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Elder Abuse and Neglect

Brenda Holmes MSN/Ed, RN

Elderly abuse is not often reported because the abusers usually are people the victims

Elder abuse is a general term used to describe harmful acts toward an elderly adult, such as physical abuse, sexual abuse, emotional or psychological abuse, financial exploitation, and neglect, including self-neglect.

Elderly Abuse
Elder Abuse Prevention Identification and Treatment Act passed in 1985 (modeled after the Child Abuse Act of 1974) 2004: 564,747 reports of elder abuse to the Adult Protective Services but only 191,908 were substantiated 1.2 % were over 65 years of age Higher for those over 80 years of age Estimated about 7% go unreported Importance to distinguish between
Reported Suspected Substantiated

Difficult to prove at times due to elders fear of the abuser or some type of retribution

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 care giving strategies.

Types of Abuse
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).

Types of Abuse
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.

Types of Abuse
Self Neglect: The older person fails to meet their own physical, psychological, and/or social needs. Usually seen in those with Alzheimer or some form of dementia

Types of Abuse
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.

Types of Abuse
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

Types of Abuse
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

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)

Potential Indicators of Abuse

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

Potential Indicators of Abuse

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.

Potential Indicators of Abuse

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

Potential Indicators of Abuse

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 elder1s mail Caregiver intentionally obstructs the older person1s 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.

Potential Indicators of Abuse

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 over sedation

Notify staff immediately on recognition of any problems that might indicate abuse and/or neglect.
Even raising your voice or tone of voice can be used as a form of abuse

Report to Ombudsman.
Responsible to investigate complaints on the behalf of the public

Case Scenario #1
Lets see if you can recognize if this is abuse: An elderly lady lives at home alone. She had just came home from the hospital due to severe illness and required help. Her niece lived next door and took the responsibility in caring for her. She would help her up to the wheel chair and get her settled in her home, bring her food during the day. Even take her out to sit on the porch. One day the niece wanted to go to a party on the weekend and asked her cousin to watch out for her grandmother.

The neighbor noticed that the elderly lady has not been out on the porch and saw that the niece has not come by over the weekend. She went to check on the elderly lady, finding her still in bed, laying in feces and urine, and no water near her. The elderly was not responding to her when she asked where her family was. Adult protective services was called.
Name the type of abuses do you see.

Case Scenario #2
Marian is the youngest of four daughters. Aged 42, she is still unmarried, although she became engaged about a year ago. Marians mother has suffered from dementia for the last six years. After a bout with pneumonia and a stay in the hospital, it became obvious that she could not return to her home alone. All Marians sisters have their own families and naturally turned to Marian to car for their mother. Marian felt guilty. It had only been fives years ago that she got her own apartment, and she wondered whether her departure contributed to her mothers downhill course. So her mother come to live in Marians apartment. Initially things went well but after several months Marians fianc, who had begun to see himself as married to two women, broke off the engagement. Marian was heartbroken and angry. She resented having to be a caretaker for her mother and having to eke out a meager income as a psychiatric aide. Soon after her fianc broke their engagement, Marian discovered that a bottle of wine after dinner eased her sorrow. Her mother was beginning to become disturbed at night, waking up several times each night and sometimes wandering out of the house. Marian had to get up from a sound sleep to put her mother back in bed and had difficulty functioning at work the next day. Eventually her mother became incontinent of urine and stool, falling, turning on the gas stove with no flame. Over time Marian lost her job for shouting out at a patient, drinking more, tying up her mother with a vest restraint she had stolen from the nursing home when she had to go to the store so she would not fall, and began to resorting to hitting her mother. Name the type of abuse.

Case Scenario Cont

Even though Marian was wrong in what she was doing, she did attempt to apply for a nursing home placement. The sisters, who rarely came by to assist, spoke with their mother and sided with their mother that there was nothing wrong. This presented a problem for Marian. Marian felt she has been abandoned by her family and sentenced to a life of hell.

Case Scenario #3
An elderly lady is present in the hospital with pneumonia. She is dependent in all ADLS, has a feeding tube, incontinent of bladder and bowels. She is unable to express her needs or wants. The oldest child was visiting her mother in the hospital when another sibling (she has been taking care of her mother) came by to have the mother sign her check so she can buy her daughter some clothes. This began an argument between siblings. 1. Do you think the sibling had the right to get her mothers check? 2. What do you suspect might be going on at home? What type of abuse would be suspected?


Woolf, L. M. Ph.D., Webster University Concise Dictionary of Modern Medicine. (2002) McGrawHill. http://medicaldictionary.thefreedictionary.com/elder+abuse Adams, C. H. & Jones, P. D. (2011). Therapeutic Communications for Health Professionals. New York: McGraw-Hill.