Continuing medical education
Geriatric dermatology: Part II. Risk factors and cutaneous signs of elder mistreatment for the dermatologist

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Cutaneous signs may be the most visible hint of elder mistreatment. Dermatologists are in a unique position to recognize and report physical abuse and neglect in the older patient population. In this review, we describe the scope and impact, risk factors, cutaneous signs, and appropriate responses to suspected elder mistreatment. There is a critical need for additional evidence to inform clinical practice in the field of elder abuse and neglect. Recognition and reporting of suspected elder mistreatment by the dermatologist can be life-saving for the older patient.

Section snippets

Scope and impact of the problem

Multiple studies have suggested that elder mistreatment is a highly prevalent yet underreported phenomenon.2, 3, 4, 5, 6, 7, 8 In 2003, the National Research Council reported that an estimated 1 to 2 million Americans ≥65 years of age have been mistreated by a caregiver.3 Other estimates are similar, ranging from 1% to 10% of the population >60 years of age that are believed to have been abused.2, 3, 4, 5 The reporting rate in noninstitutional settings is lower than that in nursing homes, with

Definition of elder abuse and neglect

Elder abuse describes a range of acts that cause harm or potential for harm, intentionally or by neglect, to an older adult.7 While elder abuse can be categorized in several ways, types of abuse with visible cutaneous manifestations include physical abuse (including sexual abuse) and neglect (including self-neglect).7 In the community setting, self-neglect is more common than elder abuse or neglect.17 The definition of self-neglect includes failure to provide oneself with means to physical

Risk factors for elder abuse and neglect

Key point

  1. Recognition of key risk factors can flag the most vulnerable older patients for a more comprehensive skin examination

Physicians’ limited knowledge of key risk factors for elder mistreatment can be a barrier to appropriate detection and response.17 Demographic and psychosocial risk factors based on reported data in the medical literature are listed in Table II, Table III. Table II outlines risk factors of potential victims, and Table III summarizes risk factors predicting abusive caregivers. In

Cutaneous manifestations of elder abuse

Key points

  1. Cutaneous signs of elder abuse, such as purpura and petechiae from intentional trauma, must be differentiated from vasculitis, vasculopathy, and unintentional injury, such as from falls

  2. Elder physical abuse includes sexual abuse and should be suspected when older patients without decision-making ability present with cutaneous signs of sexually transmitted disease

Recognizing important risk factors for elder abuse can flag patients for a more comprehensive skin examination for cutaneous signs of

Cutaneous manifestations of elder neglect

Key points

  1. Nutritional deficiencies from elder neglect (including self-neglect) can lead to a variety of skin manifestations, and must be distinguished from conditions such as photosensitive dermatitis from nonnutritional causes, paraneoplastic syndromes, and drug side effects

  2. Pressure ulcers can be a sign of elder neglect from lack of repositioning, but nutritional deficiency, another sign of elder neglect, can also lead to poor wound healing

Elder neglect is more common than elder abuse and may be

Responding to suspected cases of elder abuse or neglect

Key points

  1. In cases of suspected elder mistreatment, interview the patient apart from the caregiver if possible

  2. When the medical history and skin examination are not congruent, elder mistreatment may be suspected

  3. Reporting suspected cases of elder mistreatment to Adult Protective Services is mandated by law, even though many patients with decision-making capacity may eventually decline the services offered

After the consideration of risk factors, history, and skin findings, timely management of suspected

Conclusion

Given the prevalence of elder abuse and neglect and the underreporting of such cases by physicians, a dermatologist should be aware of risk factors and cutaneous manifestations along with their differential diagnoses. There are several potential barriers in detecting and managing elder abuse or neglect, and recognizing these barriers is the first step to reducing them. Having a plan to report or refer suspected elder abuse may be life-saving, and will better serve our growing population of

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      Citation Excerpt :

      Physicians should be especially aware of injuries to areas not commonly injured, such as the inner thigh, top of the feet, inner ankles, palms/soles, and posterior neck, as these areas are not commonly involved in daily activities or accidental trauma.13 More commonly, elderly patients will present with bruises and burns; physicians should take note of unusual locations, such as those not over bony prominences, or patterns, such as a stocking-glove distribution, which may suggest an abusive injury.13-15 Additionally, diaphyseal fracture of the ulna is an injury uncommon in accidental trauma that has been associated with elder abuse.16

    View all citing articles on Scopus

    Supported in part by the D. W. Reynolds Foundation, American Federation for Aging Research, and the John A. Hartford Foundation (Dr Endo).

    Dr Chang is an investigator in clinical trials sponsored by Genentech, Novartis, Galderma, and Nuskin.

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