Ophthalmologists may be first to spot elder abuse

Baltimore-Elder abuse is a relatively common occurrence, with more than 1 million cases reported each year in the United States. In all likelihood, elder abuse is underreported, according to Myron Miller, MD.

Dr. Miller highlighted the risk factors for elder abuse and what to look for during a physical examination.

Ninety percent of episodes of elder abuse are initiated by the spouse or a child of the older individual, and a small incidence of elder abuse arises from paid caregivers.

Surveys conducted in the United States indicate that about 3.2% of individuals older than 65 years experience one or more episodes of elder abuse, representing 1 million reported cases annually, Dr. Miller explained. Surprisingly, episodes of elder abuse occur much more commonly in an individual's home compared with an institutional setting.

"There are characteristics of the older population that put individuals at greater risk of being a victim of abuse," he said. "In particular, those who are highly dependent, vulnerable, have dementia, and persons-especially women-over the age of 80 years are at highest risk."

Contributing factors Factors that may contribute to elder abuse are caregiver stress, ignorance, frustration, or desperation-resulting in retaliation on the part of the caregiver against the older person.

"This may occur in settings in which there is a transgenerational history of violence; that is, in a household with younger individuals who have displayed violence toward each other," Dr. Miller said. "The presence of alcohol or other substance abuse by a caregiver also puts the older individual at increased risk of abuse, as does environmental or social isolation. In addition, if there is a financial dependence by the abuser on the elderly person, this is a fertile ground for elder abuse."

Clinical clues to elder abuse may arise in the patient history, from the individual's inappropriate dress or poor hygiene, and poor nutritional or hydration status. There may be burns or ecchymoses on the skin, lacerations, or decubitus ulcers. The oral examination may show tooth fractures, mandibular fractures, and poor dental hygiene. There may be ecchymoses on the neck, hand imprints, whiplash injury, or vertebral fracture, Dr. Miller said.

In a more comprehensive examination, bruises and rib fractures, pneumothoraxes, or severe trauma may be evident. In the musculoskeletal system, abrasions of the wrists or ankles or old or recent fractures may be apparent. Neurologic signs may be head trauma, subdural or epidural hematoma, or spinal cord injury.

Finally, psychiatric manifestations include excessive anxiety, depression, or withdrawal, according to Dr. Miller.

Ophthalmologic signs "Ophthalmologists may recognize the pres- ence of dehydration; sunken eyes; scalp, facial, or neck ecchymoses; abrasions; burns or lacerations; recent trauma to the eyes reflected in subconjunctival or vitreous hemorrhages; traumatic cataract, retinal detachment, or orbital fractures; and more commonly, individuals may have broken their glasses and do not have a full explanation of why it happened," Dr. Miller said. "In addition, there may be an inadequate response to what should be a straightforward medical treatment for a problem or noncompliance to a prescribed treatment regimen.