Elder abuse is a serious issue that affects families and society. Elder abuse involves the acts of commission (abuse) and omission (neglect), as do other definitions of domestic violence. Unlike spouse and child abuse, which were defined as key social issues in the 1960s, elder abuse did not surface as a social problem until the late 1970s in congressional hearings examining the status of aging in the United States. The awareness generated through government and the media brought attention to the phenomenon. There are many questions about the prevalence of elder abuse and the vulnerability of certain categories of elders to abuse.
One thing that makes elder abuse difficult to discuss is that it is difficult to measure. Because domestic issues remain largely private, the true prevalence of elder abuse is not known. The best estimates, based on national samples and state data, indicate that about 5 percent of persons over age 65 will be abused in some way. It seems that spouse abuse is the most common abuse of those past retirement age, although abuse by adult children does contribute to the problem. Given the dependencies that most aged persons have, their reliance on others sets the stage for exploitation. Elders are potential victims whether they are being cared for in their own homes by family or at a nursing home by paid staff. There is evidence to suggest that, as today’s elders are more likely to have retirement accounts and pension plans, their likelihood of being a victim of financial abuse is increasing.
I. What Is Elder Abuse?
II. Types of Elder Abuse
A. Physical Abuse
B. Sexual Abuse
C. Emotional Abuse
D. Financial Abuse
III. Brief History of Elder Abuse
IV. Controversies in Elder Abuse
V. Contributing Factors in Elder Abuse
VI. Gender Issues in Elder Abuse
VII. Help for the Elderly
What Is Elder Abuse?
Elder abuse is the sometimes intentional, but often times unintentional, mistreatment of a person over the age of 65. Elder abuse involves several aspects, including financial, physical, and emotional abuse. A special subcategory of physical abuse is sexual abuse. An inclusive definition of elder abuse would also consider neglect and self-neglect as additional aspects. Abuse of elders can lead to a worsening of the elder’s health or even to death. Questions surround the causes of elder abuse as well as the ways that treatment and prevention should be approached. The different categories of abuse do not affect all elders in the same way.
Types of Elder Abuse
Physical abuse can be any of the following: pushing, kicking, slapping, choking, beating, punching, pinching, throwing, hitting, paddling, shoving, inappropriate restraints, assaulting, or harming with hand or objects. This force can lead to pain, injury, impairment, and disease of an elderly person. Given that humans get weaker and frailer as they age, abuse of elderly persons is particularly likely to result in injury. Additionally, these persons are less likely to be strong enough to defend themselves from attack and may even be confined to a wheel chair or bed due to their physical conditions. For the oldest old persons, age 85 and over, the consequences of physical beatings can be severe. The physical indicators of abuse are dehydration, malnourishment, sprains, dislocations, bite marks, internal injuries, unexplained bruises and burns, welts, skull fractures, lacerations, black eyes, and abrasions. Older persons, due to dementia or other memory-impairing conditions, may be unable to explain how their injuries occurred and may find it difficult to get assistance or intervention from law enforcement.
Sexual abuse is any sexual activity performed on an elder without consent. Sexual abuse can be sexual intercourse, anal intercourse, or oral sex. Other sexual behaviors, however, can also be termed abuse if the elder is not a willing participant or is unable to provide consent. These activities include displaying one’s genitals or making the elder display his or hers, watching while the elder does sexual things, or making the elder watch while the perpetrator does sexual things. It can even include watching pornography, taking pictures, and sex talk. The most likely perpetrator of sexual abuse is a family member. This is because the elder trusts the family member and allows closeness without knowing that the family member wants to do harm. It is also possible for an elder to be abused in a nursing home or for an outside caregiver to be the perpetrator of sexual abuse, but these cases are more limited. An elder with a severe disability is more likely to be abused because of dependency on the help of the nursing home staff or outside caregiver. Indicators of sexual abuse include genital or urinary irritation, frequent infections, vaginal or anal bleeding, bruising on the inner thighs, sexually transmitted diseases, depression, conversation regularly is of a sexual nature, severe agitation when being bathed or dressed, agitation during medical examination, and sudden confusion. Depending on the circumstances, sexual abuse can involve both physical and emotional elements.
With emotional abuse, the elder is distressed, upset, depressed, experiencing withdrawal, and in emotional pain in this nonverbal or verbal situation. When elders are emotionally abused they become unresponsive, fearful, lack social interests, and evade others. Emotional abuse is equally likely to be perpetrated by a family member, nursing home staff, and outside caregivers. Elders may be particularly prone to emotional abuse, because they question their role in the family and society. Many persons perceive that, as they age, they are more of a burden on the family and have a harder time fitting in. They may feel that they deserve any treatment they receive because they cannot keep up mentally and physically with the younger generations. Some common types of emotional abuse include ignoring the elder, harassment and intimidation, insults and yelling, embarrassing or humiliating the elder, odd forms of punishment, and blaming. Also included are isolation from others or activities and not attending to the elder when necessary.
Financial abuse is the improper or illegal use of an elder’s money and property. The financial abuser can be anyone but is most likely a family member because family members have more direct access to aged family members’ resources. For various practical reasons, including fear of money management, tax savings, and inheritance, among others, elders may ask family members to tend to their financial concerns. Sometimes this takes the form of a power of attorney, where the family member is the legal guardian of the older person’s estate and is authorized to act as his or her agent. Other times the arrangement is informal, and the older person just asks someone else to keep his or her bank accounts and take care of daily financial transactions. Government estimates indicate that approximately 5 million elders are victims of financial abuse each year, with most cases going unreported.
A dishonest person can take advantage of the elder, misinforming him about his assets or using the money for one’s own needs. The person may even get the elder to consent to such things through threats or constantly harassing the elder about her financial status. Elders can be financially abused in many ways. They include exploitation and fraud by both primary and secondary contacts, signature forging, embezzling, and theft of property. Certain areas of fraud have targeted older persons and include home repair fraud, insurance fraud, medical fraud, telemarketing, and confidence games. Another egregious component is nursing home theft. Considering that most very old people are women, who often have fewer funds available at retirement than do men and often relied on their husbands to manage their funds prior to his death, the costs of financial abuse can be very high.
Neglect can occur when the elder is in isolation, has been abandoned, or a caregiver refuses to provide the elder with essential needs, including physical and emotional needs. Just as neglect is the most frequent type of child abuse, neglect is considered the most common type of elder abuse. Self-neglect is also a problem with elders. This can occur when an elder neglects his own needs. There are two types of neglect: active and passive. Active neglect is defined as refusal or failure to fulfill the needs of the elder. This would be intentional neglect. Passive neglect is also failing to fulfill an elder’s needs, but this type is unintentional. It has been known to occur in nursing homes that do not have the most qualified staff or the resources to meet the needs of the elder residents. Neglect is also done by family members and by outside caregivers. Examples of neglect include denial of needs such as food and water, lack of assistance with food and water (if required), improper supervision, inappropriate clothing for the type of weather, or inadequate help with bathing or other hygiene practices. Other examples are lack of access to the toilet, lack of diaper changing, strong smell of urine or feces, and physically restraining the elder without medical cause. Finally, refusing to seek required medical care for the elder is a type of neglect.
Brief History of Elder Abuse
Elder abuse first appeared on the public radar in the 1970s. However, many professionals did not care much about abuse of the elderly at the time and were more concerned with child abuse and abuse against women. Consequently, elder abuse was not taken very seriously. There was inadequate knowledge about the scope of the issue and what to do for such situations. There were few ways that family professionals could intervene in such cases. In the late 1970s, Congress began to hear of “granny battering” and became interested in this issue. As groups began to testify in Congress in defense of older Americans, the tide began to turn. In 1989, the Older Americans Act was proposed. While there was not a lot of money available to assist in stopping elder abuse, it was recognized as a problem, and, over time, more and more people became interested in this issue. The media helped to spread the word about elder abuse, getting the attention of medical professionals and the criminal justice system. Researchers began to attend to the issue as well. However, the extent of the problem remains hidden. The best estimates indicate that for every abuse case reported, there are about five more that are not reported.
Controversies in Elder Abuse
Although it is generally accepted that abuse is a problem in the culture that needs to be eradicated, the paths to decreased violence are often contradictory. Often experts suggest that one cannot end abuse without knowing the causes of abuse. Elder abuse shares some links with domestic violence causes in general, but because of the intergenerational nature of the abuse, there are some important differences. Another area of controversy involves whether gender plays a role in the status of both victim and perpetrator. Other questions remain as to the best course of action when dealing with older persons who have been abused and the role that the state plays in providing assistance to them.
Contributing Factors in Elder Abuse
There have been wide-ranging suggestions as to the factors that contribute to elder abuse. Not only have the ideas of “violence as a way of life” in U.S. society been blamed, but the cultural belief in the value of youth and devaluing of elderly, referred to as ageism, have been touted as a contributing factor. It seems likely that there are factors both within the culture as a whole and in the personal interactions of families that make abuse more likely to occur. Among the explanations in the literature are caregiver stress, victim disability, social isolation, perpetrator deviance, and victim-perpetrator dependency.
Situational factors can make caring for an elder particularly difficult. The caregiver may have emotional, psychological, financial, and mental problems of her own. These can become compounded when caring for an elderly person. A family member caring for an older relative may experience financial problems due to the material needs of the elder or missing work to care for the elder. The caregiving is particularly likely to compound any financial problems that were already there, leading to increasing stress for the caregiver. If the physical space is inadequate for the caring tasks, any poor housing conditions can become more concerning. Additionally, caregiving is stressful work, and many caregivers will feel overburdened after an extended time in the role. It is quite hard if persons are caring for more than one dependent at a time, such as caring for one’s child and aging parent simultaneously. The more dependent on a caregiver the elder person is, the more the stress for the person caring for the elder.
Some of the dependencies that exist between an abusive caregiver and victimized elder relate to the tactics and responses developed in family life that can carry over into adulthood. For example, a history of psychological or mental health problems, physical abuse, or poor communication or relationships in a family may continue. There also may be personality problems and difficult behavior displayed by the elder that compound the problem.
Abuse in an institutional setting such as a nursing home might occur, because an elder is cared for in an institution that lacks proper resources. This might refer to the physical structure of the facility but also includes a lack of training for the staff, inadequate staffing relative to need, and stressful work conditions. It is important to remember that there is a component of today’s society that argues the elderly are not important. They can no longer contribute to the economy and become costly. This approach suggests that elders feel unimportant as they age and become less critical in the operations of community life. The removal of older members from society and into nursing homes marginalizes elders, making them ripe for exploitation.
While each of these approaches may contribute to the abuse of any given elder, there is no definitive statement about which is the most powerful in explaining the phenomenon. Another variable in the abuse model is the gender of the victim and perpetrator.
Gender Issues in Elder Abuse
Are elders at differential risk of abuse by gender? Because the population of elderly is comprised of more women than men, due to women’s greater life expectancy, women have a higher chance of becoming a victim. Not only are there more women, but in general women have less power in society. Research on violent crime shows that women are more likely the victims of assaults perpetrated by family members and acquaintances than those by strangers. Does this pattern hold for elders?
One of the critical elements in elder abuse seems to be dementia. Elders with dementia and related problems are more likely to be victimized. In three out of four cases where the wife abused her husband, he was suffering from severe dementia. In those cases where the son was the abuser, the man also suffered from mild dementia. Dementia featured less prominently in the cases of men being psychologically abused. Daughters, fathers, and sons all abused mothers with severe dementia. For most of the elderly women who are abused, it is generally by someone they live with. Regardless of sex, the worse the health of the elder is, the more likely that the elder will be abused. Overall, women are abused more than men. This is partly because women live longer but they suffer from different health issues. Elder women’s health deteriorates more over the years, which makes them more prone to being abused.
Men and women are not equally likely to abuse elders. As the ones primarily responsible for caregiving, women have a greater likelihood of abusing elders. This is a point that has been quite controversial due to the assumption that men are more likely to use violence than women and that women are more nurturing than men. Although women relatives outnumber men relatives as abusers, it is wives who constitute the majority of abusers. In some studies, men have been found to be more likely to neglect an elder than are women. It is more likely that men financially abuse elders, and women physically abuse elders.
Help for the Elderly
The type of help proposed to counteract and decrease elder abuse depends on which of the explanations for abuse is applied. When the abuse is thought to be the result of caregiver stress, which is often associated with neglect, the abuse may be ameliorated by reducing how dependent the victim is on the caregiver. One way to assist is to bring services into the home so that the caregiver does not have to do everything. Meals on Wheels, respite care, skilled nursing care, housekeeping services, and so forth have all been proposed as strategies to reduce caregiver stress. Another component in reducing stress is the use of adult day care. Skill building and counseling for the caregiver have also been recommended.
If the abuse or mistreatment has more to do with the dependency, emotional or financial, between the perpetrator and the elder, which is often linked to physical abuse, the strategies change. Successful interventions might include mental health services, alcohol or drug treatment, job placement, housing assistance, or even vocational training. Sometimes emergency intervention is necessary, and courts may have to assign a guardian for the elderly person.
The National Center on Elder Abuse, part of the Administration on Aging of the U.S. Department of Health and Human Services, has been active in providing assistance to both caregivers and elders. It educates and advocates for better circumstances for senior citizens and is among the many groups focusing on elder abuse. It may be hard for an elderly person to come forward and ask for help after abuse, because he may not be able to do so, or may be afraid of getting hurt even worse. Elders can also have feelings of embarrassment, being ashamed of their victimization and expecting that no one will believe in them.
There is a lot that can be done to help. Abuse reporting hotlines are available to help caregivers and the elderly. Volunteers working at nursing homes can help identify problems or just be a friendly face who can listen to elders’ concerns. One group called Beyond Existing was formed for victims of elder abuse. This group determines the exact abuse problem, talks over the problem with the elder, lets the elder meet others that were in a similar position, and helps the elder plan for the future. Finally, there is also help for elders through physicians, nurses, social workers, and case management workers.
As a public health issue, elder abuse is not expected to end but to increase. Elders are treated by health care professionals, social workers, and case management workers to make sure their needs are met. Health care professionals indicate that elder abuse adds to a health care system already experiencing problems. Nurses play an important role in the detection and resolution of elder abuse. They work as individuals or in a team setting to assess elder mistreatment. If any degree of abuse is present, the most important goal of the nurse is to maintain the safety of the elder and possibly remove her from that care setting. It is also the nurse’s job to teach caregivers proper caring procedures for an elderly person, because they may lack the proper knowledge needed to care for an elder. Physicians have an ethical and, in most states, a legal role in the recognition of and intervention in suspected cases of elder mistreatment. To be fully successful, physicians should be aware of legal issues, ethical issues, and communication needs and have a solid base in principals of geriatric care. Physicians must be able to detect mistreatment bruises from normal bruises. The presence of physical abuse marks and the stated causes of them must be documented. If a physician suspects mistreatment, he or she is expected to report it. It is also the responsibility of the physician to interview the elder to assess the elder’s relationship with the caregiver. Social workers also have an important role in assessing elder abuse. Their main goal is to investigate any allegations of harm being done to an elder.
Elder abuse is a serious issue that society and families must examine and end. As U.S. society continues to age, the already large number of elders who are dependent upon others for daily care will only increase. To ensure that the aged are properly cared for, caregivers need support and training from a variety of sources and settings. Institutions should be monitored to ensure that they have all the proper resources to care for elderly patients, including a well-educated and not overburdened staff . The government plays a role through monitoring and legal regulation. Health care professionals should properly assess mistreatment of the elderly and get help right away.
- Anetzberger, Georgia J., The Clinical Management of Elder Abuse. New York: Haworth Press, 2003.
- Bonnie, Richard J., and Robert B. Wallace, Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Washington, DC: National Academic Press, 2003.
- Brownwell, Patricia J., and Stuart Bruchey, Family Crimes against the Elderly: Elder Abuse and the Criminal Justice System. New York: Garland, 1998.
- Hoff man, Allan M., and Randal W. Summers, Elder Abuse: A Public Health Perspective. Washington, DC: American Public Health Association, 2006.
- Nerenberg, Lisa, Elder Abuse Prevention: Emerging Trends and Promising Strategies. New York: Springer, 2008.
- Payne, Brian K., Crime and Elder Abuse: An Integrated Perspective. Springfield, IL: Charles C. Thomas, 2005.