Elder Abuse and Maltreatment: A Case Series Synopsis of 612 Victims
Written by Kathleen Thimsen & Diana Faugno   

ELDER ABUSE is an under-reported crime that is estimated to occur in 14-15% of the population over 65 years of age. Data shows that the crime is witnessed in most cases, but not reported. The reasons for under-identification and under-reporting include the concept of ageism or bias against the elderly, time constraints and prioritization of care in the emergency department, age related changes, cognitive impairment, co-morbidities, and the lack of validated instruments for screening.

This article appeared in the July-August 2020 issue of Evidence Technology Magazine.
You can view that issue here.

Cases of elder abuse that are reported are those that have blatant, overt signs and conditions that compel health-care professionals to respond and report to adult protective services. Most of the cases reported are of a catastrophic nature, with severe signs, symptoms, or with grossly evident injuries. Despite the severity of the abuse, prosecution rates decline as the age of the victim increases.

Vulnerable populations do not routinely receive screening for abuse (Administration on Aging 1998). The actual prevalence of elder abuse cases is unknown for a variety of reasons. Self-reporting, discussing what occurs in the privacy of one’s home, and any reporting of historic and persistent maltreatment usually fails to happen due to embarrassment, fear of punishment, or loss of freedom and independence.

The health-care profession is among other disciplines that play a role in the under-reporting of elder abuse. Lack of knowledge and inadequate training of health-care providers and first responders through professional education potentiates the under-identification of abuse. Additionally, there is a generalized acceptance of certain forms of abusive behaviors presenting in health-care access encounters (Laumann, Leitsch & Waite 2008). The need to advance education and skills development for professionals working in the adult-abuse environment is imperative given the fact that 10,000 Baby Boomers turn 65 years of age each day.

Chism (2013) discussed the fact that, given the political activism and advocacy of the Baby Boomer generation, the face of aging will be changed with renewed beliefs and expectations for a more proactive stance on how aging is perceived. Likewise, consumerism may shift toward a healthier approach to living and lifestyles. Considering this, the issue of elder abuse will become a challenged occurrence with much more avid attention to cases, reporting, investigations, and prosecutions. Gone are the days that ageism will be the lens that society casts upon those over 50 years of age (Butler 1969 & 1975).

The term ageism—that is, bias against the elderly—was coined in 1969 by Dr. Robert Butler, the first Director of the National Institute of Aging. The social condition still exists today. Ageism takes on many forms and most of us have a degree of ageism that taints our perspective on older people. This bias, as it relates to elder abuse and neglect, serves as an explanation and an excuse to downplay observations of—and, perhaps, participation in—maltreatment. This bias is not intentional in our conduct; rather, it is embedded in our perspectives and expectations of what aging involves that is limited to a small percentage of the aged population. Most persons over the age of 50 are healthy, active, vibrant, and contribute to society in viable and productive ways. The small percentage of the aged that are frail, sick, and debilitated live in nursing facilities or assisted living and are dependent on others for routine care. Cases of elder maltreatment are reported to occur 78% of the time in care facilities.

To identify elder maltreatment case reports, investigations, and follow up, a retrospective review was performed to recognize patterns and trends in the life, personal care, medical treatment, and safety planning of the persons involved in the cases. The secondary aim of the study was to interpret the findings and create opportunities and care strategies to prevent abuse and neglect of the elderly (K. Thimsen, pers. comm.).

A retrospective review of 612 cases of suspected elder abuse was conducted to identify if abuse or neglect played a role in the deterioration of the elder. Data that was used in the review included medical records, state investigations, crime reports, and death certificates.

  • Data was entered into Excel and de-identified and maintained for confidentiality.
  • Data was sorted and assigned coding to create themes and timelines for tracking and trending signs, symptoms, and medical events that occurred.
  • Themes were identified, and timelines were created, resulting in a trajectory of decline for most of the cases.

Ageism and elder abuse have been shown to impact health-care access and delivery. Studies show significant health disparities in the population (Dong & Simon 2014; Acierno 2009, Brozowski & Hall 2010). Data shows that victims of elder abuse present to emergency departments four times more often than other seniors of the same age that are not victims of abuse and maltreatment (H-Cup Data). Elders presenting to emergency departments for care are at increased risk due to the complexities of the screenings and the examinations that are indicated to be carried out related to the primary presenting complaint and associated comorbidities.

Assessment and differentiation of elder abuse from co-morbidities and age-related changes creates the obstacles to specific diagnosis and response to a victim of abuse given the time required for thorough workup and the time-sensitive nature of emergency-department treatment. This is also a huge obstacle for first responders to home environments or assisted, long-term care homes. Differentiating illness and disease-related conditions from abuse symptoms is difficult.

The prevalence of chronic disease and comorbidities also contributes to polypharmacy. According to economic data, numerous medications prescribed to people over 50 carry with them high costs, as well as drug interactions. This is compounded by the use of self-prescribed herbal, over-the-counter (OTC) remedies, as well as alcohol and street drugs. This polypharmacy creates difficulty in the appropriate discernment of the actual underlying condition of abuse.

Many OTC medications have a significant impact on the mental status of older adults. Some medications that are self-prescribed have a benzodiazepine effect on neural transmission that often causes cloudy, confused, and impaired thinking and behaviors. Medication effects and dehydration-related altered mental status are often not differentiated from dementia and delirium. This can result in misdiagnosed mental-status changes and the mislabeling of dementia or Alzheimer’s Disease.

A retrospective study of 612 persons reported to have been victims of elder maltreatment (abuse and neglect) was carried out by analysis of the clinical records. Of the 612 cases, only 10% of the cases were found to be abuse cases by adult protective services. The remaining cases that had not been formally noted to be abuse cases, were in fact significant for signs, symptoms, injury, or death attributable to neglect and abuse. The severity of decline and worsening of physical capacity and performance was shown to be so significant that once emergent care was sought, it was too late in the decline; the result was amputation or death.

The themes of abuse and neglect were specific and significant for showing patterns and trends with resulting amputation or death. Earlier identification and intervention would have mitigated injury and harm and ultimately pain, suffering, and death. In the cases reviewed, 100% involved hydration (or dehydration) as a major perpetration of the abuse. Further, 87% of the cases involved a minimum of two of the following themes: nutrition and hydration; medication management and administration; falls; and skin alterations.

Lateral aspect of left heel with 100% eschar, firmly adherent with periwound mottling and tissue induration with bogginess and 7-8 o'clock position. Etiology: Pressure injury from TED stocking not removed for 7 weeks.

Nutrition And Hydration
Unintentional weight loss greater than 5% in a 30-day period is considered starvation, and places the individual in a catabolic state with high potential for malnutrition. Diagnostic laboratory findings of an albumin screen (3.5–5.0 g/dL) is a measure of protein stores. Albumin levels are indicative of the preceding 20–27 days. A prealbumin screen (15–36 mg/dL) is a more definitive evaluation of nutritional status as the half-life is 2–4 days as compared to albumin that is 20–27 days.

Albumin levels are also sensitive to hydration status. In the presence of dehydration or altered kidney function, an albumin screen may be falsely inflated and appear normal. In many patients with malnutrition, sub-therapeutic prealbumin or albumin levels may be used to gauge prognosis, as nutritional status may not be responsive to aggressive nutritional support when values reach a specific level and are untreated at an early point in time.

In the patient series studied, the trajectory of the elders’ decline was evident (on average) at 10 months prior to onset of acute illness, catastrophic injury, or death. The severity of the malnutrition, as evidenced by albumin levels below 2.2 and pre-albumins below 10, made the patients’ prognosis poor, with resulting death within 7 months of the initial decline. Aggressive nutritional interventions were not successful at reversing the condition.

Medication Management And Administration
Patients in the series that had medication administration maltreatment were shown to have hypo-therapeutic levels or hyper-therapeutic levels of medications. In some cases, there was no medication found on laboratory evaluation, despite reports and medical record documentation of medications being administered. Most common medications found to have altered or absent levels included anticoagulants, anti-seizure, pain/analgesia, diuretics, and dementia medications.

The medical records of the patients in the series were often found with unexplained injuries or deformities to extremities when being evaluated for other complaints or in routine health encounters. Persons presenting with complaints of pain receiving diagnostic x-rays found old, untreated fractures.

In the cases of altered mental status, changed in vision, and with and without history of a fall, head trauma and subdural hematoma were consistent findings incident to other workups or on autopsy. Most falls with head trauma received no imaging studies, even in those patients at highest risk for brain bleeds related to concurrent anti-coagulant or aspirin therapy.

Skin Alterations
Many of the cases were brought to medical attention due to the visual observation of burns, extensive bruising, and numerous lacerations. Most cases presenting to an emergency department involved severe, chronic, and infected, catastrophic wounding that was odorous or so extensive that family initiated the transfer for emergent care.

Pressure injuries (such as bed sores or pressure ulcers) were of a severity of Stage 3 and greater. Stage 3 pressure injuries involve tissue destruction that extends to the subcutaneous tissue and deeper into tendon, muscle, and bone involvement. This type of wound results from unrelieved pressure, immobility, and malnutrition. Wounds of this type and severity are very painful. Wounds that were gangrenous, covered with necrosis, or that resulted in amputation represented 79% of the wounds in the series.

Coccyx injury is 4 x 7 cm x 7 mm with depth to 4 mm. Actual depth not able to be determined due to 100% of wound being covered with slough tissue and necrotic debris. Periwound tissue is erythematous, with denuding and hyperemia. Non-blanchable with induration. Etiology: Ischemic event related to prolonged pressure to area from immobility and no routine pressure relief.

The science of aging is in a novel position as advancements have been made that have introduced and made available many tools, instruments, and technology to differentiate abuse and maltreatment from age-related changes and comorbidities. Accurate identification and response depends on the use of these resources, and being aware of bias that creates disparities in the treatment and safe discharge of this valuable and yet vulnerable portion of our society. This will affect evidence-collection potential for your cases.

Given the graying of society, it is critically important to better identify, report, investigate, and prosecute cases of adult and elder maltreatment. All professionals and disciplines involved in working with or caring for the elderly must recognize their professional responsibility and heed the call for improving the ethical response to victims of maltreatment by implementing innovative strategies to present abuse and neglect while ensuring improvements in screening, identification, and appropriate response to elder abuse (Ash & Miller 2014).

People who witness or who are complicit with observing abuse must be held accountable for reporting abuse. The issue of elder abuse must become a priority for mandated reporters, as we aim to aid an unseen population of victims of crimes who have a limited voice. Look for education on this topic to increase your understanding of potential evidence collection in this area.

Case Study
A 72-year-old female takes a bus to the emergency room and states to the nurse that someone entered her apartment and sexually assaulted her. The nurse notifies law enforcement, as the nurse knows that reporting of sexual assault is mandatory. The emergency room also calls the forensic nurse in sexual assault care to see this patient for a medical forensic examination. The patient discloses that someone who she does not know came through her garden wall to steal food out of her refrigerator. She reports that she is diabetic but has not taken her medicine for some time because she ran out. She is also complaining of burning and pain in the genital area. This morning she put cold cream on it, “but it still burns down there.” There are no relatives to call or notify. The forensic nurse notifies the emergency social worker for assistance in comprehensive notification of adult protective services and community organizations who will help to locate family members in the area. Law enforcement is dispatched to the apartment building to locate any evidence there. The head-to-toe examination reveals a blue bruise on her left inner thigh area. She complains of pain and pulls away when this area is touched. She cannot remember how that happened. The genital examination discovers a white “cold cream-like” substance in the genital area. The yeast odor and the presentation of the area reveals that she has a very large area affected by yeast, extending out beyond the genital area into the folded-skin spaces at the top the legs. She pulls away in pain when touched. No acute lacerations or abrasions are observed by the forensic nurse. Blind vaginal swabs are obtained in lieu of a speculum examination after discussion about the method with the patient. The evidence collection kit is completed and signed over to law enforcement, maintaining the chain of custody. The emergency room nurse practitioner orders standard lab tests, revealing a blood glucose of 460 and urine dipstick showing 4+ ketones. Other lab work is pending so the patient is admitted to the hospital for observation and continued medical evaluation. Social services will follow her while in the hospital and after discharge.

Issues with this case:

  • Diabetic in ketoacidosis, and no proper care of diet or medication, with late encounter for care
  • Yeast infection in the genital area
  • Mentation with acute illness not trustworthy, and history is questionable due to medical condition
  • Law enforcement will follow up with a forensic interview


  • Adult protective service
  • Higher level of care for her safety
  • Notification of relatives
  • Diet and medications with follow-up medical care

This case was complex for many reasons. The investigation and evidence collection did go forward, but it was determined that no one had entered her apartment and she needed a higher level of care at this time in her life. The case was closed and upon discharge the patient was admitted to assisted living.

Points to ponder:

  • Did the evidence collection kit get analyzed by the crime lab for DNA?
  • Was DNA identified on evidence collected?
  • How was mental status screening and evaluation carried out? Was patient suffering from dehydration? Was a drug screen run? Was a medication reconciliation carried out?
  • Did ageism play a part in the case and care that was provided?

About The Authors
Kathleen Thimsen (DNP, RN), an assistant professor at Goldfarb School of Nursing at Barnes Jewish College, always had an interest in vulnerable populations and action-focused research. As a young nurse, Thimsen pursued interests in an evolving specialty of nursing, Enterostomal Therapy (now known as Wound, Ostomy Continence) that started her trajectory into evidence-based research that focused on gaps in care and medical practices, resulting in numerous publications and four patents aimed at quality and safety in patient care. Further pursuit of her interest put her on track to address violence and personal-violence intervention research to improve care, nursing practice, and, ultimately, to advance person-centered care for those impacted by violence. Thimsen’s current work involves community-based participatory research and evidence-based practices across the specialty of forensic nursing—specifically elder abuse and sexual violence.

Diana K. Faugno (MSN, RN, CPN, SANE-A, SANE-P, FAAFS, DF-IAFN, DF-AFN) is a Founding Board Director for End Violence Against Women International (EVAWI), is the current president of the Academy of Forensic Nurses, as well as a retired-fellow in the American Academy of Forensic Science and a Distinguished Fellow in the Academy of Forensic Nursing. She now works for Life Safe as a forensic nurse in Marietta, Georgia.


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American College of Emergency Physicians. 2013. Geriatric Emergency Department Guidelines [Practice guidelines]. Irving, TX: Author.

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Brozowski, K., and D. R. Hall. 2010. Aging and risk: physical and sexual abuse of elders in Canada. Journal of Interpersonal Violence. 25:1183-1199.

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Dong, X., M. A. Simon, K. Rajan, and D. A. Evans. 2011. Association of cognitive function and risk of elder abuse in community-dwelling population. Dementia and Geriatric Cognitive Disorders. 32:209–215. https://doi.org/10.1159/000334047

Grant, L. D. 1996. Effects of ageism on individual and health care providers’ responses to healthy aging. Health Social Work. 21(1):9–15.

Hospital Cost & Utilization Project (H-Cup). Online.


Laumann, E. O., S. A. Letsch, and L. J. Waite. 2008. Elder mistreatment in the United States: Prevalence estimates from a nationally representative study. J of Gerontology: Series B. 63(4):S248–245. https://doi.org/10.1093/geronb/63.4.S248

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