Assessing Patients for
Signs of Elder
Mistreatment
Module 7
Nursing Responses to Elder Mistreatment
An IAFN Education Course
1
Learning Objectives

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Discuss steps of assessment for elder
mistreatment (EM)
Recognize signs in cases of neglect,
physical abuse, emotional/psychological
mistreatment, sexual abuse,
abandonment, financial exploitation and
violation of personal rights
2
Case Study: Mrs. Amos

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What are the signs of potential
mistreatment in this case?
What is the nurse’s role in this
situation? What else does she need to
do?
3
Assessment Steps
Identify
 Evaluate
 Document
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4
Identification through…
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Physical examination
Discussions with patients,
family members and caregivers
Review of medical records
5
Evaluation Considerations
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Patient issues and circumstances
that influence findings
Implausible explanations and
inconsistencies regarding history of
injury and illness
Whether nature of signs agree with
what patient, family members
and/or caregiver tell you
6
Documentation



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Thorough
Accurate
Objective
In accordance with agency policy
7
General Assessment Approach
AMA’s Diagnostic and Treatment Guidelines for Elder
Abuse and Neglect (1992)
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Safety
Access to Patient
Cognitive Status
Emotional Status
Health and Functional Status
Social and Financial Resources
Frequency and Severity
o
Assessing for intent is not nurses’ duty.
8
Signs of Neglect
Return to Case of Mrs. Amos:

What are some of the signs of
neglect you identified in this case?
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Signs of Neglect
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Poor hygiene
Malnutrition
Dehydration
Inadequate medical care
o
o
o
o
Absence of physical aids
Over/under medication
Contractures
Pressure ulcers, untreated
Source for Photo: The John A. Hartford Foundation
Institute for Geriatric Nursing, New York University,
College of Nursing. Photography by James Schuck.
or under-treated
Adapted from T. Fulmer, G. Paveza, I. Abraham & S. Fairchild,
Elder neglect assessment in the emergency department, Journal
of Emergency Nursing, 2000
10
Stage 1 Pressure Ulcer
Intact skin with non-blanchable
redness of a localized area usually
over a bony prominence
Darkly pigmented skin may not
have visible blanching; its color
may differ from the surrounding
area
Area may be painful, firm, soft,
warmer or cooler as compared to
adjacent tissue
 Stage I may be difficult to
detect in individuals with dark skin
tones
May indicate "at risk" persons (a
heralding sign of risk)
Slide 11-15 from National Pressure Ulcer Advisory Panel's Updated Pressure Ulcer Staging System, 2007,
in M. Baker, The Scope and Consequences of Elder Mistreatment: The Tip of the Iceberg (handouts from presentation),
Northwest Geriatric Education Center Geriatric Health Promotion Series, University of Washington. Seattle, WA; March 2010
11
Stage 2 Pressure Ulcer
 Partial thickness loss of
dermis presenting as a
shallow open ulcer with a
red or pink wound bed,
without slough
 May also present as an
intact or open/ruptured
serum-filled blister
 Presents as a shiny or
dry shallow ulcer without
slough or bruising
12
Stage 3 Pressure Ulcer

Full thickness tissue loss
 Subcutaneous fat may be
visible but bone, tendon or
muscle are not exposed
 Slough may be present but
does not obscure the depth of
tissue loss
 May include undermining and
tunneling
Depth of a Stage III
pressure ulcer varies by
anatomical location
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Stage 4 Pressure Ulcer
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Full thickness tissue loss with
exposed bone, tendon or muscle
Slough or eschar may be present
on some parts of the wound bed
Often include undermining and
tunneling
The depth of a Stage IV pressure
ulcer varies by anatomical location
Stage IV ulcers can extend into
muscle and/or supporting
structures (e.g., fascia, tendon or
joint capsule) making osteomyelitis
possible
Exposed bone/tendon is visible or
directly palpable
14
Unstageable Pressure Ulcers

Full thickness
tissue loss in which
the base of the
ulcer is covered by
slough (yellow, tan,
gray, green, or
brown) and/or
eschar (tan, brown,
or black) in the
wound bed
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Signs of Neglect

Emotional/psychological
o
o
o
o
o
Withdrawal
Depression
Agitation
Infantile behavior
Ambivalent feelings toward family
members or caregivers
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Signs of Physical Abuse
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Context and location of injuries critical
Injuries in various stages of healing
may indicate abuse
Hidden injuries typical of abuse
Abuse tends to be central, accidents
distal
California District Attorneys Association, CDAA elder physical and sexual abuse:
The medical piece, part 1 & 2 (Learning point summaries template), 2003
17
Bruising
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A bruise, or contusion, occurs when
blunt forces distort soft tissues to
an extent sufficient to result in
disruption and leakage of blood
vessels
Escape of blood from blood vessels
produces discoloration
P. Besant-Matthews, Blunt and sharp injuries, in V. Lynch, Forensic nursing, 2006
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Bruising in Geriatric Pop.
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2009 study by A. Wigglesworth, R. Austin, M. Corona, D. Schneider, S. Liao, L. Gibbs, and L. Mosqueda,
Bruising as a Marker of Physical Elder Abuse, Journal of the American Geriatric Society
o
o
Physically abused older adults had significantly
larger bruises than those in comparison group who
were not abused and more knew the cause of their
bruises
Physically abused older adults more likely to have
bruises on face, lateral aspect of right arm and
posterior torso than older adults from an earlier
study who had not been abused
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Bruising in Geriatric Pop.
Earlier study
Nearly 90% of bruises on extremities
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Not a single accidental bruise
observed was on neck, ears, genitalia,
buttocks or soles of feet
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Of 20 large bruises in this study, only
one was on trunk
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Older adults are significantly more
likely to know how the bruise
happened if it is on the trunk
L. Mosqueda, K. Burnight & S. Liao, Bruising in the geriatric
population, 2006, as cited in Baker
20
Patterned Injury

An injury that possesses features or
configuration with objects or
surfaces that produced it
W. Smock, Forensic emergency medicine,
in J. Olshaker, M. Jackson and W. Smock (Eds.), Forensic emergency medicine, 2001
21
Patterned Injury
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Grip marks around arms or neck
Rope marks or welts on wrists or
ankles
Imprints from belts, belt
buckles, straps, cords, hangers,
hairbrushes, combs, cigarettes
and cigarette lighters
Handprints, fingerprints,
knuckle prints and footprints
o
o
More on strangulation…
More on burns…
22
Fracture
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Broken bones
Includes severing of the bone or
compression of intact bone
C. Bitondo Dyer, M. Connolly & P. McFeeley,
The clinical and medical forensics of elder abuse and neglect,
in R. Bonnie & R. Wallace, Elder mistreatment, abuse, neglect and exploitation in an aging America, 2003
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Avulsion
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The tearing away of a structure
or part; often seen as a partial
avulsion
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Abrasion
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A wound in which the
outermost layer of the skin
is removed by a
compressive or sliding
force
Besant-Matthews
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Laceration
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Blunt force injuries resulting from tearing,
ripping, crushing, overstretching, pulling
apart, bending and shearing soft tissue.
Lacerations are usually found over a bony
surface and are ragged or irregular in
appearance
Besant-Matthews
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Incision
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Incision, known as a cut, is a wound
made by a sharp instrument or
object, such as a scalpel, knife, razor
or paper coming against the skin with
pressure to cause an injury
Besant-Matthews
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Stab Wound
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Result whenever a sufficiently sharp
and narrow object is forced upward
Unlike a cut, depth exceeds width in
stab wounds
Besant-Matthews
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Mechanical Restraints
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Means of controlling behavior,
especially in hospitals and nursing
facilities
Only acceptable reason for
temporarily restraining someone is to
prevent significant harm
B. Knight (Ed.), Simpson’s forensic medicine (11 ed.), 1997
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Emotional/Psychological Abuse

Feelings and behaviors associated with
emotional/psychological abuse may not
be obvious at time of assessment—
have to ask questions

Same flags may also be reactions to
other types of mistreatment
30
Sexual Abuse
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During assessment of a vulnerable
older adult who has been sexually
abused, what injuries, behaviors and
evidence might the nurse describe?
For nurse, what are some important
things to consider, questions to ask and
next steps to take when she suspects
sexual abuse?
31
Signs of Sexual Abuse
Examples of physical signs
 Bruising, inflammation, tenderness,
abrasions or trauma around the breast or
anogenital area
 Unexplained venereal disease or genital
infections
 Unexplained vaginal or anal bleeding
 Torn, stained or bloody underclothing
May/may not be obvious physical signs
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Assessing Sexual Abuse
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Refer to sexual assault forensic examiners
Type of sexual victimization suspected will
influence what is assessed
Ask when last known sexual contact occurred
Care of acute injuries and patient safety a
priority over evidence collection
Cooperation of the patient needed for exam
Preserve bodily evidence
33
Financial Exploitation, Abandonment,
Violation of Personal Rights
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What are your experiences with vulnerable older
adults who have been financially exploited? What
are questions a nurse can ask to find out about
possible financial exploitation?
What are your experiences with vulnerable older
adults who have been abandoned? What are
questions a nurse can ask to find out about possible
abandonment?
What are your experiences with vulnerable older
adults who have had their rights violated? What
are questions a nurse can ask to find out about
possible violation of personal rights?
34
Abandonment

In addition to an actual complaint by older person of
being deserted, signs of possible abandonment include:
o A vulnerable older adult with cognitive and physical
impairments is left at a hospital emergency
department without caregiver contact information
o A vulnerable older adult with cognitive impairments is
put on a bus with a one-way ticket to another town or
state
o A vulnerable older adult with cognitive impairments is
left at a public building
B. Brandl, C. Bitondo Dyer, C. Heisler, J. Marlatt Otto, L. Stiegel & R. Thomas, Elder abuse detection and intervention: A
collaborative approach, 2007
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Financial Exploitation
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Not always obvious—question for more info
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Examples:
o
o
o
o
o
o
Denying the vulnerable older adult a home
Stealing a vulnerable older adult’s money or possessions
Coercing a vulnerable older adult into signing contracts or
assigning power of attorney
Purchasing goods with a vulnerable older adult’s money for
personal gain
Coercing a vulnerable older adult into making changes in
his/her will
When a person entrusted to care for a vulnerable older adult
fails to use available resources necessary to sustain/restore
health and well-being of person
Baker
36
Violation of Rights
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Not always obvious—question for more info
Examples
o
o
o
o
Denial of older adult’s right to privacy
Not allowing older adult to make own decisions
regarding health care or personal matters
Restricting interactions with others
Forcible eviction and/or placement in a nursing
home
Elder abuse and neglect for EMS, EMSTopics.com, 2007
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