Elder Abuse: Types, Signs, Symptoms and Causes
Elder abuse has reached epidemic proportions in the United States. Elderly people may be more vulnerable to abuse than others because of social isolation and mental impairment. Abuse of the elderly can occur in the elder's home, in a nursing home, or in public. The perpetrators of elderly abuse may be professional caregivers; relatives; spouses; partners; doctors; lawyers; bankers; accountants; or strangers. A caregiver may be unable to cope with the demands of caring for an elder, and some of the stress is relieved when they take advantage of someone else who is more vulnerable.
Abusing an elderly person is like the bullying of a smaller, younger child on the playground. The older person who cannot stand up for themselves verbally or physically is an easy target. The elder, just like the young child, may not know how to stop the abuse and will therefore have to suffer relentlessly.
In this article, we discuss types of senior abuse, signs and symptoms, causes, instructions for reporting elder abuse, getting help for the abused or the abuser, and prevention of elderly abuse.
What is the definition of elder abuse?
Elder abuse is the intentional or unintentional hurting, either physical or emotional, of a person who is age sixty or older.
What are the types of elder abuse?
Elder abuse usually occurs in one of two locations:
- domestic elder abuse (in the elder's home)
- institutional elder abuse (in a nursing home or other long-term-care facility)
The types of senior abuse are:
- Physical abuse of the elderly
- Emotional abuse of the elderly (psychological or verbal)
- Neglect or abandonment of elders by caregivers
- Self-neglect by elders
- Sexual abuse of the elderly
- Financial exploitation of seniors (elder financial abuse)
- Healthcare fraud or healthcare abuse of the elderly
What is nursing home elder abuse?
Most elder abuse occurs at home. However, a significant proportion of elder abuse occurs in long-term-care facilities, such as in nursing homes, out of sight of the general public. Nursing home abuse can take any form: physical abuse, emotional abuse, sexual abuse, neglect, financial exploitation, or healthcare abuse. Elder abuse in nursing homes has recently gained media attention, and a federal program has been established to help prevent and resolve such abuse of the elderly.
Choosing a reputable nursing home is as important as continually keeping watch over the quality of care in the chosen facility. Look carefully at the contract for the residential care facility. The National Long-Term-Care Ombudsman Resource Center provides advocates to help choose a safe nursing home, as well as to resolve suspected senior abuse in a long-term-care facility.
What is physical abuse of the elderly?
Physical abuse is
- physical force that results in injury, impairment, or physical pain, or
- the threat of such physical force
Physical violence against an elder in the home is a form of domestic violence.
The injury from physical abuse may be from physical punishment of any kind, such as:
- assault (for example, during a mugging)
- beating, whipping, hitting (with or without an object), paddling, slapping, or punching
- pushing, shoving, shaking, choking, or throwing
- kicking, pinching, biting, or scratching
- spitting, force-feeding, hair-pulling, or burning
- inappropriate use of drugs and physical restraints
- rough handling during caregiving, moving the body, or administration of medicines
The practice of physically restraining elders in a nursing home is particularly troublesome and controversial. Physical restraint may sometimes seem necessary if the elder wants to get up and move around, but is unable to walk without falling. Where staffing is low, the elder cannot be left alone, so the staff uses physical restraints to keep the person in bed or in a chair. If the senior resists the physical restraints, the staff medicates them so that they are more compliant with the restraints. Physical restraint is legal, but many family members would prefer that their loved one fall occasionally, rather than be strapped into a chair or bed against their will.
What is emotional abuse of an elder?
Emotional elder abuse is a verbal or nonverbal act that inflicts emotional pain, anguish, or distress on the elder. It is sometimes also known as verbal abuse, mental abuse, or psychological abuse.
Emotional elderly abuse is almost always accompanied by another form of abuse, such as physical abuse. Emotional abuse of the elderly can range from a simple verbal insult to an extreme form of verbal punishment. The following are examples of emotional abuse:
- ignoring the elder
- isolating an elderly person from family, friends, or regular activities
- habitual scapegoating or blaming
- harassment, name-calling, cursing, humiliating, insulting, or ridiculing
- threatening to punish or deprive, intimidating
- treating an elder like an infant
- using extreme or bizarre forms of punishment, such as confinement to a closet or dark room, tying to a chair for long periods of time, or terrorizing
- yelling or screaming
Some overlap exists between the definitions of emotional abuse and emotional neglect; regardless, they are both elder abuse.
What is elder neglect?
Neglect of the elderly can be either physical or emotional. Neglect consists of confinement, isolation, or denial of essential services. The caregiver who neglects the elder refuses or fails to provide or pay for the necessities of life, such as food, water, shelter, clothing, healthcare, medicine, comfort, and safety. Abandonment, a type of neglect, is when the responsible caregiver deserts the vulnerable senior.
Physical neglect of the elderly
A caregiver who physically neglects an elder does not provide for basic physical needs. This kind of neglect includes:
- lack of supervision and monitoring
- inappropriate housing or shelter
- inadequate provision of food or water
- lack of assistance with eating or drinking
- inappropriate clothing for the weather
- denial or delay of medical care
- inadequate help with hygiene or bathing
- inadequate hand-washing on the part of the caregiver, which leads to infections
- physical restraint (in bed or in another area of the house)
- incorrect body positioning, which can lead to limb and skin damage
- lack of help in moving around, either within the bed or within the physical environment
- lack of access to the toilet or inadequate changing of diapers or disposable briefs, which can lead to incontinence, agitation, falling when trying to get to the bathroom independently, skin damage from sitting in urine and feces, and indignity
Emotional neglect (psychological neglect) of the elderly
Emotional neglect is a lack of basic emotional support, respect, and love, such as:
- not attending to the elder; ignoring moans, calls for help, or hospital call bells
- inattention to the elder's need for affection
- failure to provide necessary psychological care to the senior, such as therapy or medications for depression
- isolation of the elder from the outer world, including restriction of phone calls, mail, visitors, and outings
- lack of assistance in doing interesting activities, such as watching preferred television programs or going out for cultural or intellectual activities
Some overlap exists between the definitions of emotional abuse and emotional neglect; regardless, they are both elder abuse.
What is elder self-neglect?
Elders can neglect themselves by not caring about their own health or safety. Elder self-neglect can lead to illness or injury. The senior may deny themselves or ignore the need for:
- food or water
- bathing or other personal hygiene
- proper clothing for the weather
- shelter, adequate safety, or clean surroundings
- essential medications or medical attention for serious illness
In addition, self-neglectful elders may have the following behaviors:
- leaving a stove on, but unattended
Note that some elders who are sound of mind may choose to deny themselves some health or safety benefits. This is not self-neglect, but, rather, personal choice. Others must therefore be sensitive about intervention.
What is sexual abuse of the elderly?
Elder sexual abuse is sexual contact with an elder without that person's consent. This includes:
- coerced nudity
- fondling, touching, or kissing, particularly the genitals
- making the elderly person fondle someone else's genitals
- forcing the elder to observe sexual acts
- photographing the elder in sexually explicit ways
- sexual assault of any type (coercion to perform sexual acts), including rape or sodomy
- showing the elder pornographic material
- spying on the elder in the bathroom or bedroom
- telling "dirty" stories
What is financial exploitation of the elderly?
Financial or material exploitation of an elder is when someone illegally or improperly uses an elder's assets, funds, or property. Because elderly people are sometimes unable to hear or see well or to be as forceful physically or verbally as they used to be, they are easy targets for exploitation. The financial abuser may take, misuse, or conceal the elder's belongings or money. The financial abuser can be a family member; a caregiver or caretaker; a professional, such as an accountant, lawyer, doctor, or banker; a new boyfriend, girlfriend, spouse; or partner; or a stranger.
A caregiver who financially exploits an elder takes control of the elder's world. The caregiver might isolate the senior from the outside world, handle all financial matters, withhold food and medicine to weaken the elder, and psychologically abuse the elder so that he or she is afraid of doing anything about the situation. Such a caregiver tells elders that no one else cares about them; that if they don't do what the caregiver says, they will lose their house and have to go into a nursing home; and that they must listen to the caregiver or be punished with physical harm or neglect. If isolated and weakened enough, the elder cannot tell the difference between a caring person who is trying to put financial matters in order and a scheming person who is taking advantage of them.
Some of the types of financial elder abuse are:
- cashing an elder's checks without authorization
- using the elder's charge card number for one's own benefit
- handling an elder's money without durable power of attorney (which authorizes the person to manage the elder's finances)
- withdrawing cash from an elder's bank account with an ATM card, without the elder's permission
- scamming an elder by convincing him or her to withdraw money from the bank, and then taking the money
- stealing elders' checks, such as Social Security checks or pension checks, from the U.S. mail
- identity theft, including collecting checks and cashing them after the person has died
- convincing or forcing an elder to sign a contract that results in unwanted financial or material commitments
- convincing or forcing an elder to alter a will to benefit someone that a clear-thinking elder would not have chosen
- enrolling a senior in unneeded services or subscriptions
- getting donations from an elder under false pretenses
- defrauding an elder so that they sign up for a particular investment opportunity that isn't really appropriate (investment fraud)
- giving the elder incorrect change for a purchase in a store
- stealing household goods or money while caring for an elder
- telemarketing fraud
- selling sweepstakes entries where the elder is extremely unlikely to win anything
- forging the senior's signature
- in a long-term-care facility, not depositing resident funds in separate interest-bearing accounts
- marrying someone for his or her money, either for a current lifestyle change or to inherit their money after death
What is healthcare fraud or healthcare abuse of the elderly?
Healthcare fraud or abuse is less visible than some other forms of elder abuse. Healthcare abuse includes:
- not providing healthcare, but charging for it
- overcharging or double-billing for medical care or services
- getting kick-backs for referrals to other providers or for prescribing certain drugs
- patient abuse or neglect in a hospital, at home, or in a residential care setting
- overmedicating or undermedicating
- recommending fraudulent remedies for illnesses or other medical conditions
- Medicaid fraud: includes any of the above types of healthcare fraud or abuse, but specifically carried out in a Medicaid facility or funded by Medicaid
Those who carry out healthcare abuse can be doctors, nurses, hospitals, caregivers, unlicensed medical "professionals," and nonprofessional healthcare providers.
Some overlap exists between the definitions of caregiver neglect and healthcare abuse.
What are the signs and symptoms of elder abuse?
The following are warning signs of some kind of elder abuse:
- frequent arguments or tension between the caregiver and the elderly person
- changes in personality or behavior in the elder
If you suspect elderly abuse, but aren't sure, look for clusters of the following physical and behavioral signs.
Some signs and symptoms of physical abuse of the elderly
- symmetric injuries on two sides of the body
- unexplained bruises, pressure marks, black eyes, welts, lacerations, cuts, or burns
- bone fractures or broken bones
- sprains or dislocations
- internal injuries or bleeding
- bite marks
- broken eyeglasses or frames
- signs of being restrained, such as rope marks
- laboratory findings of medication overdose
- under-utilization of prescribed drugs
- a sudden change in behavior
- caregiver's refusal to allow visitors to see the elder alone
- an elder's report of being physically abused
Some signs and symptoms of emotional abuse of the elderly
- being upset or agitated
- apathy, withdrawal, depression, non-communication
- sucking, biting, or rocking (behaviors usually attributed to dementia)
- caregiver behaviors such as belittling, threats, or other powerful or controlling behavior
- an elder's report of being verbally or emotionally mistreated
Some signs and symptoms of elder neglect
- dehydration, malnutrition, extreme hunger
- untreated health or medical problems, such as bed sores
- hazardous or unsafe living conditions (e.g., improper wiring, no heat, or no running water)
- unsanitary and unclean living conditions (such as dirt, fleas, body lice, soiled bedding, or fecal or urine smell)
- unsuitable clothing for the weather
- being dirty or unbathed
- unusual weight loss
- desertion of the elder at a hospital, nursing facility, or other similar institution
- desertion of an elder at a shopping center or other public location
- physical restraints
- chemical restraints (drugs used for behavior control)
- contractures (muscles that are too stiff to move easily)
- an elder's report of being mistreated or abandoned
Some signs and symptoms of elderly self-neglect
- dehydration or malnutrition
- physical weakness
- foul body odor, poor personal hygiene
- foul household odor
- human or animal feces and urine in the house
- medical conditions left untreated
- lack of medical aids such as hearing aids, glasses, or dentures
- inadequate, unsafe, or unclean housing (no running water, no heating, no functioning toilet facilities, nonfunctional wiring, pest infestations)
- inadequate clothing for the climate
Some signs and symptoms of sexual abuse of the elderly
- bruises around the breasts or genitals
- unexplained venereal disease or genital infections
- unexplained vaginal or anal bleeding
- torn, stained, or bloody underclothing
- an elder's report of being sexually assaulted
Some signs and symptoms of financial or material exploitation of seniors
- large cash withdrawals from the elder's bank account
- the elder's withdrawal of a large sum of money from the bank when accompanied by another person
- numerous withdrawals from the elder's bank account, particularly in round amounts, such as $100 or $500
- large checks written to unusual recipients
- names being added to the senior's bank account signature card
- objects or money missing from the senior's household
- withdrawals from investments in spite of penalties for early withdrawal
- abrupt changes in wills, trusts, contracts, the power of attorney, the durable power of attorney, property titles, deeds, or mortgages
- changes in beneficiaries on insurance policies or IRAs
- sudden changes in the elder's financial situation
- home or institutional care that is lacking, despite sufficient funds to cover the care
- unpaid bills, despite enough assets to cover the payments
- forged signatures
- unnecessary services, goods, or subscriptions
- financial activity that is inconsistent with the elder's abilities, such as ATM withdrawals when the elder never leaves the house
- sudden appearance of friends or relatives claiming the right to goods or inheritance
- sudden close relationship with a much younger, more able person (including marriage or domestic partnership)
- extreme interest in and participation in the elder's financial matters on the part of the caregiver
- the caregiver has no other means of support besides caring for the elder
- the elder's sudden reluctance to discuss financial matters
- increasing tiredness or depression on the part of the elder
- increasing lack of contact with and interest in the outside world, reluctance to accept visits or phone calls
- the caregiver restricts the elder's contact with the outside world, such as speaking for the elder, refusing phone calls, preventing visits, reading mail for the elder, handling all expenditures, and not taking the elder on purchasing errands or other outings
- the elder's admission of financial or material exploitation or suspected exploitation
Some signs and symptoms of healthcare abuse or fraud of the elderly
- duplicate billings for a medical service or device
- the count of pills left in a container is either under or over the expected amount for the period of time for which they were prescribed
- lack of or inadequate medical care, even though bills are being paid
- in the elder's living space, a huge number of remedies for various medical conditions, including many non-prescription remedies
What are the causes of elder abuse?
Sometimes those who care for elders are not suited to the requirements of the job, and they allow themselves to vent their impatience, frustration, and anger on the elder whom they are supposed to be protecting and nurturing.
In nursing homes, in particular, staff may be prone to elder abuse because of:
- insufficient staffing
- lack of training
- stressful working conditions
- staff burnout
Sometimes neglect is not intentional; it may be the result of lack of adequate training about how to care for the elderly or because staff members cannot monitor needy elders in a timely manner.
Taking care of the elderly, whether at home or in an institution, can be very stressful. The incidence of depression is very high among caregivers. Caregivers habitually lack exercise and outdoor time, have inadequate nutrition, and need more sleep. Many people with dementia have trouble sleeping, so caregivers are kept up caring for them. Caregivers have a high level of anxiety. Because stress affects the heart and cardiovascular system, the stresses of caregiving can even lead to death in the caregiver.
The amount of stress that the caregiver experiences depends upon:
- the elder's type of disease or dementia
- the progression of the elder's requirements for care: at first, care may have been mundane errands or financial management, but the needs may have progressed to helping to eat, bathe, and toilet
- how the caregiver perceives the responsibility of caring for the elder (burdensome or not)
- what the elder thinks about the caregiver
- how the caregiver perceives the care recipient: if the caregiver finds the care recipient to be ungrateful, the caregiver is more likely to feel stressed
- how close the elder and caregiver were before and how close they are now
- how the caregiver copes with stress, in general (resilience)
- whether others help with the caregiving
- violence or aggression from the elder
Caregiver depression and living with the care recipient are predictors of caregiver elder abuse.
Violence from a care recipient toward the caregiver is strongly related to subsequent caregiver violence. A history of domestic violence in the household makes a senior more likely to be included in the domestic violence.
Financial exploitation of the elderly is related to the lack of boundaries regarding using another person's belongings and money. Sometimes this lack of boundaries is criminal, and sometimes it is simply a lack of ethical behavior. The exploiter gains because of the vulnerability of the elder.
Who abuses the elderly?
Most elder abuse occurs in the elder's home, and the abuser is usually a family member. Most commonly, the perpetrators of elderly abuse are spouses or partners of elders. Next most frequent abusers are the adult children of elders.
Abusers can be men or women. Men ages thirty-six to fifty are the most common perpetrators.
In nursing homes and other long-term-care facilities, the abusers may be employees, outside visitors, or intruders.
Anyone associated with an elder may abuse them: friends, relatives, doctors, lawyers, bankers, accountants, clergy, caregivers, or strangers.
What are the results of elder abuse?
Elder abuse can have a host of resultant conditions:
- inability to move (immobility)
- longer time to heal
- pressure sores or bed sores
- dehydration, malnutrition, or starvation
- loss of dignity or self-esteem
- loss of friendships and companionship
- loss of assets, poverty, homelessness
- criminal attack (due to lack of precautionary measures)
- worsening or irremediable medical conditions