Elder abuse is physical or psychological mistreatment, neglect, or financial exploitation of older adults.
Common types of elder abuse include physical abuse, psychological abuse, neglect, and financial exploitation. Each type may be intentional or unintentional. Polyvictimization (co-occurrence of multiple types of abuse) is common. The perpetrators are often adult children but may be other family members or paid or informal caregivers.
Physical abuse is use of force resulting in physical or psychological injury or discomfort. It includes striking or blunt assault with open or closed hand or with an object, kicking, shoving, shaking, beating, restraining, forceful feeding, and unwarranted administration of medications. It may include sexual assault (any form of sexual intimacy without consent or by force or threat of force).
Psychological abuse is use of words, acts, or other means to cause emotional stress or anguish. It includes issuing threats (eg, of institutionalization), insults, and harsh commands, as well as remaining silent and ignoring the person. It also includes infantilization (a patronizing form of ageism in which the perpetrator treats the older adult as a child), which encourages the older adult to become dependent on the perpetrator.
Neglect is the failure or refusal to provide food, medicine, personal care, or other necessities; it also includes abandonment. Neglect that results in physical or psychological harm is considered abuse.
Financial or material exploitation is the illegal, improper, or unauthorized use of an older adult's money or property for the benefit or monetary gain of someone other than the older adult. It includes swindling, pressuring a person to distribute assets, and managing a person’s money irresponsibly as well as inattention to a dependent person’s possessions or funds.
Although the true incidence is unclear, elder abuse appears to be a growing public health problem in the United States. Several studies report approximately 1 in 10 older adults older than 65 are victims of physical abuse, psychological abuse, sexual abuse, financial exploitation, and neglect (1). Worldwide as many as 1 in 6 community-dwelling people age ≥ 60 are victims of abuse (2), and the rates are higher in long-term care facilities (3). Approximately 12% of elder abuse victims experience multiple types of abuse (4). Elder abuse is associated with physical injuries, poor physical health, psychological damage, repeated hospitalization, financial ruination, and premature mortality.
Abuse usually becomes more frequent and severe over time. Reports of elder abuse increased during the COVID‐19 pandemic; also, rates of physical and emotional abuse and cases of multiple types of abuse were significantly higher (5), possibly because of the increased vulnerability of victims and more stressors and/or triggers affecting abusers due to social isolation, financial hardships, and poor mental health. Thus, physicians must remain vigilant in identifying older patients at risk of mistreatment and providing appropriate referrals for intervention and counseling.
References
1. Patel K, Bunachita S, Chiu H, et al. Elder Abuse: A Comprehensive Overview and Physician-Associated Challenges. Cureus. 2021;13(4):e14375. Published 2021 Apr 8. doi:10.7759/cureus.14375
2. Mikton CR, Beaulieu M, Yon Y, et al. Protocol: Global elder abuse: A mega-map of systematic reviews on prevalence, consequences, risk and protective factors and interventions. Campbell Systematic Reviews. 18 (2): e1227. https://doi.org/10.1002/cl2.1227
3. Yon Y, Mikton CR, Gassoumis ZD. et al. Elder abuse prevalence in community settings: A systematic review and meta-analysis. Lancet Glob Health. 5 (2):e147-e156, 2017. doi: 10.1016/S2214-109X(17)30006-2
4. Wong JS, Breslau H, McSorley VE, et al. The social relationship context of elder mistreatment. Gerontologist. 60 (6):1029–1039, 2020. doi: 10.1093/geront/gnz154
5. Weissberger GH, Lim AC, Mosqueda L, et al. Elder abuse in the COVID-19 era based on calls to the National Center on Elder Abuse resource line. BMC Geriatr. 22 (1):689, 2022. doi: 10.1186/s12877-022-03385-w
Risk Factors for Elder Abuse
For the victim, risk factors for elder abuse include:
Impairment due to chronic disorders
Functional impairment
Cognitive impairment
Difficulty communicating
Social isolation
For the perpetrator, risk factors include:
Substance or alcohol use disorders
Psychiatric disorders
History of violence
Stress
Dependence on the victim (including shared living arrangements)
(See table Risk Factors for Elder Abuse).
The prevalence of elder abuse increased dramatically during the COVID-19 pandemic, which suggests the need for assessment of potential abuse during times of crisis and disaster when risk factors are exacerbated (1).
Risk Factors for Elder Abuse
Factor | Comments |
|---|---|
For the victim | |
Social isolation | Abuse of isolated people is less likely to be detected and stopped. Social isolation can intensify stress. |
A chronic disorder, functional impairment, or both | The ability to escape, seek help, and defend self is reduced. People with a chronic disorder or functional impairment may require more care, increasing stress for the caregiver. |
Cognitive impairment | Risk of financial abuse and neglect is particularly high. People with dementia may be difficult to care for, frustrating caregivers, and may be aggressive and disruptive, precipitating abuse by overwhelmed caregivers. |
For the perpetrator | |
Substance use disorders | Alcohol or drug use disorders, intoxication, and substance withdrawal are the leading predictors of abusive behavior. Substance-dependent caregivers may attempt to use or sell drugs prescribed to the older adult, depriving the person of treatment. |
Psychiatric disorders | Psychiatric disorders (eg, schizophrenia, post-traumatic stress disorder) and affective disorders (eg, major depressive disorder) increase the risk of abusive behavior. Adult children discharged from an inpatient psychiatric facility may return to their older parents’ home for care. These patients, even if not violent in the facility, may become abusive at home. |
History of violence | A history of violence in a relationship (particularly between spouses) and outside the family may predict elder abuse. One theory is that violence is a learned response to difficult life experiences and a learned method of expressing anger and frustration. Because reliable information about past family violence is difficult to obtain, this theory is unsubstantiated. |
Dependence of the perpetrator on the older adult | Dependence on the older adult for financial support, medical or functional assistance, housing, emotional support, and other needs can cause resentment, contributing to abuse. If the older adult refuses to provide resources to a family member (especially an adult child), abuse is more likely. |
Stress | Stressful life events (eg, chronic financial problems, death in the family) and the responsibilities of caregiving increase the likelihood of abuse. Difficulties managing stress or coping with caregiving burdens may contribute to abuse. |
For both victim and perpetrator | |
Shared living arrangements | Older adults living alone are much less likely to be abused. When living arrangements are shared, opportunities for the tension and conflict that usually precede abuse are greater. |
Adapted from Pillemer K, Burnes D, Riffin C, Lachs MS. Elder Abuse. Global Situation, Risk Factors, and Prevention Strategies. Gerontologist. 2016;56 Suppl 2(Suppl 2):S194-S205. doi:10.1093/geront/gnw004 | |
Risk factors reference
1. Chang ES, Levy BR. High Prevalence of Elder Abuse During the COVID-19 Pandemic: Risk and Resilience Factors. Am J Geriatr Psychiatry. 2021;29(11):1152-1159. doi:10.1016/j.jagp.2021.01.007
Diagnosis of Elder Abuse
Elder abuse is difficult to detect because many of the signs are subtle, and the victim is often unwilling or unable to discuss the abuse. Victims may hide abuse because of shame, fear of retaliation, or a desire to protect the perpetrator. Sometimes when abuse victims seek help, they encounter ageist responses from health care professionals, who may, for example, dismiss complaints of abuse as confusion, paranoia, or dementia.
Social isolation of the victim often makes detecting elder abuse difficult. Abuse tends to increase the isolation because the perpetrator often limits the victim’s access to the outside world (eg, denies the victim visitors and telephone calls).
Symptoms and signs of elder abuse may erroneously be attributed to a chronic disorder (eg, a hip fracture attributed to osteoporosis). However, the following clinical situations are particularly suggestive of abuse:
Delay between an injury or illness and the seeking of medical attention
Disparities in the patient’s and caregiver’s accounts
Injury severity that is incompatible with the caregiver’s explanation
Implausible or vague explanation of the injury by the patient or caregiver
Frequent visits to the emergency department for exacerbations of a chronic disorder despite an appropriate care plan and adequate resources
Absence of the caregiver when a functionally impaired patient presents to the physician
Laboratory findings that are inconsistent with the history
Reluctance of the caregiver to accept home health care (eg, a visiting nurse) or leave the older patient alone with a health care professional
Physicians are encouraged to consider routine inquiry (recommended by the American Medical Association) or routine screening for elder abuse (recommended by the Joint Commission, National Center on Elder Abuse, and National Academy of Sciences). Routine inquiry by physicians is based on increased suspicion and involves nonsystematic interviewing about possible elder abuse. Routine screening involves the systematic use of instruments that have been validated in the primary care setting, such as the 6-item Elder Abuse Suspicion Index (EASI ©). For screening of Spanish-speaking populations, the Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS) has been translated and validated in a population of Spanish-speaking older adults in the United States (1).
History
If elder abuse is suspected, the patient should be interviewed alone, at least for part of the time. Other involved people may also be interviewed separately. The patient interview may start with general questions about feelings of safety but should also include direct questions about possible mistreatment (eg, physical violence, restraints, neglect). If abuse is confirmed, the nature, frequency, and severity of events should be elicited. The circumstances precipitating the abuse (eg, alcohol intoxication) should also be sought.
Social and financial resources of the patient should be assessed because they affect management decisions (eg, living arrangements, hiring of a professional caregiver). The examiner should inquire whether the patient has family members or friends able and willing to nurture, listen, and assist. If financial resources are adequate but basic needs are not being met, the examiner should determine why. Assessing these resources can also help identify risk factors for abuse (eg, financial stress, financial exploitation of the patient).
In the interview with the family caregiver, confrontation should be avoided. The interviewer should explore whether caregiving responsibilities are burdensome for the family member and, if appropriate, acknowledge the caregiver’s difficult role. The caregiver is asked about recent stressful events (eg, bereavement, financial stresses), the patient’s illness (eg, care needs, prognosis), and the reported cause of any recent injuries.
In small communities, including rural towns and tribal communities, additional processes must be developed to preserve confidentiality and privacy when screening for and responding to suspected elder abuse because patients, perpetrators of abuse, providers, medical office staff, and interventionists are often known to one another. Reassurance of such processes during interviews is needed to facilitate reporting by victims.
Physical examination
The patient should be thoroughly examined, preferably at the first visit, for signs of elder abuse (see table Signs of Elder Abuse). The physician may need help from a trusted family member or friend of the patient, state adult protective services, or, occasionally, law enforcement agencies to encourage the caregiver or patient to permit the evaluation. If abuse is identified or suspected, a referral to Adult Protective Services is mandatory in most states.
Signs of Elder Abuse
Item | Sign |
|---|---|
Behavior | Withdrawal by the patient Infantilization of the patient by the caregiver Caregiver’s insistence on providing the history |
General appearance | Poor hygiene (eg, unkempt appearance, uncleanliness) Inappropriate dress |
Skin and mucous membranes | Poor skin turgor or other signs of dehydration Bruises, particularly multiple bruises in various stages of evolution Unexplained abrasions or lacerations Pressure ulcers Deficient care of established skin lesions |
Head and neck | Traumatic alopecia (distinguished from male- or female-pattern alopecia by distribution) |
Trunk | Contusions (shape may suggest implement—eg, utensil, stick, belt) |
Genitourinary region | Rectal bleeding Vaginal bleeding Pressure ulcers Infestations such as pubic lice Sexually transmitted infections |
Extremities | Wrist or ankle lesions suggesting use of restraints or immersion burns (ie, in a stocking-glove distribution) |
Musculoskeletal system | Previously undiagnosed fracture Unexplained pain Unexplained gait disturbance |
Mental and emotional health | Depressive symptoms Anxiety |
Cognitive status should be assessed (see sidebar Examination of Mental Status). Cognitive impairment is a risk factor for elder abuse and may affect the reliability of the history and the patient’s ability to make management decisions.
Mood and emotional status should be assessed. If the patient feels depressed, ashamed, guilty, anxious, fearful, or angry, the beliefs underlying the emotion should be explored. If the patient minimizes or rationalizes family tension or conflict or is reluctant to discuss abuse, the examiner should determine whether these attitudes are interfering with recognition or admission of abuse.
Functional status, including the ability to do activities of daily living (ADLs), should be assessed and any physical limitations that impair self-protection noted. If help with ADLs is needed, the examiner should determine whether the current caregiver has sufficient emotional, financial, and intellectual ability for the task. Otherwise, a new caregiver needs to be identified.
Coexisting disorders caused or exacerbated by the abuse should be identified.
Laboratory tests
Imaging and laboratory tests (eg, electrolytes to determine hydration, albumin to determine nutritional status, medication levels to document compliance with prescribed regimens) are done as necessary to identify and document the abuse.
Documentation
The medical record should contain a complete report of the actual or suspected abuse, preferably in the patient’s own words. A detailed description of any injuries should be included, supported by photographs, drawings, radiographs, and other objective documentation (eg, laboratory test results) when possible. Specific examples of how needs are not being met, despite an agreed-on care plan and adequate resources, should be documented.
Diagnosis reference
1. Ramirez M, Solomon J, Riquelme M, et al. Development and Spanish translation of the Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS). J Elder Abuse Negl. 31 (1):38–55, 2019. doi: 10.1080/08946566.2018.1531099 Epub 2018 Nov 8
Treatment of Elder Abuse
An interdisciplinary team approach (involving physicians, nurses, social workers, lawyers, law enforcement officials, psychiatrists, and other professionals) is essential. Any previous intervention (eg, court orders of protection) and the reason for its failure should be investigated to avoid repeating any mistakes.
Intervention
If the patient is in immediate danger, the physician, in consultation with the patient, should consider hospital admission, law enforcement intervention, or relocation to a safe home. The patient should be informed of the risks and consequences of each option.
If the patient is not in immediate danger, steps to reduce risk should be taken but are less urgent. The choice of intervention depends on the perpetrator’s intent to harm. For example, if a family member administers too much of a medication because the physician’s directions are misunderstood, the only intervention needed may be to give clearer instructions. A deliberate overdose requires more intensive intervention.
In general, interventions need to be tailored to each situation. Interventions may include:
Medical assistance
Culturally sensitive education (eg, teaching victims about abuse and available options, helping them devise safety plans)
Trauma-informed psychological support (eg, short-term or long-term psychotherapy for the victim and possibly the family to address depression and the role of specific traumas in the person's life)
Law enforcement and legal intervention (eg, arrest of the perpetrator, orders of protection, legal advocacy including asset protection)
Alternative housing (eg, sheltered senior housing, nursing home placement, abuse shelters)
Referral to services that provide basic support (eg, transportation, food assistance) and reduce social isolation
If victims have decision-making capacity, they should help determine their own intervention. If they do not, the interdisciplinary team, ideally with a guardian or objective conservator, should make most decisions. Decisions are based on the severity of the violence, the victim’s previous lifestyle choices, and legal ramifications. Often, there is no single correct decision; each case must be carefully monitored.
Nursing and social work issues
As members of the interdisciplinary team, nurses and social workers can help prevent elder abuse and monitor their results. A nurse, social worker, or both can be appointed as coordinator to ensure that pertinent information is accurately recorded, that relevant parties are contacted and kept informed, and that necessary care is available 24 hours a day.
In-service education about elder abuse should be offered to all nurses and social workers annually. In some states, education about child abuse is mandatory for physician, nursing, and social work licensure. However, mandated professional education on elder abuse is established in just a few states.
Reporting
All states in the United States require that suspected or confirmed abuse in an institution be reported, and most states require that abuse in the home also be reported. In addition, all states have laws protecting and providing services for vulnerable, incapacitated, or disabled adults.
In most states in the United States, the agency designated to receive abuse reports is the state social service department (Adult Protective Services). In the remaining states, the designated agency is the state unit on aging. For abuse within an institution, the local long-term care ombudsman office should be contacted. Telephone numbers for these agencies and offices in any part of the United States can be found by contacting the Eldercare Locator (800-677-1116) or the National Center on Elder Abuse (855-500-3537). Health care professionals should know reporting laws and procedures for their own states.
Caregiver issues
Caregivers of a physically or cognitively impaired older adult may not be able to provide adequate care or may not realize that their behavior sometimes borders on abuse. These caregivers may be so immersed in their caregiving roles that they become socially isolated and lack an objective frame of reference for what constitutes normal caregiving. The deleterious effects of caregiver burden, including depression, an increase in stress-related disorders, and a shrinking social network, are well-documented. Physicians need to point out these effects to caregivers. Services to help caregivers include adult day care, respite programs, and home health care. In the United States, families should be referred for such services by using the Eldercare Locator (800-677-1116 ) or the National Association of Area Agencies on Aging (202-872-0888).
Prognosis for Elder Abuse
Abused older adults are at high risk of serious negative outcomes including premature mortality, depression, poor mental health, psychological distress, anxiety, and suicidal thoughts (1). In community-dwelling adults over age 65 referred for protective services for abuse, exploitation, or neglect, abuse appears to independently predict lower survival rates than among age-matched controls.
Prognosis reference
1. Yunus RM, Hairi NN, Choo, WY. Consequences of elder abuse and neglect: A systematic review of observational studies. Trauma Violence Abuse. 20(2):197–213, 2019. doi: 10.1177/1524838017692798 Epub 2017 Feb 22.
Prevention of Elder Abuse
A physician or other health care professional may be the only person an abuse victim has contact with other than the perpetrator and should therefore be vigilant for risk factors and signs of abuse. Recognizing high-risk situations can prevent elder abuse—eg, when a frail or cognitively impaired person is being cared for by someone with a history of substance or alcohol use disorder, violence, a psychiatric disorder, or caregiver burden. Physicians should pay particular attention when an older adult who is frail (eg, a person with a recent history of stroke or a newly diagnosed condition) is discharged into a precarious home environment. Physicians should also remember that perpetrators and victims may not fit stereotypes.
Older adults often agree to share their homes with family members who have substance or alcohol use disorders or serious psychiatric disorders. A family member may have been discharged from a mental or other facility to an older adult’s home without having been screened for risk of causing abuse. Physicians should therefore counsel patients considering such living arrangements, especially if the relationship was fraught with tension in the past.
Additional considerations should be made for the screening and hiring of in-home helpers, both from formal service agencies and informal private arrangements. A small, but meaningful, proportion of patients who use in-home helpers report concerns of theft, neglect, or mistreatment. Screening and training for such workers may help in preventing mistreatment.
Patients can also actively decrease their risk of abuse (eg, by maintaining social relationships, by increasing social and community contacts). They should seek legal advice before signing any documents related to where they live or who makes financial decisions for them.
