Elder Abuse: A Comprehensive Guide for MCCQE1

Introduction

Elder abuse is a critical topic for the Medical Council of Canada Qualifying Examination Part I (MCCQE1), falling under the domain of Geriatrics and Internal Medicine. It represents a significant public health issue in Canada. As a future Canadian physician, you are expected to demonstrate the CanMEDS roles of Medical Expert, Communicator, and Health Advocate by identifying, assessing, and managing cases of elder mistreatment.

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Canadian Context: In Canada, the prevalence of elder abuse is estimated to be between 4% and 10% of older adults. However, it is widely acknowledged to be underreported. The aging Canadian population makes this a high-yield topic for the MCCQE1.

Definition

The World Health Organization (WHO) and Canadian authorities define elder abuse as:

“A single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.”

Types of Elder Abuse

Understanding the specific types of abuse is essential for recognition during clinical encounters.

Physical & Sexual

Physical Abuse

Use of physical force resulting in bodily injury, pain, or impairment.
Signs: Unexplained bruises, fractures, burns, restraint marks, hair loss.

Sexual Abuse

Non-consensual sexual contact of any kind.
Signs: Genital/anal trauma, unexplained STIs, stained undergarments.

Risk Factors

Identifying risk factors is key to the Health Advocate role.

Comparative Risk Factors

Category	Risk Factors
Victim Factors	• Female gender • Cognitive impairment (Dementia) • Functional dependency (ADL/IADL) • Social isolation • History of domestic violence
Perpetrator Factors	• Caregiver burnout/stress • Substance abuse • Mental illness • Financial dependence on the victim • History of violence
Institutional Factors	• Inadequate staffing • Poor working conditions • Lack of supervision

Canadian Epidemiology Note

In Canada, the perpetrator is most often a family member. Adult children are the most common perpetrators, followed by spouses. This dynamic complicates reporting and intervention due to the victim’s fear of losing family connection or care.

Clinical Assessment

For MCCQE1, you must know how to approach a patient where abuse is suspected.

Step 1: The Interview Approach

Safety and Privacy are paramount.

Interview the patient alone, separate from the caregiver.
Use a non-judgmental, supportive tone.
Start with general questions before moving to specifics.

Step 2: Screening Tools

Utilize validated tools like the EASI (Elder Abuse Suspicion Index), developed in Canada.


EASI Questions (for the patient):
1. Have you relied on people for any of the following: bathing, dressing, shopping, banking, or meals?
2. Has anyone prevented you from getting food, clothes, medication, glasses, hearing aids or medical care, or from being with people you wanted to be with?
3. Has anyone upset you because someone talked to you in a way that made you feel shamed or threatened?
4. Has anyone tried to force you to sign papers or to use your money against your will?
5. Has anyone made you afraid, touched you in ways that you did not want, or hurt you physically?

(For the Physician):
6. Elder abuse may be associated with findings such as: poor eye contact, withdrawn nature, malnourishment, hygiene issues, cuts, bruises, inappropriate clothing, or medication non-compliance. Did you notice any of these today?

Step 3: Physical Examination

Look for “Red Flags”:

Bruising: Especially on the torso, ears, neck, or usually covered areas. Large bruises >5cm.
Fractures: Spiral fractures, or fractures inconsistent with the reported mechanism.
General: Dehydration, malnutrition, pressure ulcers (decubitus ulcers), poor hygiene.
Behavioral: Withdrawn, fearful, poor eye contact, “caregiver guarding” (caregiver answers for the patient).

Step 4: Ancillary Tests

Laboratory: CBC, electrolytes, BUN/Cr, Albumin (assess hydration/nutrition), drug levels (over/under-medication).
Imaging: Skeletal survey if physical abuse is strongly suspected.

Management and Canadian Guidelines

Management depends heavily on the patient’s cognitive capacity and the urgency of the situation.

1. Assessing Capacity

This is the pivotal step in the management algorithm.

Capable Patient: Competent adults in Canada have the right to live at risk. If they refuse intervention, you cannot force it unless a crime has been committed or specific provincial laws apply. Your role is to educate, provide resources, and develop a safety plan.
Incapable Patient: If the patient lacks capacity (e.g., advanced dementia), you must intervene to protect them. This may involve the Public Guardian and Trustee (PGT) or substitute decision-makers.

2. Mandatory Reporting in Canada

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CRITICAL MCCQE1 KNOWLEDGE: Reporting laws in Canada vary significantly by province and territory.

Long-Term Care / Retirement Homes: Mandatory reporting is generally required across most provinces.
Community-Dwelling: Mandatory reporting for competent adults is NOT universal. (e.g., In Ontario, reporting is not mandatory for competent adults in the community, but it is in Nova Scotia).
General Rule for Exam: If the patient is in immediate danger, ensure safety (call 911). If not immediate, determine capacity. Always document meticulously.

3. Intervention Strategies

Multidisciplinary Approach: Involve social work, CCAC (Home and Community Care), nursing, and geriatric services.
Safety Planning: Emergency numbers, safe places to go, hiding money/documents.
Medical Management: Treat injuries, correct malnutrition/dehydration.

Key Points to Remember for MCCQE1

Most Common Type: Financial abuse is the most commonly reported; Neglect is also highly prevalent.
Most Common Perpetrator: Adult children or spouses.
Interviewing: Always interview the patient ALONE.
Capacity: Competent patients can refuse help (Autonomy).
Documentation: Use the patient’s own words. Draw diagrams of injuries. Take photos (with consent).
CanMEDS:
- Health Advocate: Recognizing vulnerability and navigating social systems.
- Collaborator: Working with social work and community agencies.

Mnemonic: SOS

Screen (Use EASI, ask direct questions)
Observe (Physical signs, patient-caregiver dynamic)
Safety (Assess immediate danger, capacity, and plan accordingly)

Sample Question

Clinical Scenario

A 79-year-old female presents to the emergency department after a fall. She has a history of mild vascular dementia and hypertension. She lives with her unemployed 45-year-old son. On examination, she appears disheveled, with poor hygiene and dry mucous membranes. You notice bruising in various stages of healing on her upper arms and back. When you ask her about the fall, she looks at the floor and remains silent. Her son interrupts, stating, “She is just very clumsy and falls all the time. Can we just get this over with?”

Which one of the following is the most appropriate initial step in the management of this patient?

Options

A. Report the case immediately to the police.
B. Confront the son regarding the suspected abuse.
C. Ask the son to leave the room to interview the patient privately.
D. Order a skeletal survey to look for occult fractures.
E. Refer the patient to a long-term care facility immediately.

Explanation

The correct answer is:

C. Ask the son to leave the room to interview the patient privately.

Detailed Explanation

Choice C is correct: The immediate priority in suspected elder abuse is to establish a safe environment to assess the patient. This requires separating the patient from the potential perpetrator (the son) to interview her alone. This allows for a proper history, assessment of capacity, and screening for abuse without intimidation.
Choice A is incorrect: While reporting may eventually be necessary (depending on provincial laws and immediate danger), it is not the initial step. You must first gather information and assess the patient’s wishes and capacity.
Choice B is incorrect: Confronting the son can escalate the situation, putting the patient at further risk of retaliation and destroying the therapeutic relationship needed to help the mother.
Choice D is incorrect: While a skeletal survey might be part of the workup later, the history and physical exam (facilitated by a private interview) take precedence.
Choice E is incorrect: You cannot institutionalize a patient without a thorough assessment of their capacity and needs, and without their consent (if capable).

References

Public Health Agency of Canada. (2022). Elder Abuse in Canada: A Gender-Based Analysis.
Medical Council of Canada. (2023). MCCQE Part I Objectives: Care of the Elderly.
Toronto Notes. (2023). Geriatric Medicine: Elder Abuse.
Yaffe, M. J., et al. (2008). Development and validation of a tool to improve physician identification of elder abuse: The Elder Abuse Suspicion Index (EASI). Journal of Elder Abuse & Neglect.
Canadian Task Force on Preventive Health Care. (2013). Screening for Cognitive Impairment in the Elderly. (Contextual reference for capacity).