An 83 year-old patient lives with his daughter. At his examination, the advanced practice registered nurse (APRN) notes numerous bruises and scars. The patient is making less eye contact than usual. The daughter is initiating all inquiries and responding to all questions. The patient usually engages in the conversation during regular office visits. These assessment findings are most concerning for which differential diagnosis?

Assessment of unexplained physical and behavioral changes in older adults requires careful consideration of both medical and psychosocial causes. Elder abuse should be suspected when there are signs of injury, behavioral withdrawal, and caregiver dominance during interactions. Bruising, reduced eye contact, and altered patient participation in conversation can indicate possible neglect, physical abuse, or coercion. Identifying abuse early is essential to ensure patient safety and initiate protective interventions. Rationale: A. Elder abuse is the most concerning diagnosis because it involves physical, emotional, or psychological harm inflicted on an older adult, often by a caregiver. Unexplained bruises and scars raise concern for physical abuse, while reduced eye contact and decreased engagement may indicate fear, intimidation, or emotional withdrawal. The daughter controlling the interaction and the patient’s deviation from baseline behavior strongly support possible abuse or neglect. B. Anemia may cause symptoms such as fatigue, pallor, and weakness but does not explain bruising patterns combined with behavioral changes in caregiver interaction. While some bleeding disorders can contribute to bruising, anemia alone does not account for the observed psychosocial dynamics or decreased patient engagement. Therefore, it does not fully explain the clinical picture. C. Depression in older adults can present with withdrawal, reduced eye contact, and decreased communication. However, depression does not typically cause multiple unexplained bruises and scars. The combination of physical injury and caregiver dominance makes abuse a more concerning and comprehensive explanation than depression alone. D. Mild cognitive impairment involves subtle memory and cognitive changes but does not usually result in behavioral withdrawal due to caregiver control or unexplained physical injuries. Patients with cognitive decline may still engage in conversation, and bruising would not be explained by this condition. The presence of physical trauma and altered interaction patterns suggests a different underlying cause.