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Gerontology, Palliative Care & Prevention · Topic 4 of 13

Elder Maltreatment & Self-Neglect

Geriatrics · abuse, neglect and exploitation

Elder Maltreatment & Self-Neglect

When the story does not fit the injury, interview the older adult alone, document carefully, and report the suspicion to Adult Protective Services.

Key numbers
Large bruises on face, lateral right arm, backbruise > 5 cm
01 · The ruleSuspected abuse: report to APS

Report suspected — not proven — abuse, neglect or exploitation to Adult Protective Services: clinicians are mandated reporters in nearly every state; facility abuse is reportable in every state (also notify the ombudsman).

02 · Look forRed flag: injury doesn't fit story

Suspect abuse with delayed care, conflicting patient and caregiver accounts, injuries inconsistent with or vaguely explained by the history, repeated ED visits despite an adequate plan, or labs that do not match the history.

03 · DoInterview the patient alone

Interview the older adult alone for at least part of the visit with direct questions about safety, violence, restraint and neglect; interview the caregiver separately and without confrontation.

01

What it is

Core idea
Physical, psychological, neglect, financial — often combined must knowElder abuse = physical (including sexual) or psychological mistreatment, neglect (including abandonment) or financial exploitation of an older adult; multiple types often coexist, and perpetrators are usually adult children, other family or caregivers.
Self-neglect: unable or unwilling to meet basic needsSelf-neglect is an older adult's inability or unwillingness to meet basic needs — hygiene, food, medications, medical care, home upkeep, bills; risks are isolation, dementia, multiple chronic disorders, substance misuse and severe depression.
02

Causes & risk factors

Why it happens
Perpetrator risk: substance use, mental illness, dependenceCaregiver substance use is the leading predictor of abusive behavior; psychiatric illness, a history of violence, caregiving stress, financial or housing dependence on the older adult and shared living also raise risk.
Victim risk: cognitive impairment and isolationOlder adults with cognitive impairment (especially at risk of financial abuse and neglect), functional impairment, chronic illness, communication difficulty or social isolation are at highest risk.
03

Presentation

What you'll see
Bruises in stages, restraint marks, immersion burnsPhysical signs: multiple bruises in different stages, unexplained fractures, wrist or ankle restraint marks, stocking-glove immersion burns, traumatic alopecia, pressure injuries, dehydration, poor hygiene, genital bleeding or STIs.
Large bruises on face, lateral right arm, backBruises from physical elder abuse are often large (> 5 cm) and on the face, lateral right arm or posterior torso; ask every older adult with bruises how they happened.
Caregiver insists on answering for the patientBehavioral clues: a caregiver who insists on giving the history, refuses to leave the patient alone with staff, declines home health services, or is absent when an impaired patient presents; a withdrawn or infantilized patient.
Self-neglect red flags: no caregiver plus declineSuspect self-neglect when a patient without a caregiver has weight loss or dehydration, untreated conditions, hypothermia or heat illness, an unsanitary home, disconnected utilities or skipped medications; social work and APS can arrange help.
04

Do right now

In this order
First moves
1
Immediate danger: admit, police or safe placement
→
2
Interview the patient alone
→
3
Document in the patient's own words
→
4
Suspected abuse: report to APS
Why each step
Immediate danger: admit, police or safe placementIf the patient is in immediate danger, consider hospital admission, law enforcement involvement or relocation to a safe place, explaining the risks and consequences of each option to the patient.
Interview the patient aloneInterview the older adult alone for at least part of the visit with direct questions about safety, violence, restraint and neglect; interview the caregiver separately and without confrontation.
Document in the patient's own wordsDocument the suspected abuse in the patient's own words, describe injuries with photographs or drawings, and add objective data (radiographs, electrolytes for hydration, albumin for nutrition, drug levels for adherence).
Suspected abuse: report to APSReport suspected — not proven — abuse, neglect or exploitation to Adult Protective Services: clinicians are mandated reporters in nearly every state; facility abuse is reportable in every state (also notify the ombudsman).
05

Management

Orders
EASI: six questions to raise suspicionThe Elder Abuse Suspicion Index (EASI) has 6 items — 5 yes/no patient questions plus 1 clinician observation; validated in adults 65 and older with MMSE ≥ 24, it prompts further evaluation.
06

The rules

Know these
Capacity decides who chooses the interventionA victim with decision-making capacity helps choose the intervention and may decline protective services, though reporting duties still apply; without capacity, the team decides, and APS may seek a guardian or court order.
USPSTF: insufficient evidence for routine screeningUSPSTF (2025) found insufficient evidence (I statement) to screen older or vulnerable adults for caregiver abuse and neglect; the Joint Commission and National Center on Elder Abuse still endorse routine screening or inquiry.
07

Caregiver abuse or self-neglect?

Commonly confused
Who fails the patientA family member or caregiver (often an adult child)
Typical findingsBruises in different stages, unexplained fractures, restraint marks, delayed care
Key risk factorsCaregiver substance use, psychiatric illness, stress, dependence on the victim
Who to involveAdult Protective Services; ombudsman if in a facility
08

More detail

Reference
Show 4 reference facts
About 1 in 10 US adults over 65 are victims of abuse (worldwide up to 1 in 6 aged 60 or older); rates are higher in long-term care, and abuse usually worsens over time.
Abused older adults have higher mortality, depression, anxiety and suicidal thoughts, and more hospitalizations than age-matched peers.
Signs of abuse are easily misattributed to chronic disease (a fracture blamed on osteoporosis) or dismissed as confusion or dementia; distinguishing self-neglect from a chosen lifestyle often needs social work input.
Watch for high-risk discharges: a frail or cognitively impaired patient going home to a caregiver with substance use, violence, psychiatric illness or caregiver burden; offer caregivers respite, adult day care and home health support.
Pearl

You report a suspicion, not a proof — Adult Protective Services investigates.

Sources · Merck Manual Professional — Elder Abuse (Jan 2026) · Merck Manual Professional — Self-Neglect in Older Adults · USPSTF. Intimate Partner Violence and Caregiver Abuse of Older or Vulnerable Adults: Screening — Final Recommendation Statement (June 24, 2025) · McGill University Department of Family Medicine — Elder Abuse Suspicion Index (EASI) · Wiglesworth A et al. Bruising as a forensic marker of physical elder abuse (NIJ-funded study; abstract) · National Center on Elder Abuse (NCEA/ACL) fact sheet — Adult Protective Services, What You Must Know (mandated reporters; right to decline services with capacity) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).