Tarnished Golden Years

There is no single group or population that is immune from being abused, but one set of people that are at particularly high risk are the elderly. Elder abuse is the intentional mistreatment of an older person by an individual with whom they have an established relationship. The perpetrators of these crimes then are not some random stranger, but rather someone who the elderly person knows like a hired caregiver, a spouse, a partner, a family member, a friend, or a neighbor. Sadly, the most common offender in these cases are adult children or spouses.

It is estimated that approximately 1 in 10 Americans over the age of 60 experience some form of elder abuse, and only 1 in 14 of those cases will ever be reported. A recent report found that nearly half of all elderly individuals who suffer from dementia will be victims of abuse.

EMS professionals, due to the fact that they have access to people’s homes and can witness an individual’s living conditions and observe how they interact with their caregivers, are in a unique position to observe, report, and prevent further elder abuse.

Health Consequences

The health consequences of elder abuse are serious and have a wide-ranging effect on their quality of life. Due to their age and presence of other medical conditions, regaining this lost quality of life for victims of elder abuse is frequently very difficult. Some of these health consequences include:

  • Loss of functional abilities
  • Learned helplessness
  • Increased sense of helplessness and stress
  • Posttraumatic stress disorder (PTSD)
  • Sleep disturbances
  • Psychological decline
  • Exacerbation of preexisting health conditions
  • Increased susceptibility to new illnesses
  • Malnutrition
  • Bed sores
  • Increased risk of premature death

Forms of Elder Abuse

Elder abuse can take many different forms. These include the following:

  • Physical abuse: This includes such active forms of abuse as hitting, kicking, burning, and restraining someone and passive forms of abuse like withholding food or required medications.
  • Emotional abuse: This can involve verbal forms like yelling, insulting, mocking, criticizing, and blaming as well as non-verbal forms like shunning, silence, refusing to acknowledge them, and the withdrawal of affection.
  • Sexual abuse: This would involve forcing someone to take part in a sexual activity or a conversation of a sexual nature without their consent. This would also include sexual situations where the elderly individual was not capable of giving consent like in cases of dementia.
  • Financial abuse: This would encompass both exploiting an elderly individual for financial gain and also the use of financial control to enable other forms of abuse.
  • Neglect: This is the most common form of elder abuse and occurs when the elderly individual is denied appropriate medical treatment, food, clothing, heat, accommodations, or other needed services. This would also include leaving an at-risk elderly individual without proper supervision. Passive neglect occurs when the neglect is unintentional, while active neglect occurs as a result of intentional actions on the part of the abuser.

Signs of Elder Abuse

The patient assessment is used by EMS personnel to determine the type and extent of an injury, but it is also an opportunity to look for indications of elder abuse. Each of the different types of elder abuse that were previously listed, have their own unique physical and behavioral signs.

Physical Abuse:
  • Bruises in unusual areas like the inner arm or thigh
  • Bilateral or circumferential arm bruising that might be the result of being grabbed, shaken, or restrained
  • Wounds in various stages of healing
  • Burns from hot water or cigarettes
  • Recurring injuries to the same area
  • Traumatic hair or tooth loss

Emotional Abuse:
  • Is suspicious towards caregivers
  • Is unwilling to answer questions
  • Avoids talking about the care they receive

Sexual Abuse:
  • Bruises in unusual areas like the inner arm or thigh
  • Bleeding, pain, or irritation in the anal or vaginal area
  • Torn, stained, or bloodied underwear
  • A sexually transmitted disease

Financial Abuse:
  • Sudden changes in financial situations

Neglect:
  • Decreased skin turgor as a result of dehydration
  • Poor personal hygiene and grooming
  • Soiled clothing or bedding
  • Clothing not appropriate to the weather or the season
  • Emaciation
  • Sunken eyes
  • Intoxication
  • Withdrawal
  • Bed sores
  • Thirst and hunger

Risk Factors

There are many risk factors that increase the chance that an elderly individual will become a victim of elder abuse. Knowing and understanding these various risk factors can help aid an EMT in recognizing when elder abuse is occurring. An elderly person is at a higher risk of suffering abuse if they:

  • Have memory problems
  • Have a physical handicap
  • Suffer from depression
  • Lack social support
  • Are an alcoholic or abuse other substances
  • Are verbally or physically combative with their caregiver
  • Have a shared living situationn

There is also a combination of risk factors that can increase the likelihood that a caregiver will participate in elder abuse. These factors can be grouped into individual, relationship, and community categories.

Individual Risk Factors:
  • Mental illness
  • Alcoholism
  • High levels of stress or hostility
  • Anger management problems
  • Poor training as a caregiver
  • Poor coping skills
  • Previous history of being abused

Relationship Risk Factors:
  • Being financially and emotionally dependent on the elderly individual
  • Lack of social or formal support
  • Previous conflict with the elderly individual

Community Risk Factors:
  • Limited, inaccessible, or unavailable formal services for the elderly

Behavior

In addition to knowing the various risk factors, knowing the typical behavior of both the abused and the abuser in cases of suspected elder abuse can help you recognize when these tragic situations are happening. The following are some of the behaviors that an elderly individual being abuse may exhibit but remember, abuse can also exist in the absence of these behaviors:

  • Multiple “accidental” injuries
  • Appearing isolated or signs of depression
  • Looking afraid
  • A history of alcohol or substance abuse
  • Presents as a “difficult” patient
  • Has non-specific and chronic complaints
  • Delay in seeking medical help

Some of the behaviors that someone abusing an elderly person may exhibit includes the following:

  • Attempt to convince you that the elderly person is incompetent, untrustworthy, or crazy
  • Is overly attentive, friendly, or charming to EMS
  • Attempts to answer all questions directed at the elderly individual
  • Refuses to let the elderly person be interviewed without them being present
  • Talks about the elderly individual as if they were not there
  • Controls the elderly person’s activities and outside contacts
  • Cancels the elderly person’s medical appointments

Documentation and Reporting

As in all cases, if you did not document it, then it did not happen. Creating an objective and comprehensive patient care report is a critical component when it comes to a future investigation of elder abuse. The following are some general guidelines to follow when documenting known or suspected elder abuse:

  • Document factual observations of the scene including things like the patient’s living conditions and hygiene.
  • Do not offer your opinion on what you believe happened or who is at fault.
  • Do not speculate of the cause or age of injuries.
  • Use quotation marks to denote when you are recording the patient’s own words and keep them in the context in which they were said
  • Report any family members, caregivers, or EMS personnel present during the assessment.
  • Report the names of any agencies that were contacted and when they were contacted. This includes agencies like adult protective services and any branches of law enforcement.
  • If the elderly individual is transported to a medical facility, include the names of the staff to whom you reported the known or suspected elder abuse.
  • Do not use the terms “abuse”, “abuser”, or “victim” when documenting your encounter as they suggest blame or fault.


Because EMS professionals have access to people’s homes and can witness firsthand an individual’s living conditions and how they interact with their caregivers, you are in unique position to observe elder abuse. In the vast majority of states, EMS personnel are mandated reporters and therefore have a legal obligation to report suspected or known cases of elder abuse. In some states, abuse reports can be submitted to a statewide elder abuse hotline or to a local adult protective services agency. You should know and follow your state and local protocols regarding your requirements to report elder abuse and who should receive those reports.

Sources & More Information

Centers for Disease Control and Prevention, “Elder Abuse” https://www.cdc.gov/violenceprevention/elderabuse/index.html

EMS World, “Geriatric Abuse” https://www.emsworld.com/article/10319448/geriatric-abuse

EMS World, “How EMS Can Recognize and Report Elder Abuse” https://www.emsworld.com/news/12343499/how-ems-can-recognize-and-report-elder-abuse

Journal of Emergency Medicine, “Emergency Medical Services Perspectives on Identifying and Reporting Victims of Elder Abuse, Neglect, and Self-Neglect” https://www.ncbi.nlm.nih.gov/pubmed/28712685
By Jeremiah Johnson, MD

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