Key Facts

Elder abuse is under-reported and under-recognised. All healthcare professionals have a responsibility to safeguard adults at risk.

Epidemiology

• ~500,000 older people in the UK affected at any time
• Prevalence in community: 2-5%; in care homes: 15-25%
• Financial abuse most common in community; neglect most common in institutions
• Often perpetrated by family members, carers, or paid care staff
• Under-reporting is significant: estimated only 1 in 24 cases reported

Aetiology

• Perpetrator factors: carer stress, mental illness, substance misuse, financial dependence on victim, history of domestic abuse
• Victim factors: dependency, social isolation, dementia/cognitive impairment, physical disability, communication difficulties
• Situational factors: overcrowded living, poor institutional culture, inadequate staffing, lack of training

Pathophysiology

Not a pathological process but a pattern of harmful behaviour. The impact includes:

• Physical injury (fractures, burns, bruising)
• Psychological harm (depression, anxiety, PTSD, withdrawal)
• Financial loss
• Neglect of medical needs
• Death (in severe cases)

Types of Abuse

• Physical: hitting, pushing, restraint, inappropriate medication administration
• Psychological/emotional: threats, humiliation, controlling behaviour, isolation
• Financial: theft, fraud, coercion, misuse of benefits, pressure to change will
• Sexual: any sexual activity without consent (including with patients who lack capacity)
• Neglect: failure to provide adequate food, warmth, medication, hygiene, medical care
• Self-neglect: refusal of care, hoarding, self-harm through neglect (if has needs for care and support)
• Organisational: poor institutional practices, inadequate care, rigid routines
• Domestic abuse: controlling/coercive behaviour by partner or family member

Warning Signs

• Unexplained injuries (bruises in unusual locations, burns, fractures at different stages of healing)
• Withdrawal, fearfulness, or agitation in presence of carer
• Poor hygiene, malnutrition, pressure ulcers in a cared-for person
• Unexplained financial transactions or sudden changes to will
• Frequent A&E attendances
• Inconsistent history between patient and carer
• Patient not allowed to speak alone

Red Flags

• Non-accidental pattern of injuries
• Delay in seeking medical help
• Carer preventing patient from being seen alone
• Signs of restraint (wrist marks)
• Genital/rectal trauma without explanation
• Rapid unexplained weight loss
• Withdrawal of food/drink/medication as punishment

Bedside

• Full examination: skin (bruises, burns, pressure ulcers), nutritional status, hygiene, hydration
• Document injuries: describe precisely (location, size, colour, stage of healing); photograph with consent
• Speak to patient alone (essential)
• Mental capacity assessment: for decisions about safeguarding and information sharing
• Assessment of mood and anxiety
• Nutritional assessment (MUST)

Bloods

• FBC, clotting screen (exclude coagulopathy)
• U&Es (dehydration)
• Albumin (malnutrition)
• Drug levels (if medication abuse suspected — over-sedation or withholding)
• STI screening (if sexual abuse suspected)

Imaging

• X-rays: if fractures suspected
• Skeletal survey: rarely needed in adults (more common in child safeguarding)

Special Tests

• Body map documentation
• Safeguarding referral (Section 42 enquiry)
• Police referral if criminal act suspected
• Social work assessment
• Carer assessment

Non-pharmacological

• Immediate safety: ensure the person is safe; separate from alleged abuser if necessary
• Raise a safeguarding concern: contact local authority adult safeguarding team (regardless of the person's capacity)
• Document thoroughly: clinical notes, body maps, photographs (with consent), chronology
• Involve the patient: discuss concerns with them; obtain their views and wishes (unless doing so would increase risk)
• Consent: seek consent to share information, but override if serious risk of harm
• Multi-agency safeguarding: local authority leads Section 42 enquiry; involves police, social care, health, CQC
• Protection plan: developed by safeguarding meeting; may include changes to care arrangements, legal action, monitoring
• Support for the patient: advocacy, counselling, practical support
• Support for carers: carer assessment, respite, education (if abuse relates to carer stress and patient wishes to remain with carer)

Pharmacological

• Not directly applicable
• Treat physical and psychological consequences of abuse

Surgical/Interventional

• Not applicable

Referral Criteria

• All suspected abuse: raise safeguarding concern with local authority
• Immediate danger: call police (999)
• Organisational abuse: CQC notification (registered provider)
• Complex cases: adult safeguarding board
• Domestic abuse: MARAC (Multi-Agency Risk Assessment Conference) if high risk

• Elder abuse is associated with 2-3× increased mortality
• Depression and anxiety are common consequences
• Financial abuse can have devastating long-term impact
• Early recognition and intervention can prevent escalation
• Organisational abuse can be addressed through systemic changes
• Many victims of elder abuse do not self-report; healthcare professional vigilance is essential

Care Act 2014 — Section 42 Enquiry Criteria

Types of Abuse Summary