Elder Abuse in the ED
/Elder abuse is an underrecognized public health crisis, with millions of older Americans experiencing physical, emotional, financial, or sexual abuse or neglect each year. Because emergency physicians are poised to identify patterns of abuse, it is critical that they understand the clinical findings, screening tools, documentation pearls, and legal responsibilities associated with suspected abuse. This review provides a practical, evidence-based approach to recognizing, evaluating, documenting, and reporting elder abuse in the emergency department.
Background
Just over 1 in 10 adults over the age of 60 experience some form of abuse each year in the United States [1]; yet, less than 5% of cases are reported. [2] Whether it be managing the aftermath of an acute act of physical harm or caring for the long-standing chronic wounds of a patient experiencing neglect, emergency physicians are uniquely positioned to identify and respond to suspected cases of elder abuse. Thus, it is critical that emergency physicians are primed with the knowledge to recognize and provide quality care for geriatric patients experiencing abuse.
Types of elder abuse
The most commonly identified type of elder abuse is physical abuse, which includes acts of violence such as hitting, kicking, burning, slapping, or pushing that result in bodily injury. While it is undoubtedly important to recognize signs of physical abuse, other forms of abuse exist that are equally important to identify and respond to.
In addition to physical abuse, the four other types of elder abuse include the following [3]:
Sexual Abuse
Any nonconsensual sexual contact
Emotional Abuse
Threats, humiliation, manipulation, intimidation, and harassment
Financial Abuse
Misusing or withholding an elderly person’s property or financial assets
Neglect/Abandonment
When a caregiver fails to provide for the basic needs of an elderly person, such as when food, water, or medications are withheld
Because emergency physicians routinely conduct physical exams and address bodily concerns and complaints, they are often well-positioned to detect signs of physical abuse, sexual assault, and neglect. Identifying financial or emotional abuse may require a more detailed patient history and/or a careful evaluation of the family dynamics present in the clinical setting.
Risk Factors
Factors that place certain individuals at higher risk for experiencing elder abuse include the following [4]:
Dementia
Shared living situation
Social isolation
Three common characteristics of individuals who become abusers include the following:
Mental illness
Alcohol abuse
Dependency on the abused
Screening tools
Several screening tools have been developed for the recognition of elder abuse, some of which are more suited for the fast-paced, chaotic environment of an emergency department. The Elder Mistreatment Screening and Response Tool (EM-SART) and Elder Abuse Suspicion Index (EASI) are two validated tools for identifying elder abuse in the emergency department. [5,6] EM-SART was developed by the National Collaboratory to Address Elder Mistreatment and includes a pre-screen, full-screen, and pathway for responding to a positive screen. Given its comprehensiveness, it may be best implemented at multiple stages of an emergency department patient encounter, such as starting with the pre-screen in triage. In contrast, the EASI is brief, consisting of a total of six questions (five of which are asked to the patient and one that is to be answered by the emergency physician). For busier departments or those without a strong social work presence, the EASI may be the better choice of a screening tool for the emergency physician.
History and Physical Exam
The European Council of Legal Medicine (ECLM) has published guidelines on the examination of suspected elder abuse [7]:
Essential Elements of the Patient History
Detailed history of current +/- prior alleged abuse (type of abuse, relationship with abuser, duration of abuse, injuries or other consequences of the abuse)
Functional history and presence of any preexisting physical or psychological disabilities
Use of any physical or chemical restraints (and is used, who prescribed them and for what purpose)
Past medical history, including relevant medications
Physical Examination
Psychiatric/cognitive assessment (i.e., Mini-Mental State Examination)
General appearance (including appearance of clothing, habitus, and hydration)
Vitals
Pain scale
Description of any and all external injuries, including any patterns of abuse (e.g., ligature marks on the wrists)
Gynecological/urological exam
Evidence collection, as indicated
There are several injury patterns that are indicative of likely abuse, such as [7,8]:
Patches of alopecia
Bruises to the ears or retroauricular area, periorbital region, palms and soles, buttocks, inside of the arms or thighs
Bruises in various stages of healing
Hand marks
Cluster bruises (from the pressure of multiple fingers)
Cigarette burns
Patterned contusions from objects (e.g., belt buckle)
Defensive stab wounds to the volar forearm
Laboratory studies
While no particular laboratory test can confirm the presence of elder abuse or neglect, there are a variety of findings commonly seen in these cases; thus, the following tests may be helpful in caring for a geriatric patient who is suspected of having experienced abuse or neglect [9]:
CBC
Elevated Hgb or Hct from dehydration or anemia from malnutrition
Leukocytosis from infections (recurrent urinary tract infections or sexually transmitted infections)
CMP
Hypernatremia from dehydration, low albumin in malnutrition
CK
Elevated level from rhabdomyolysis
Urine Drug Screen
Presence of substances not prescribed or absence of substances that have been prescribed
Documentaion Pearls
As with all patient charts, documentation of the patient’s history and physical exam should be as unbiased and objective as possible; assumptions should be avoided. Photographing injuries within the electronic health record (EHR) is one of the important ways that documentation of objective findings of suspected physical abuse can be optimized. Interestingly, research on techniques and best practices for medical photography is limited.
Bloemen et al. developed one protocol for photographing injuries of suspected abuse in the emergency department. [10] They recommend taking four photographs of each injury: two at ~3 feet away from the injury (one with and one without a ruler/color guide), and two photographs at ~1 foot from the injury (again, one with and one without a ruler/color guide). In this study, physicians demonstrated reliability in characterizing the size, side of the body, precise location of the injury, and type of abrasion. Shape and predominant bruise color were less reliably characterized. Unfortunately, this study had several limitations; for example, 95% of their study population was white, so this protocol may be less helpful in documenting injuries sustained to patients of different races. Still, this protocol offers an evidence-based, more standardized approach to documenting injuries efficiently and intentionally in the emergency department.
For EHRs that do not allow photographs to be incorporated into the chart, the Geriatric-Injury Documentation Tool (Geri-IDT) is one tool developed to assist with the documentation of injury-related physical exam findings for geriatric patients. [11] This tool provides detailed guidance on terminology for various injuries in addition to several pictograms of the human body over which physical exam findings can be more easily documented.
Mandated Reporting
Mandatory reporting of suspected or known elder abuse is dictated by state law. While some states have adopted universal reporting, meaning everyone in the state is required to report abuse, others only enforce a duty to report for members of certain professions.
In Ohio, the following professions are considered “mandatory reporters,” as defined by Ohio Revised Code (ORC 5101.63) [12]:
Attorneys practicing law in Ohio
Individuals authorized to practice medicine and surgery, osteopathic medicine and surgery, or podiatric medicine and surgery
Individuals licensed as a chiropractor, dentist, psychologist, pharmacist, registered nurse, or licensed practical nurse
Individuals licensed as a social worker, independent social worker, professional counselor, professional clinical counselor, marriage and family therapist, or independent marriage and family therapist
Individuals holding a certificate to practice as a dialysis technician
Employees of a home health agency, outpatient health facility, hospital, public hospital, or community mental health agency
Employees of a nursing home or residential care facility
Employees of a residential facility licensed under section Ohio Revised Code (ORC 5119.22) that provides accommodations, supervision, and personal care services for three to sixteen unrelated adults
Employees of a health department operated by the board of health of a city or general health district or the authority having the duties of a board of health; agents of a county humane society
Firefighters for lawfully constituted fire departments
Ambulance drivers for emergency medical service organizations
First responders, emergency medical technician-basic, emergency medical technician-intermediate, or paramedic
Officials employed by a local building department to conduct inspections of houses and other residential buildings;
Peace officers;
Coroners;
Members of the clergy;
Certified public accountants or anyone registered under that chapter as a public accountant;
Licensed real estate brokers or real estate salespersons;
Notary publics (appointed and commissioned);
Employee of a bank, savings bank, savings and loan association, or credit union organized under the laws of this state, another state, or the United States;
Dealers, investment advisers, salespersons, or investment advisor representatives;
Financial planners accredited by a national accreditation agency;
Senior service providers other than representatives of the Office of the State Long-Term Care Ombudsman.
For any patient who arrives at the emergency department by ambulance one can see the chain of mandated reporters who are likely to have been involved in that patient’s care prior to the emergency physician’s initial evaluation, likely a combination of EMS personnel, firefighters, and/or peace officers. While in the emergency department, social work may be involved in the patient’s care, and nurses most certainly. Assuming the patient is admitted to the hospital, there will certainly be other physicians and nurses taking care of the patient more definitively. Knowing this chain is present and exists, it may be easy to pass off the responsibility of reporting to another party, especially if the emergency physician thinks of themself as a “middleman” for a patient who will be admitted. This does not change the law that emergency physicians are mandated reporters for suspected abuse and bear a responsibility for ensuring that a report is filed, even if the filing of that report is practically performed by ancillary staff, such as through a social worker.
The agency and associated hotline for reporting naturally also varies by state. In Ohio, the Adult Protective Services, a program within the Department of Job and Family Services, should be contacted to file a report; their number is +1 (855) 644-6277. For Hamilton County’s Adult Protective Services, call 513-421-5433.
When making a report of elder abuse, it is helpful to have the following information [13]:
Name, age, home address, and current location (i.e., your emergency department) of the patient suspected of being abused
Name and home address of the….
Suspected abused
Person responsible for the patient’s care, if applicable
Patient’s legal guardian, if applicable
Reason why you suspect that abuse has occurred with a close description of the suspected abuse, including its impact on the patient’s health, safety, rights, etc.
Any information about past episodes of suspected abuse or exploitation, if applicable
Additional Resources
For more information about elder abuse, please visit the following:
Post by: Mel Ebeling
Dr. Hoeflinger is a PGY-1 in Emergency Medicine at the University of Cincinnati
Editing by: Ryan LaFollette, MD
Dr. Ryan Lafollette is an APD in Emergency Medicine at the University of Cincinnati and Co-editor of Tamingthesru.com
References
Rosay AB, Mulford CF. Prevalence Estimates and Correlates of Elder Abuse in the United States: The National Intimate Partner and Sexual Violence Survey. Journal of Elder Abuse & Neglect. 2016;29(1):1-14. Accessed May 17, 2026. https://nij.ojp.gov/library/publications/prevalence-estimates-and-correlates-elder-abuse-united-states-national-1
Rosen T, Hargarten S, Flomenbaum NE, Platts-Mills TF. Identifying Elder Abuse in the Emergency Department: Toward a Multidisciplinary Team-Based Approach. Ann Emerg Med. 2016;68(3):378-382. doi:10.1016/j.annemergmed.2016.01.037
Jandu JS, Mohanaselvan A, Johnson MJ, et al. Elder Abuse. [Updated 2024 Oct 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560883/
National Research Council (US) Panel to Review Risk and Prevalence of Elder Abuse and Neglect; Bonnie RJ, Wallace RB, editors. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington (DC): National Academies Press (US); 2003. 5, Risk Factors for Elder Mistreatment. Available from: https://www.ncbi.nlm.nih.gov/books/NBK98788/
Platts-Mills TF, Sivers-Teixeira T, Encarnacion A, et al. EM-SART: A Scalable Elder Mistreatment Screening and Response Tool for Emergency Departments. 2020;44:51–8.
Yaffe MJ, Wolfson C, Lithwick M, Weiss D. Development and validation of a tool to improve physician identification of elder abuse: the Elder Abuse Suspicion Index (EASI). J Elder Abuse Negl. 2008;20(3):276-300. doi:10.1080/08946560801973168
Keller E, Santos C, Cusack D, et al. European council of legal medicine (ECLM) guidelines for the examination of suspected elder abuse. Int J Legal Med. 2019;133(1):317-322. doi:10.1007/s00414-018-1880-y
Gibbs LM. Understanding the medical markers of elder abuse and neglect: physical examination findings. Clin Geriatr Med. 2014;30(4):687-712. doi:10.1016/j.cger.2014.08.002
LoFaso VM, Rosen T. Medical and laboratory indicators of elder abuse and neglect. Clin Geriatr Med. 2014;30(4):713-728. doi:10.1016/j.cger.2014.08.003
Bloemen EM, Rosen T, Cline Schiroo JA, et al. Photographing Injuries in the Acute Care Setting: Development and Evaluation of a Standardized Protocol for Research, Forensics, and Clinical Practice. Acad Emerg Med. 2016;23(5):653-659. doi:10.1111/acem.12955
Kogan AC, Rosen T, Navarro A, Homeier D, Chennapan K, Mosqueda L. Developing the Geriatric Injury Documentation Tool (Geri-IDT) to Improve Documentation of Physical Findings in Injured Older Adults. J Gen Intern Med. 2019;34(4):567-574. doi:10.1007/s11606-019-04844-8
134th General Assembly. Reporting Abuse, Neglect or Exploitation of Adult. Vol 5101.63.; 2023. Accessed May 17, 2026. https://codes.ohio.gov/ohio-revised-code/section-5101.63
Elder Abuse Reporting Checklist. Accessed May 17, 2026. https://aging.ohio.gov/care-and-living/get-help/elder-justice/elder-abuse-reporting-checklist-1
