Elsevier

Clinics in Dermatology

Volume 36, Issue 2, March–April 2018, Pages 264-270
Clinics in Dermatology

Signs of physical abuse and neglect in the mature patient

https://doi.org/10.1016/j.clindermatol.2017.10.018Get rights and content

Abstract

Neglect and physical abuse of elderly are worrisome health problems, which are expected to grow even further, considering the aging of the population. By 2060, the number of people aged above 65 years is expected to double, whereas birth rates are low. This trend will cause a significant imbalance between different age groups and put more senior adults at risk for abuse. Risk factors, associated with abuse and neglect, are well established and can be categorized in sociodemographic-, victim-, or perpetrator-related risk factors. The effects of these risk factors depend mainly on the setting, which can be community-dwelling or institutionalized older adults. In community-based settings, 90% of perpetrators are family members. In each setting, suspicious physical injuries should be recognized and addressed promptly. This can be very challenging in elderly, among others, due to the age-related skin changes, which can mimic abuse; however, there are some cutaneous clues that should always raise suspicion of abuse, such as patterned shape or distribution, different healing stages of wounds, parallel injuries, signs of blunt trauma, and irregular patches of alopecia. General awareness is needed, and the advice of dermatologists, who are best trained to differentiate between those lesions, should be systematically sought, to reduce false-positive and false-negative interpretations.

Introduction

Physical abuse and neglect in the elderly are serious public health problems, which will become even more visible in the future due to the growing imbalance between different age groups, resulting in an increasing health care burden on informal caregivers. The elder are one of the most vulnerable groups in the general population, mainly due to increasing social isolation and their dependence on caregivers.1 Physical abuse in this fragile population might not be limited to pain and emotional distress but can contribute to morbidity and even lead to increased mortality.

The World Health Organization defined elder abuse in the Toronto declaration of 2002 as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person. It can be of various forms: physical, psychological, emotional, sexual, and financial, or simply reflect intentional or unintentional neglect.”2

The most common form of elder abuse is neglect. Neglect can be active or passive and is defined as “the refusal or failure by those responsible to provide a care dependent older adult with assistance in daily living tasks, or essential support such as food, clothing, shelter, health and medical care. This can include desertion of a care-dependent older adult, also called abandonment.”2

The most visible form of elder abuse is physical abuse, which is defined as “actions intended to cause physical pain or injury to an older adult, such as pushing, grabbing, slapping, hitting, or assaulting with a weapon or thrown object.”2

General practitioners are the first in line to notice these types of mistreatment; however, dermatologists are more trained to recognize suspicious skin and mucosal lesions. As a result, all dermatologists should be aware of this rising problem and should keep signs of neglect and abuse in mind while performing a full-body examination of the skin.

Although systematic screening has not been recommended, due to high risks of false interpretation of the lesions, dermatologists might play a particular role in case finding.3 To the best of our knowledge, no studies have been carried out to examine the effectiveness of screening for elder abuse by dermatologists.

Section snippets

Epidemiology

Aging of the population is a worrisome public health problem that will become even more visible in the near future. Longer life expectancies and the current trend of low birth rates are the main reasons for this future imbalance between age groups. In 2015, the prevalence of people aged above 65 years was estimated at 12% of the U.S. population or 47 million people; this number is expected to increase to 98 million people aged above 65 years by 2060.4

The prevalence of abuse is difficult to

Risk factors

Some risk factors are direct consequences of the dynamic changes in sociodemographic factors. Other risk factors are associated with the characteristics of the potential victims or of the potential abusive caretakers.

Role of the dermatologist

Dermatologist should be able to recognize the red flags of elder abuse when examining older adults. They should know to whom address these situations and what further steps to take to ensure the safety of the victim.

As many elderly develop skin problems, a dermatologist should be able to distinguish between normal skin aging and current age-related pathology, which can mimic abuse, and red flags suggestive of abuse. It may not always be simple to differentiate between these two, because there

Types of abuse

The World Health Organization defined elder abuse in the Toronto declaration of 2002 as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person. It can be of various forms: physical, psychological, emotional, sexual, and financial, or simply reflect intentional or unintentional neglect.”2

The three types of abuse that result in visible physical injuries are discussed in

Age-related skin changes versus markers of abuse

When examining the elderly, it is important to differentiate between normal age-related skin changes and skin changes caused by physical abuse. The fragility of aging skin and the more common use of oral anticoagulation medication in the elderly can lead to more severe bruising that can mimic physical abuse.11

When confronted with suspicious lesions, comprehensive history should be taken to find out exactly how this lesion has appeared and if the history is consistent with the physical

Conclusions

Increased awareness for neglect and physical abuse in the elderly is important for the dermatology community, because dermatologists are specially trained to differentiate skin lesions due to normal signs of aging and current pathology from neglect and abuse. Because family practitioners, geriatricians, and the lay public are the first to encounter those lesions, increased knowledge about the high prevalence and signs of neglect and physical abuse in the elderly is important. Institutions

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    1

    These two authors contributed equally to this work.

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