Non-accidental injury
Overview
•Non-accidental injury (NAI) in older adults encompasses all forms of elder abuse: physical, emotional, financial, sexual, and neglect
•WHO estimates 1 in 6 older adults affected globally; UK community prevalence ~2-5% per year - considered an underestimate due to widespread under-reporting
•Care Act 2014 defines an adult at risk as aged 18+ with care and support needs who cannot protect themselves from abuse or neglect
Presentation
•Unexplained or inconsistently explained injuries - history changes between tellings or is inconsistent with physical findings or patient's mobility
•Injuries in protected anatomical areas - inner arms, inner thighs, buttocks, genitalia, face, and ears are rarely injured in accidental falls
•Patterned bruising - shape of hands, belt buckles, or ligatures; bilateral bruising; bruising at multiple stages of healing
•Bruising in pre-mobile or bedbound patients - accidental bruising is rare; any unexplained bruise is highly suspicious
•Signs of neglect - poor hygiene, pressure sores, malnutrition, dehydration
•Behavioural features - fearfulness or withdrawal in presence of carer; patient becomes quiet or guarded when carer speaks
•Delayed presentation - injuries presented late; history of multiple prior attendances for injuries
•Financial/medication indicators - unable to afford food or heating despite apparent means; medications repeatedly missing or never collected
Investigations
🥇 First-line
•FBC including platelets and blood film - exclude thrombocytopenia, haematological malignancy, anaemia from neglect
•Coagulation screen (PT, APTT, fibrinogen) - exclude bleeding disorder
•Urine dipstick - haematuria suggesting vasculitis or urinary tract injury
•Bone profile and vitamin D - nutritional deficiency; severe deficiency may indicate neglect
•Radiological skeletal survey or targeted X-rays - document fractures including healing fractures at different stages
•Cognitive assessment (MMSE or 4AT) - establish capacity and vulnerability status
🥈 Second-line
•CT head - signs of head injury, altered consciousness, or mechanism suggesting head trauma
•Forensic photography - with consent or best-interests decision; stored securely in medical record
Differential diagnosis
•Coagulopathy - thrombocytopenia, haemophilia, von Willebrand disease; check FBC and clotting screen
•Anticoagulant therapy - warfarin, apixaban, rivaroxaban; always check medication list
•Senile (actinic) purpura - common in older adults, especially dorsal forearms; caused by loss of dermal collagen and subcutaneous fat
•Vasculitis - palpable purpura; check urine dipstick for haematuria
•Osteoporosis and fragility fractures - pathological fractures from minimal trauma; DEXA, bone profile
Management
•Address immediate medical needs first, then initiate safeguarding - clinicians do NOT need proof of abuse; reasonable suspicion is sufficient and legally expected
•Make a safeguarding referral to the MASH under Section 42 of the Care Act 2014 for any Care Act-eligible adult
•If immediate risk to life or serious harm - contact police directly
•DASH risk assessment tool may be used in cases of domestic violence or coercive control
•Information can be shared with other agencies without consent where there is an overriding public interest or serious risk of harm
Types of abuse
•Physical - hitting, pushing, inappropriate restraint, misuse of medication (over-sedation or withholding drugs)
•Emotional/psychological - threats, humiliation, isolation, controlling behaviour
•Financial - theft, fraud, misuse of power of attorney, coercion regarding wills
•Sexual - any non-consensual sexual act; particularly important where victim has impaired capacity
•Neglect/omission - failure to provide adequate food, warmth, hygiene, medical care, or prescribed medications
•Institutional - poor care standards within care home or hospital; disrespect, deprivation of rights, systemic neglect