Older people may be abused, neglected, or both.

Abuse

Abuse can be physical, sexual, psychologic, or financial. Older people may be subjected to one or more of these types of 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People who are psychologically abused may become passive and withdrawn, anxious, or depressed.

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.

Neglect

Neglect is the failure to provide food, drugs, personal hygiene, or other necessities. Necessities may be withheld intentionally or simply be forgotten or overlooked by irresponsible or inattentive caregivers. Some caregivers are unaware that their treatment of an older person has crossed the line from being less than ideal to being mistreatment. 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.

Older people who are neglected may lose weight because of undernutrition, and their skin and mouth may become dry because of dehydration. They may have an unpleasant odor if they are inadequately cleaned. Pressure sores may develop on the buttocks or heels if people with limited mobility are left to sit or lie in one position too long. Necessary aids, such as eyeglasses, hearing aids, or dentures, may be missing. People may miss scheduled doctors appointments or not be taken for care when disorders are obviously worsening.

When People Neglect Themselves
When people do not provide food, drugs, personal hygiene, or other necessities for themselves, the problem is called self-neglect. Self-neglect occurs more often than mistreatment. Similar to mistreatment, self-neglect is most likely when older people Live alone and isolate themselves Have a disorder that impairs their judgment and memory (such as Alzheimer's disease) Have several chronic disorders Have severe depression However, some people have no particular medical problems. Why such people neglect themselves is unclear Self-neglect can range from not keeping themselves or their clothing clean to not paying bills to not seeing a doctor when they have a life-threatening condition. People may eat too little and may become dehydrated and malnourished. If they see a doctor, they may refuse treatment, not fill their prescriptions, or skip follow-up visits. Their home may be filthy, in hazardous disrepair, or infested by animal or insect pests. Sometimes self-neglect endangers public health, for example, when people's behavior causes risk of fire. Knowing where to draw the line between self-neglect and the right to autonomy and privacy can be very difficult for family members, friends, and health care practitioners. Older people may be making informed and capable choices. They may simply have decided to live in a way that others find undesirable. Often, a social worker is in the best position to make such a determination and can intervene if alerted by family members or friends. If intervention is thought to be needed, help can be just a phone call away. Contacting the person's primary care doctor is a good way to start. Adult Protective Services or the state unit on aging (whose numbers are available through the Eldercare Locator at 800-677-1116) can also be contacted.

Last full review/revision February 2009 by Mark S. Lachs, MD, MPH