Eric Mercier: Elder Abuse in the Emergency Department


Elders are proportionately the highest consumers of emergency department (ED) care.(1) With the population ageing in an unprecedented way, ED physicians need to recognize and adequately intervene on geriatric specific conditions. For instance, elder abuse is a geriatric condition that is insufficiently and inadequately addressed by current ED clinical care. ED physicians are frequently confronted to confirmed or suspected cases of elder abuse and, as of now, it remains one of the most under-recognized and under-reported condition.(2-4)

Elder abuse is defined as an action or negligence against a vulnerable older adult that causes harm or risk of harm, either committed by a person in a relationship with an expectation of trust or when an older person is targeted based on age or disability.(5). Elder abuse is surprisingly frequent although good prevalence data are scant.(6) Epidemiologic surveys from Canada and USA in community-dwelling elders have shown abuse rate ranging from 7.6 to 10%.(7-11) These numbers likely represent under-estimation, as patients needed to self-report their situation making demented patients unable to answer while dementia is a known strong risk factor to be a victim of abuse.(12) Numbers as high as 33% have been reported in the medical literature.(13, 14) A recent systematic review highlighted that 11% and 19% of demented patients are victim of domestic physical and psychological abuse, respectively.(15)


ED is a unique environment that provides unequal opportunity to identify and intervene on many vulnerable populations such as elders at risk or victims of abuse.(2) Geriatric patients who are victims of abuse are more prone to use ED and are less likely to have regular medical follow-up. ED is often their only interfacing with formal health-care services(2) and their needs exceed their primary presenting problem.(16) In the context of time pressure to assess, diagnose and treat, increased awareness and development of easy, applicable and rapid screening tools are cornerstone of success. ED healthcare providers often feel poorly equipped to intervene and the training seems insufficient.(5) Therefore, the importance of appropriate training(17, 18) and the use of a multidisciplinary approach involving emergency medicine services (EMS), ED physicians, research assistants and nurses are increasingly recognised.(5, 19)

Accurate ED epidemiologic data are difficult to obtain. Although not easily quantified, it is estimated that only 5 % of elder abuse cases are recognized and less than 2% are reported by ED physicians.(20) Therefore, only a few ED cases are reported to the proper law authorities.(21)

Research on elder abuse is charged with methodological challenges including strong legal and ethical aspects. Cases of elder abuse are often complex and can be highly confronting to clinicians.(22) Initial presentation involves a large range of behaviours and varies widely from trivial physical injury to psychological distress, malnourishment and life-threatening conditions. Moreover, the consequences of abuse extend well beyond the immediate traumatic injury and carry significant morbidity. For instance, abuse has been linked to long-term debilitating psychological effects that include, but are not limited to, anxiety, depression and suicidal ideation.(23, 24) Elders victim of abuse are also at increased risk of hospitalisation(25) and long-term facility placement.(26) Furthermore, they are at increased risk of death compared with other individual presenting similar demographic characteristics and chronic physical health disorders.(27-29) Unfortunately, delay in recognising this condition has detrimental effect on the patient’s quality of life. Frequently, recognition is difficult as comorbid conditions such as dementia and dependency to the abuse perpetrator contribute to this hidden phenomenon with poor prognosis.

A precise characterisation and specific Canadian ED point-of-view of elder abuse is essential to guide and optimise patient’s care. The emergency physician caring for geriatric patients will encounter an elder victim of abuse on a regular basis.. Fortunately, elder abuse has recently been identified as one of the geriatric research priority(30, 31) and it is becoming an increasingly prominent concern for the whole society.(32)


  1. Scoping review of elder abuse in the ED
  • Objective: To describe the epidemiology, risk factors, clinical presentation, screening tools, prevention and interventions regarding elder abuse in the emergency department.
  • Methods: Systematic scoping review of the literature
  • Timeline: Expected to be completed by March 2018
  1. Epidemiology and ED attendances
  • Objectives: i) To describe the characteristics of geriatric patients who are victims of abuse at home as self-reported during a home care assessment; ii) To describe the frequency of ED attendances and the ED discharge diagnosis of geriatric patients who are victims of abuse at home as self-reported during a home care assessment; iii) To describe the current and the trends on elder abuse reporting in the SCHIRPT database
  • Methods: Databases survey (CIHI, InterRAI, CHIRPP), cohort and case-control studies
  • Timeline: Expected to be finished by December 2018
  1. What is next? How?



  1. Gruneir A, Silver MJ, Rochon PA. Emergency department use by older adults: a literature review on trends, appropriateness, and consequences of unmet health care needs. Medical care research and review : MCRR. 2011;68(2):131-55.
  2. Phelan A. Elder abuse in the emergency department. International emergency nursing. 2012;20(4):214-20.
  3. Bond MC, Butler KH. Elder abuse and neglect: definitions, epidemiology, and approaches to emergency department screening. Clinics in geriatric medicine. 2013;29(1):257-73.
  4. Stevens TB, Richmond NL, Pereira GF, Shenvi CL, Platts-Mills TF. Prevalence of nonmedical problems among older adults presenting to the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2014;21(6):651-8.
  5. Rosen T, Hargarten S, Flomenbaum NE, Platts-Mills TF. Identifying Elder Abuse in the Emergency Department: Toward a Multidisciplinary Team-Based Approach. Annals of emergency medicine. 2016;68(3):378-82.
  6. Lachs MS, Pillemer KA. Elder Abuse. The New England journal of medicine. 2015;373(20):1947-56.
  7. Laumann EO, Leitsch SA, Waite LJ. Elder mistreatment in the United States: prevalence estimates from a nationally representative study. The journals of gerontology Series B, Psychological sciences and social sciences. 2008;63(4):S248-S54.
  8. Brozowski K, Hall DR. Aging and risk: physical and sexual abuse of elders in Canada. Journal of interpersonal violence. 2010;25(7):1183-99.
  9. Burnes D, Pillemer K, Caccamise PL, Mason A, Henderson CR, Jr., Berman J, et al. Prevalence of and Risk Factors for Elder Abuse and Neglect in the Community: A Population-Based Study. Journal of the American Geriatrics Society. 2015;63(9):1906-12.
  10. Peterson JC, Burnes DP, Caccamise PL, Mason A, Henderson CR, Jr., Wells MT, et al. Financial exploitation of older adults: a population-based prevalence study. Journal of general internal medicine. 2014;29(12):1615-23.
  11. Amstadter AB, Begle AM, Cisler JM, Hernandez MA, Muzzy W, Acierno R. Prevalence and correlates of poor self-rated health in the United States: the national elder mistreatment study. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2010;18(7):615-23.
  12. Dong X, Chen R, Simon MA. Elder abuse and dementia: a review of the research and health policy. Health affairs (Project Hope). 2014;33(4):642-9.
  13. Wiglesworth A, Mosqueda L, Mulnard R, Liao S, Gibbs L, Fitzgerald W. Screening for abuse and neglect of people with dementia. Journal of the American Geriatrics Society. 2010;58(3):493-500.
  14. Cooper C, Selwood A, Blanchard M, Walker Z, Blizard R, Livingston G. Abuse of people with dementia by family carers: representative cross sectional survey. BMJ (Clinical research ed). 2009;338:b155.
  15. McCausland B, Knight L, Page L, Trevillion K. A systematic review of the prevalence and odds of domestic abuse victimization among people with dementia. International review of psychiatry (Abingdon, England). 2016:1-10.
  16. Bridges J, Meyer J, McMahon K, Bentley J, Winter J. A health visitor for older people in an accident and emergency department. British journal of community nursing. 2000;5(2):75-80.
  17. Snider T, Melady D, Costa AP. A national survey of Canadian emergency medicine residents’ comfort with geriatric emergency medicine. Cjem. 2016:1-9.
  18. Hogan TM, Losman ED, Carpenter CR, Sauvigne K, Irmiter C, Emanuel L, et al. Development of geriatric competencies for emergency medicine residents using an expert consensus process. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2010;17(3):316-24.
  19. Phelan A. Elder abuse and neglect: the nurse’s responsibility in care of the older person. International journal of older people nursing. 2009;4(2):115-9.
  20. Rosenblatt DE, Cho KH, Durance PW. Reporting mistreatment of older adults: the role of physicians. Journal of the American Geriatrics Society. 1996;44(1):65-70.
  21. Mosqueda L, Burnight K, Gironda MW, Moore AA, Robinson J, Olsen B. The Abuse Intervention Model: A Pragmatic Approach to Intervention for Elder Mistreatment. Journal of the American Geriatrics Society. 2016.
  22. DeLiema M, Homeier DC, Anglin D, Li D, Wilber KH. The Forensic Lens: Bringing Elder Neglect Into Focus in the Emergency Department. Annals of emergency medicine. 2016;68(3):371-7.
  23. Wu L, Shen M, Chen H, Zhang T, Cao Z, Xiang H, et al. The relationship between elder mistreatment and suicidal ideation in rural older adults in China. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2013;21(10):1020-8.
  24. Hybels CF, Blazer DG. Epidemiology of late-life mental disorders. Clinics in geriatric medicine. 2003;19(4):663-96, v.
  25. Dong X, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA internal medicine. 2013;173(10):911-7.
  26. Lachs MS, Williams CS, O’Brien S, Pillemer KA. Adult protective service use and nursing home placement. The Gerontologist. 2002;42(6):734-9.
  27. Schofield MJ, Powers JR, Loxton D. Mortality and disability outcomes of self-reported elder abuse: a 12-year prospective investigation. Journal of the American Geriatrics Society. 2013;61(5):679-85.
  28. Dong X, Simon M, Mendes de Leon C, Fulmer T, Beck T, Hebert L, et al. Elder self-neglect and abuse and mortality risk in a community-dwelling population. Jama. 2009;302(5):517-26.
  29. Lachs MS, Williams CS, O’Brien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. Jama. 1998;280(5):428-32.
  30. Carpenter CR, Heard K, Wilber S, Ginde AA, Stiffler K, Gerson LW, et al. Research priorities for high-quality geriatric emergency care: medication management, screening, and prevention and functional assessment. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2011;18(6):644-54.
  31. Houry D, Cunningham RM, Hankin A, James T, Bernstein E, Hargarten S. Violence prevention in the emergency department: future research priorities. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2009;16(11):1089-95.
  32. Mandiracioglu A, Govsa F, Celikli S, Yildirim GO. Emergency health care personnel’s knowledge and experience of elder abuse in Izmir. Archives of gerontology and geriatrics. 2006;43(2):267-76.

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