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Overview of Elder Abuse

By Daniel B. Kaplan, PhD, MSW, Institute of Geriatric Psychiatry, Weill Cornell Medical College ; Barbara J. Berkman, DSW, PhD, Boston College Graduate School of Social Work;Columbia University School of Social Work;Hartford Geriatric Social Work Faculty Scholars Program

Elder abuse refers to harm or the threat of harm to an older person by another person.

Older people can be abused by having harmful things done or said to them or by having necessary things withheld from them. Abuse usually becomes more frequent and severe over time.

Each year in the United States, thousands of older people are abused or neglected. The perpetrator is usually a family member, most often an adult child who is the older person’s caregiver. Sometimes professional caregivers, such as home health care workers or employees of nursing homes and other institutions, abuse older people.

Caregivers are often overwhelmed by the demands of care, have inadequate preparation or resources, or do not know what is expected of them. They may also become increasingly socially isolated, sometimes increasing their resentment and making abuse more likely. Many caregivers do not intend to abuse the person, and some may not even know that they are abusing the person.

Common types of elder abuse include physical abuse, sexual abuse, psychologic abuse, neglect, and financial abuse.

Physical abuse is the use of force to harm or to threaten harm. Examples are striking, shoving, shaking, beating, restraining, and force-feeding. Possible indications of physical abuse include unexplained injuries or injuries that are not treated adequately, rope burns and other rope marks, broken eyeglasses, and scratches, cuts, and bruises. A caregiver’s refusal to allow an older person to have time alone with visitors or health care practitioners can raise concerns about physical abuse.

Sexual abuse is sexual contact without consent or by force or threat of force. Examples are intimate touching and rape. Bruises around the breasts and genital area or unexplained bleeding from the vagina or anus may indicate sexual abuse. However, sexual abuse does not always result in physical injuries.

Psychologic abuse is the use of words or actions to cause emotional stress or anguish. It may involve

  • Issuing threats, insults, and harsh commands

  • Ignoring the person (for example, by not speaking for a long time or after being spoken to)

  • Treating the older person like a child (infantilization), sometimes with the goal of encouraging the person to become dependent on the perpetrator

People who are psychologically abused may become passive and withdrawn, anxious, or depressed.

Neglect is the failure to provide food, drugs, personal hygiene, or other necessities. Some older people neglect themselves (called self-neglect). Others are neglected by their caregivers. Necessities may be withheld intentionally or simply be forgotten or overlooked by irresponsible or inattentive caregivers. Signs of neglect include

  • Weight loss because of undernutrition

  • Dry skin and mouth because of dehydration

  • Unpleasant odor from being inadequately cleaned

  • Pressure sores on the buttocks or heels from being left to sit or lie in one position too long

  • Missing necessary aids, such as eyeglasses, hearing aids, or dentures

  • Missing scheduled doctor appointments or not be taken for care when disorders are obviously worsening

Some caregivers are unaware that their treatment of an older person has crossed the line from being less than ideal to being neglect. These caregivers may lack a sense of what constitutes adequate and appropriate care, or they may have very different notions of what conduct is and is not acceptable. Sometimes neglect results from desperate circumstances, such as financial difficulties, despite the caregiver’s best intentions. Sometimes willing caregivers are unable to provide adequate care because of their own physical limitations or mental impairment. For example, caregivers may be unable to bathe the older person or to remember to give the person a drug.

Financial abuse is the exploitation of a person's possessions or funds. It includes

  • Swindling

  • Pressuring an older person to distribute assets

  • Managing an older person's money irresponsibly

Caregivers may spend most of an older person's income on themselves and provide only a minimum amount for the older person.

Restricting an older person’s freedom to make important life decisions, such as whom to socialize with and how to spend money, is sometimes considered another, more subtle form of abuse.

Risk factors

Any older person, regardless of health, can be abused. However, abuse is more likely when older people

  • Are physically frail, often because of disabling chronic disorders

  • Are socially isolated

  • Have dementia or confusion

Abuse is also more likely when the perpetrators

  • Are financially dependent on or living with the older person

  • Abuse alcohol or drugs

  • Have a psychologic disorder, such as schizophrenia

  • Have been violent before

  • Have stress, such as financial problems or a family death

  • Lack skills and resources, making caregiving frustrating

  • Have a disorder (such as dementia) that makes them agitated or violent (even if they were previously mild-mannered)

Signs of abuse

Doctors, nurses, social workers, friends, and family members often do not recognize the signs of abuse. The signs can be difficult to distinguish from other problems. For example, if an older person has a hip fracture, health care practitioners may be unable to distinguish whether the cause is physical abuse or osteoporosis, falls, or both (which are much more common causes). Also, if older people are confused, they may not have their complaints of abuse taken seriously, so the abuse goes unrecognized.

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