As the number and percentage of individuals 65 and over has increased in this country, so has the incidence of elder abuse. Unfortunately, the prevalence and nature of this growing problem has generally remained hidden from public view. It is imperative that both professionals and lay persons become more aware of the scope and many issues surrounding this sensitive topic.

This article addresses many of the concerns surrounding elder abuse ranging from information concerning the incidence of abuse to a discussion of intervention strategies. It is essential that the incidence of abuse and awareness of the range and breadth of various types of abuse be discussed and understood. However, an awareness of the problem of elder abuse is not enough. Therefore, issues surrounding detection of abuse and strategies for prevention and intervention will also be addressed.

Types of Abuse
Potential Indicators of Abuse
Possible Causes of Elder Abuse
Recommended Readings

Types of Abuse
Passive and Active Neglect: With passive and active neglect the caregiver fails to meet the physical, social, and/or emotional needs of the older person. The difference between active and passive neglect lies in the intent of the caregiver. With active neglect, the caregiver intentionally fails to meet his/her obligations towards the older person. With passive neglect, the failure is unintentional; often the result of caregiver overload or lack of information concerning appropriate caregiving strategies.
Physical Abuse: Physical abuse consists of an intentional infliction of physical harm of an older person. The abuse can range from slapping an older adult to beatings to excessive forms of physical restraint (e.g. chaining).
Material/Financial Abuse: Material and financial abuse consists of the misuse, misappropriation, and/or exploitation of an older adults material (e.g. possessions, property) and/or monetary assets.
Psychological Abuse: Psychological or emotional abuse consists of the intentional infliction of mental harm and/or psychological distress upon the older adult. The abuse can range for insults and verbal assaults to threats of physical harm or isolation.
Sexual Abuse: Sexual abuse consists of any sexual activity for which the older person does not consent or is incapable of giving consent. The sexual activity can range from exhibitionism to fondling to oral, anal, or vaginal intercourse.
Violations of Basic Rights: Violations of basic rights is often concomitant with psychological abuse and consists of depriving the older person of the basic rights that are protected under state and federal law ranging from the right of privacy to freedom of religion.
Self Neglect: The older person fails to meet their own physical, psychological, and/or social needs.
Potential Indicators of Abuse
Below are some potential indicators for each type of elder abuse. Please be aware that this does not represent a definitive listing.
Passive and active neglect
  • Evidence that personal care is lacking or neglected
  • Signs of malnourishment (e.g. sunken eyes, loss of weight)
  • Chronic health problems both physical and/or psychiatric
  • Dehydration (extreme thirst)
  • Pressure sores (bed sores)
Physical Abuse
  • Overt signs of physical trauma (e.g. scratches, bruises, cuts, burns, punctures, choke marks)
  • Signs of restraint trauma (e.g. rope burns, gag marks, welts)
  • Injury – particularly if repeated (e.g. sprains, fractures, detached retina, dislocation, paralysis)
  • Additional physical indicators – hypothermia, abnormal chemistry values, pain upon being touched
  • Repeated “unexplained” injuries
  • Inconsistent explanations of the injuries
  • A physical examination reveals that the older person has injuries which the caregiver has failed to disclose
  • A history of doctor or emergency room “shopping”
  • Repeated time lags between the time of any “injury or fall” and medical treatment
Material or Financial Abuse
  • Unusual banking activity (e.g. large withdrawals during a brief period of time, switching of accounts from one bank to another, ATM activity by a homebound elder)
  • Bank statements (credit card statements, etc.) no longer come to the older adult
  • Documents are being drawn up for the elder to sign but the elder can not explain or understand the purpose of the papers
  • The elders living situation is not commensurate with the size of the elder’s estate (e.g. lack of new clothing or amenities, unpaid bills)
  • The caregiver only expresses concern regarding the financial status of the older person and does not ask questions or express concern regarding the physical and/or mental health status of the elder
  • Personal belongings such as jewelry, art, furs are missing
  • Signatures on checks and other documents do not match the signature of the older person
  • Recent acquaintances, housekeepers, “care” providers, etc. declare undying affection for the older person and isolate the elder from long-term friends or family
  • Recent acquaintances, housekeeper, caregiver, etc. make promises of lifelong care in exchange for deeding all property and/or assigning all assets over to the acquaintance, caregiver, etc.
Psychological Abuse
    • Psychological Signs:
  • Ambivalence, deference, passivity, shame
  • Anxiety (mild to severe)
  • Depression, hopelessness, helplessness, thoughts of suicide
  • Confusion, disorientation
      • Behavioral Signs:
  • Trembling, clinging, cowering, lack of eye contact
  • Evasiveness
  • Agitation
  • Hypervigilance
  • Sexual Abuse
    • Trauma to the genital area (e.g. bruises)
    • Venereal disease
    • Infections/unusual discharge or smell
    • Indicators common to psychological abuse may be concomitant with sexual abuse
    Violation of basic rights
      • Caregiver withholds or reads the elder’s mail.
      • Caregiver intentionally obstructs the older person’s religious observances (e.g. dietary restrictions, holiday participation, visits by. minister/priest/rabbi etc.)
      • Caregiver has removed all doors from the older adult’s rooms.
      • As violation of basic rights is often concomitant with psychological abuse the indicators of basic rights violations are similar indicators as those for

    psychological abuse.

    Self Neglect – to be discussed in greater depth below.
    Additional Indicators of Abuse or Neglect
    • Elder is not given the opportunity to speak without the caregiver being present.
    • Caregiver exhibits high levels of indifference or anger towards the older adult.
    • Overmedication or oversedation.
    Elder Abuse Hotline:
    Your local phone book (usually the Blue Pages) or phone operator can provide you a local phone number.
    Be prepared to give:
    • Name of elder.
    • Address (include room number if in a long-term care facility).
    • Age (if known).
    • Phone number (if known).
    • Specifics of what is happening now – Why did you decide to call today?
    Calls are confidential
    After a call is received, a trained elder abuse case worker will respond. The most serious/dangerous cases will be responded to within the shortest period of time (within 24 hours).
    Adult Protective Services: In many states, Adult Protective Services, the Area Agency on Aging, the Division of Aging, the Department of Aging, or the Department of Social Services is designated to receive and investigate allegations of elder abuse and neglect. Your local phone book (usually the Blue Pages) or phone operator can provide you a local phone number.
    Local Law Enforcement: 911 or your local police number. Best place to call if the elder is in immediate danger
    Long Term Care Ombudsman Program: Designed to provide assistance in cases of abuse/neglect within a nursing home setting. Your local phone book (usually the Blue Pages), phone operator, or state agency on aging can provide you a local phone number
    Local Area Agency on Aging: Every area agency on aging operates an information and referral service. They can provide individuals with information concerning a broad range of services and programs available to individuals 60 and older. Your local phone book (usually the Blue Pages) or phone operator can provide you a local phone number.
    National Center on Elder Abuse: 1-202-682-2470 or 1-202-682-0100.
    810 First Street, N.W.
    Suite 500
    Washington, DC 20002
    Self-Neglect is a controversial category in relation to elder abuse. The following questions lie at the heart of the controversy. If an individual is competent but chooses to neglect their personal health or safety, it this abuse? Is intervention, particularly involuntary intervention, appropriate in cases of self-neglect.
    These questions go beyond the scope of this web site. Instead, this site will address issues factors involved in self-neglect, and potential intervention strategies.Self-neglect, if included statistically as a form of elder abuse, represents the highest percentage of cases of elder abuse. In fact, the Public Policy Institute of AARP estimates that self-neglect represents 40 to 50 percent of cases reported to states Adult Protective Services.Unfortunately, these statistics fail to take into account the fact that self-abusers do not fit a uniform profile. There are many factors which may lead one to self-neglect and the subsequent intervention necessary for each is unique.
    Potential Factors Leading to Self-NeglectLong-Term Chronic Self-Neglect: These individuals have engaged in self-neglecting behaviors periodically or consistently throughout adulthood. Thus, the pattern of self-neglect is not unique to old age. Often times, the individual may have an undiagnosed and/or untreated mental health problem.The problem may escalate when paired with physical impairment, social isolation, malnutrition, substance abuse, cognitive impairment, and/or limited financial recourses. Often times these individuals may be resistant to intervention as prior experiences with intervention (voluntary and/or involuntary) has not been positive and perhaps experienced as harmful. Therefore, interventions must begin small with a high degree of respect for the elder and their decisions. As trust increases, so can the amount of intervention or help provided.Dementia: The vast majority of older adults are not suffering from any form of dementia. However, those who may be in the early stage of dementia (e.g. Alzheimer’s Disease, Multi-Infarct Dementia) may be undiagnosed and susceptible to self-neglect. Clearly, the first step for intervention is diagnosis and appropriate medical treatment.

    Illness, Malnutrition, & Overmedication: Many illnesses (e.g. low grade infections, endocrine imbalance) may result in dementia-like symptoms. If left untreated, these symptoms may interfere with the older adult’s ability to care for themselves. For a variety of reasons, an older adult may be malnourished (poor nutrition, physiological changes).

    One of the symptoms of malnutrition, particularly in older adults, is dementia-like symptoms. In addition, overmedication (a common problem in old age due to overprescription of medications and/or age-related changes in the older person’s physiology) may also result in dementia-like symptoms and associated self-neglect. Again, diagnosis and appropriate medical treatment is imperative.

    Depression: Depression can be an issue for older adults much as it can be for individuals of any age. While there is a broad range of symptomatology for depression (too extensive for discussion here), two symptoms are particularly relevant: difficulty maintaining self-care and dementia-like symptoms. Contrary to common myth, depression is highly treatable in old age. Rapid intervention and treatment is particularly essential as there is a high risk of suicide for older white males in the United States; it is estimated that the rate of suicide for older white males may by as much as 12 times higher than for any other demographic/age group.

    Substance Abuse: Substance abuse can also be an issue for older adults. Some older adults suffer from long-term addictions and the concomitant disorders that accompany such additions (e.g. Korsakoff’s Syndrome with accompanying dementia). Thus, not only may the older person self-neglect as a direct result of the addiction but they may also self-neglect as a function of the resultant disorder. In addition, some older adults develop substance abuse problems in old age possibly in response to depression, stress, loss, or anxiety.

    They may also develop a substance abuse problem as a result of overprescription of medicines (e.g. Valium, Xanax) by their physician. Therefore, the substance abuse by itself, the underlying cause of the substance abuse, and/or the often accompanying dementia-like symptoms may result in self-neglecting behavior.
    Poverty: Many older adults live on the edge financially. Below are the 1990 census data for median incomes per month based on gender and race for individuals 70 or older.

    Male Female
    White 1034 646
    African-American 602 419
    Hispanic 568 426
    The figures above represent the median incomes per month. This means that 50 percent of the individuals in each category have less than the median income per month. For example, over half of older African American women had an income of less than 419 per month during the last U.S. census of 1990.

    Clearly, many of these individuals are forced to choose between food, housing, and medication. From the outside looking in, it may appear that the individual is choosing to self-neglect (e.g. he/she neglects take their heart medication or are undernourished) when in fact, they simply can not afford to adequately care for themselves. Therefore, intervention must take the form of increased social services/supports (e.g. rental subsidies, food stamps, low cost health care). Note that currently most older adults are not eligible for many of these services/subsidies as their income is above the Federal Poverty Line for individuals 65 and over (in 1990, the poverty line for seniors was 437.91 per month).

    Isolation: There is a clear cut correlation between social support and life satisfaction. As life satisfaction decreases, the risk for self-neglect increases. Isolation is a risk factor for all forms of elder abuse. Intervention entails the creation of trust, increased involvement of the older adult in the community, and the creation of social supports. This, of course, may be problematic for those individuals who have had little social support throughout their life-span.

    Possible Causes of Elder Abuse
    Elder abuse is an extremely complex problem. Below is simply a listing of some of the possible contributory factors related to elder abuse. It is important to also remember that these factors usually do not operate in isolation but rather interact in unique ways depending on the victim and perpetrators’ situation.

    Caregiver stress: Caring for a non-well older adult suffering from a mental or physical impairment is highly stressful. Individuals who do not have the requisite skills, information, resources, etc. and who are otherwise ill-prepared for the caregiving role may experience extreme stress and frustration. This may lead to elder abuse and/or neglect.

    Dependency or impairment of the older person: It has been argued that as an older adult1s dependency increases so does the resentment and stress of the caregiver. Studies have found that individuals in poor health are more likely to be abused that individuals who are in relatively good health. In addition, caregivers who are dependent on the elder financially is also more likely to perpetrate abuse. This is hypothesized to counteract the feelings of powerlessness that may be experienced by the caregiver.

    External Stress: External stress such as financial problems, job stress, and additional family stressors have been hypothesized to also increase the risk for abuse. This correlation has been clearly demonstrated in studies examining spousal or child abuse.

    Social Isolation: Abuse, whether spousal abuse, child abuse, or elder abuse occurs most often in families characterized by social isolation. Of course, this may be both an indicator of potential abuse as well as a potential contributing cause of abuse.

    Intergenerational transmission of violence: Individuals who are abused as children are hypothesized to become part of a cycle of violence. Violence is learned as a form of acceptable behavior in childhood as a response to conflict, anger, or tension. Thus, when these feelings arise during caregiving, the caregiver is at risk for becoming a perpetrator of elder abuse or neglect. Some have also hypothesized a “what goes around, comes around” theory of elder abuse. If the older person receiving the care previously abused their child, that child now in the role of caregiver simply is returning the abuse they suffered.

    Intra-individual dynamics or personal problems of the abuser: Some caregivers may be at risk for abusing elders as a function of their own difficulties. For example, a caregiver who suffers from such problems as alcoholism, drug addiction, and/or an emotional disorder (e.g. a personality disorder) is more likely to become an abuser than an individual who do not suffer from such problems.

    AARP has put together a comprehensive list of do1s and don1ts related to prevention of elder abuse. Consult AARP to request a copy of Domestic Mistreatment of the Elderly: Towards Prevention or consult your local AARP chapter. Some of AARP’s subjections are provided below: Towards Prevention for the Individual
    • Maintain social contacts; increase network of friends.
    • Keep in touch with old friends and neighbors even if you move.
    • Develop a buddy system with a friend outside the home.
    • Ask friends to visit you at home.
    • Participate in social and community activities.
    • Volunteer.
    • Get legal advice concerning arrangements you can make not for future disability (e.g. powers-of-attorney).
    • Review your will periodically.
    • Arrange to have your social security check or pension deposited directly into your bank account.
    • Don’t live with someone who has a history of violent behavior or substance abuse.
    • Don’t leave your home unattended.
    • Don’t sign a document unless someone you trust has reviewed it.
    Toward Prevention for Families
    • Maintain close ties with aging relatives and friends.
    • Find sources of help and use them.
    • Examine closely your family’s ability to provide long-term, in-home care.
    • Explore alternative sources of care.
    • Anticipate potential incapacitation and make plans based on discussion of the elder’s wishes.
    • Don’t offer personal home care unless you thoroughly understand the demands and can meet the responsibility and costs involved.
    • Don’t ignore your limitations and overextend yourself.
    • Don’t expect family problems to disappear once the elder moves into the home.
    • Don’t hamper the older person’s independence or intrude unnecessarily upon his/her privacy.
    Toward Prevention for Communities
    • Develop new ways to provide direct assistance to caregiving families.
    • Ask other community groups to become more involved in aging service programs.
    • Encourage both public and private employers to help caregiving families.
    • Publicize available support services and professionals available to caregivers.
    • Give public agency employees basic training in responses and case management.
    • Provide training for community “gatekeepers” and service providers.
    • Recognize that many forms of abuse or mistreatment are crimes.
    In addition, the following suggestions (perhaps a wish list) are presented in relation to prevention of elder abuse.
    1. Sufficient income, health care, and social services for all older adults.
    2. Public awareness and professional training in relation to elder abuse and other older adult issues.
    3. Coalition building.
    4. Mental health services and family counseling available to all in need of such services.
    5. Alcohol and substance abuse treatment programs available to all in need of such services.
    6. Assertiveness training, promotion of elder rights, and self-advocacy training for all older adults.
    7. Adequate caregiver training and services.
    8. Adequate and available financial management and planning services.
    9. Violence reduction, conflict resolution, and mediation programs and services available to all in need of such services/programs.
    10. Awareness and facilitation of positive and productive aging.
    Recommended Readings
    • Baumhover, Lorin A. and Beall, S. Colleen (eds.). (1996). Abuse, Neglect, and Exploitation of Older Persons: Strategies for Assessment and Intervention. Baltimore, MD: Health Professions Press.
    • Bureau of Justice Statistics. (1994). Elderly Crime Victims: National Crime Victimization Survey. Washington, D.C.: U.S. Dept. of Justice, Office of Justice Programs, Bureau of Justice Statistics.
    • Byers, Bryan and Hendricks, James E. (1993). Adult Protective Services: Research and Practice. Springfield, Ill.: C.C. Thomas.
    • FHP Foundation. (1995). Silent Suffering: Elder Abuse in America: Elder Abuse in Rural and Urban Settings: Report on Focus Group Activities and Recommendations for the 1995 White House Conference on Aging. Long Beach, CA: FHP Foundation.
    • Kosberg, Jordan (Ed.) (1983). Abuse and Maltreatment of the Elderly: Causes and Interventions. Boston: John Wright.
    • Galbraith, Michael (Ed.) (1986)Elder Abuse: Perspective on an Emerging Crisis. Kansas City, Kansas: Mid-American Congress on Aging.
    • National Institute of Justice et al. (1993).Triad: Reducing Crime Against the Elderly: An Implementation Handbook. Washington, D.C.: U.S. Dept. of Justice, National Institute of Justice.
    • Nerenberg, Lisa. (1993).Improving the Police Response to Domestic Elder Abuse: Instructor Training Manual and Participant Training Manual. Washington, D.C.: Police Executive Research Forum.
    • Quinn, Mary, and Tomita, Susan. (1986). Elder Abuse and Neglect: Causes, Diagnosis, and Intervention Strategies. New York: Springer Publishing.
    • Tatara, Toshio. (1995). An Analysis of State Laws Addressing Elder Abuse, Neglect, and Exploitation: A Final Report. Washington, D.C.: National Center on Elder Abuse.
    • Tatara, Toshio. (1993).Summaries of the Statistical Data on Elder Abuse in Domestic Settings for FY90 and FY91: A Final Report. Washington, D.C.: National Aging Resource Center on Elder Abuse.
    • Victim Services. (1993).Close to Home: Elder Abuse: Intervention Strategies for Clinicians.New York: Victim Services. (Videotape)
    • Vinton, Linda. (1993). Abused Elders or Older Battered Women?: Report on the AARP Forum, October 29-30, 1992, Washington, D.C. Washington, D.C.: AARP Women’s Initiative.
    Copyright 1998 Linda M. Woolf, Ph.D., Webster University