Introduction
Elder abuse is the physical, emotional, or psychological injury or risk of injury; financial exploitation; or neglect in providing basic needs of an older adult. Although there is no universally accepted definition of old age, generally sixty or sixty-five years is considered the beginning of old age. Older Americans are the fastest growing population in the United States. According to the US Census Bureau, individuals sixty-five years of age and older made up more than 13 percent of the US population in 2012; that number is expected to increase to more than 20 percent by 2050, according to estimates by the US Department of Health and Human Services' Administration on Aging. As more responsibility is placed on family members to care for aging relatives, elder abuse is likely to increase as well.
Elder abuse usually constitutes repetitive acts of commission or omission that threaten the health and welfare of an older adult. Elder abuse does not receive the same recognition as child abuse and spousal violence and is often underreported or not reported at all. As such, the number of abused elders is probably highly underestimated. Victims often do not report abuse because they are embarrassed, fearful of repercussions by their caregivers, and likely to harbor feelings of guilt if they report their only source of shelter, support, and care.
Because so few people report elder abuse, it is important for health care providers to identify and know their obligations to report such abuse. In 1981, Congress proposed legislation to establish a national center on elder abuse, but the bill never reached the floor of Congress. In 1989, it was reintroduced as an amendment to the Older Americans Act, and elder abuse was finally recognized in federal legislation.
Types of Abuse
Physical abuse is the deliberate infliction of physical pain or injury. Examples include slapping, punching, bruising, or restraining. Psychological abuse is the infliction of mental or emotional anguish. Examples include verbal insults, humiliation, or threats. Financial exploitation is using the resources of an elderly person without consent. Examples include writing checks without permission and stealing money. Neglect is failure of a caretaker to provide basic needs to prevent physical harm, mental anguish, or illness. Examples include withholding nourishment, ignoring cleanliness, and neglecting physical needs. Self-neglect occurs when an elderly person compromises his or her health and safety by refusing assistance in care. Examples include refusing to eat and refusing needed medications. Sexual abuse is any unwanted sexual behavior. Examples include inappropriate touching and rape.
Possible Causes
Risks for elder abuse are divided into four major categories: physical and mental impairment of the victim, caregiver stress, transgenerational violence, and abuser psychopathology. Impairment of a dependent elder and a family history of violence and substance abuse are also identified as causes for elder abuse.
Though studies do not relate the victim’s level of frailty to abuse, physical and mental impairment indirectly increase the risk of abuse because the victims are unable to leave an abusive environment or effectively defend themselves.
Caregiver stress may result in acting out anger toward the elderly person. Stress factors contributing to such outbursts may be related to the victim as well as to the caregiver and include alcohol or drug abuse, employment issues, low income, increased risk of falls, incontinence, verbal or physical aggression, and poor caregiving skills caused by a lack of knowledge about how to care for the elderly.
Transgenerational violence supports the premise that abuse is a learned behavior passed between generations. As such, a child who was abused by a parent may be abusive to the parent on becoming the caregiver. Domestic violence can persist throughout the life span and does not necessarily stop in old age.
Abuser psychopathology relates elder abuse to substance abuse and addiction, personality and mental disorders, and dementia. Risk factors for elder abuse as identified by the American Medical Association include living with the abuser, dementia, social isolation, and mental illness as well as alcohol or drug use by the caregiver. Other theories that have been used to explain elder abuse are exchange theory, which proposes dependencies between a victim and a perpetrator related to reactions and responses that continue into adulthood;
social learning theory, which proposes that abuse is learned; and political economic theory, which proposes that the challenges faced by elders leave them in poverty and take away their importance in community life. Political economic theory addresses the marginalization of elders in society.
Prevention
Every state in the United States defines elder abuse, has passed elder abuse prevention laws, and employs some form of an elder abuse reporting system. Unfortunately, laws and the definition of abuse are inconsistent among states. Adult Protective Services (APS) are available in every state but provide assistance only when the victim agrees or is rendered mentally incapable to make decisions by the courts. Education about what constitutes abuse and neglect needs to be clear. Additionally, an understanding that abusive behavior in any form is never acceptable needs to be established. Finally, information about counseling for caregivers should be available so they know that services and support exist for them when they require it. Educating the public and raising public awareness of the extent of elder abuse are effective ways to prevent elder abuse. Increased social services to provide support for caregivers, respite care and counseling for family, and information about social issues that are triggers for abuse can be instrumental in preventing abuse. Developing an understanding of the risk factors for elder abuse and its signs and symptoms are also crucial in preventing cases of elder abuse.
Psychology Today offers some tips for older adults to keep them safe from abuse. These tips include maintaining a social life, remaining in touch with friends after moving in with a relative, asking a friend to check in weekly, and inviting friends to visit often. Older adults are also encouraged to make new friends and participate in community activities. They should check their own mail, report instances in which mail is intercepted, and have their own telephones. They should keep track of their belongings and make others aware that they know where everything should be. Older adults should attend to their personal needs as much as possible and keep appointments with doctors and dentists and other planned activities. They should maintain financial control and have Social Security or pension checks deposited directly to a personal bank account. Older adults should obtain legal advice about possible future disability, wills, property, powers of attorney, guardianships, or conservatorships. They should keep records, accounts, and property available for trusted people to manage affairs when they no longer can. They should not live with a person who exhibits violent behavior or alcohol or drug abuse. They should not leave their homes unattended for lengths of time or leave signs that they are not home, such as notes on the door. Instead, they should notify the police when they will be away. Older adults should not leave cash, jewelry, or other valuables in nonsecure locations. They should not accept personal care in return for the transfer or assignments of property unless a lawyer, advocate, or trusted person acts as a witness. They should not sign documents unless someone they trust has reviewed it and should not allow anyone to keep details of their finances or property management from them.
Diagnosis and Screening
Elder abuse often goes undetected because its signs and symptoms may be missed or victims may deny that injuries are a result of abuse. Symptoms may be mistaken for dementia, or caregivers may explain them to others in that way. Because elder abuse can present itself in many different ways, injuries must be evaluated based on the victim’s general health and psychosocial environment. If elder abuse is diagnosed, then the victim’s safety must be ensured while respecting his or her autonomy and independence. Some alerts for suspected abuse include bruises and lacerations; broken or fractured bones, untreated injuries in various stages of healing; sprains, dislocations, and internal injuries; medication overdoses or underutilization of prescribed drugs; a victim’s report of being hit, kicked, or mistreated; a sudden change in behavior, such as agitation, depression, or withdrawal; dehydration or malnutrition; untreated bedsores and poor hygiene; untreated health problems; unsafe or unclean living conditions; and a caregiver’s refusal of visitors.
Besides the physical signs of abuse, there are a variety of assessment tools for screening for elder abuse. Health care providers should screen patients who are sixty years of age and older for abuse at least annually. Some questions that the American Medical Association suggests should be asked are the following:
Has anyone at home ever hurt you?
Has anyone ever touched you without your consent?
Has anyone taken anything that was yours without asking?
Has anyone ever threatened you?
Have you ever signed any documents that you didn’t understand or you didn’t want to sign?
Are you afraid of anyone at home?
Are you alone a lot?
Has anyone ever failed to help you take care of yourself when you needed help?
Reporting Abuse
Area Agency on Aging, the county Department of Social Services, and Adult Protective Services are agencies that investigate elder abuse and neglect. State ombudsman’s offices are instrumental in investigating and identifying elder abuse in long-term-care facilities. Once abuse or neglect is confirmed, protection services are mobilized. If the victim is mentally competent, then the victim must agree to accept the assistance. Alternately, the victim must be deemed by the courts to be mentally incapable of making decisions before assistance is mobilized.
All people share responsibility for reporting suspected cases of elder abuse. Professionals such as social workers, police officers, teachers, physicians, nurses, and those who provide services to the elderly are required by law to report suspected cases of elder abuse. One resource for reporting is the Eldercare Locator Hotline at (800) 677-1116. Calls are directed to a local agency for assistance. If 911 is called for suspected elder abuse, then the local police will intervene.
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