future.
When I started the first geriatric emergency medicine fellowship in the country in 2005, elder abuse was not even on my radar screen. Now it must be considered a serious and growing problem by all.
*New York State alone does not require reporting of elder abuse.