CHAPTER 298
Elder Mistreatment
Elder mistreatment refers to harm or the threat of harm to an older person by another person. It includes abuse and neglect.
Older people can be mistreated by having harmful things done to them (abuse) or by having necessary things withheld from them (neglect). Elder mistreatment is a growing problem as the number of older people increases.
Each year in the United States, thousands of older people are mistreated. The perpetrator of mistreatment is usually a family member, most often an adult child or spouse who is the older person’s caregiver. Sometimes professional caregivers, such as home health care workers or employees of nursing homes and other institutions, mistreat older people.
Any older person, regardless of health, can be mistreated. However, mistreatment is more likely when older people
Are physically frail, often because of disabling chronic disorders
Are socially isolated
Have dementia or confusion
Mistreatment is also more likely when the perpetrators
Are financially dependent on or living with the older person
Abuse alcohol or drugs
Have a psychologic disorder, such as schizophrenia
Have been violent before
Have stress, such as financial problems or a family death
Lack skills and resources, making caregiving frustrating
Have a disorder (such as dementia) that makes them (even if they were previously mild-mannered) agitated or violent
Caregivers are often overwhelmed by the demands of care, have inadequate preparation or resources, or do not know what is expected of them (see box on page 1907). They may also become increasingly socially isolated, sometimes increasing their resentment and making mistreatment more likely. Many caregivers do not intend to mistreat the person, and some may not even know that they are mistreating the person.
Many older people who are mistreated do not seek help for various reasons. They may be physically unable to do so. Or they may be afraid of being harmed further, of being abandoned, or of being forced into a nursing home. If the perpetrator is the caregiver, older people may feel too dependent on or want to protect the perpetrator, who may also be their adult child. They may feel ashamed.
The signs of mistreatment can be difficult to distinguish from other problems. For example, if an older person has a hip fracture, health care practitioners may be unable to distinguish whether the cause is physical abuse or osteoporosis, falls, or both (which are much more common causes). Also, if older people are confused, they may not have their complaints of abuse taken seriously, so the abuse goes unrecognized.
For all these reasons, doctors, nurses, social workers, friends, and family members often do not recognize mistreatment.
Types of Mistreatment
Older people may be abused, neglected, or both.
Abuse
Abuse can be physical, sexual, psychologic, or financial. Older people may be subjected to one or more of these types of abuse.
Physical abuse is the use of force to harm or to threaten harm. Examples are striking, shoving, shaking, beating, restraining, and force-feeding. Possible indications of physical abuse include unexplained injuries or injuries that are not treated adequately, rope burns and other rope marks, broken eyeglasses, and scratches, cuts, and bruises. A caregiver’s refusal to allow an older person to have time alone with visitors or health care practitioners can raise concerns about physical abuse.
Sexual abuse is sexual contact without consent or by force or threat of force. Examples are intimate touching and rape. Bruises around the breasts and genital area or unexplained bleeding from the vagina or anus may indicate sexual abuse. However, sexual abuse does not always result in physical injuries.
Psychologic abuse is the use of words or actions to cause emotional stress or anguish. It may involve
Issuing threats, insults, and harsh commands
Ignoring the person (for example, by not speaking for a long time or after being spoken to)
Treating the older person like a child (infantilization), sometimes with the goal of encouraging the person to become dependent on the perpetrator
People who are psychologically abused may become passive and withdrawn, anxious, or depressed.
Financial abuse is the exploitation of a person’s possessions or funds. It includes
Swindling
Pressuring an older person to distribute assets
Managing an older person’s money irresponsibly
Caregivers may spend most of an older person’s income on themselves and provide only a minimum amount for the older person.
Restricting an older person’s freedom to make important life decisions, such as whom to socialize with and how to spend money, is sometimes considered another, more subtle form of abuse.
Neglect
Neglect is the failure to provide food, drugs, personal hygiene, or other necessities. Necessities may be withheld intentionally or simply be forgotten or overlooked by irresponsible or inattentive caregivers. Some caregivers are unaware that their treatment of an older person has crossed the line from being less than ideal to being mistreatment. These caregivers may lack a sense of what constitutes adequate and appropriate care, or they may have very different notions of what conduct is and is not acceptable.
Sometimes neglect results from desperate circumstances, such as financial difficulties, despite the caregiver’s best intentions. Sometimes willing caregivers are unable to provide adequate care because of their own physical limitations or mental impairment. For example, caregivers may be unable to bathe the older person or to remember to give the person a drug.
When to Suspect Mistreatment
When older people have certain problems or make certain changes, family members and friends, as well as health care practitioners, should be aware that mistreatment may be the cause. These problems include the following:
Poor hygiene or an unpleasant odor
Pressure sores
Weight loss and a dry mouth
Missing eyeglasses, hearing aids, or dentures
Multiple bruises, bruises in places not usually injured by accident (such as the buttocks), or bruises in the shape of objects (such as an iron or belt)
Rope marks
Broken bones
Scratches and cuts
Anxiety, depression, or withdrawal and passivity
Sudden financial changes (such as changes in a will, loss of money or other assets, or addition of names to an older person’s bank card)
The caregiver’s behavior may also suggest mistreatment, as in the following:
Not letting the older person speak
Treating the older person like a child
Giving implausible explanations for injuries
Older people who are neglected may lose weight because of undernutrition, and their skin and mouth may become dry because of dehydration. They may have an unpleasant odor if they are inadequately cleaned. Pressure sores may develop on the buttocks or heels if people with limited mobility are left to sit or lie in one position too long. Necessary aids, such as eyeglasses, hearing aids, or dentures, may be missing. People may miss scheduled doctor appointments or not be taken for care when disorders are obviously worsening.
Prevention of Mistreatment
Older people who are worried about mistreatment can take steps to make it less likely to happen, such as the following:
Not living with someone who has a history of violent behavior or substance abuse
Keeping in touch with friends and former neighbors, especially if an older person has to move to a caregiver’s house
Staying connected with social and community organizations (increasing the chances that mistreatment, if it occurs, is noticed)
Insisting on legal advice before signing any documents related to where they will live or who controls their finances (the local Area Agency on Aging can refer people for legal help)
Family members and friends can help by maintaining close ties with an older person.
When People Neglect Themselves
When people do not provide food, drugs, personal hygiene, or other necessities for themselves, the problem is called self-neglect.
Self-neglect occurs more often than mistreatment. Similar to mistreatment, self-neglect is most likely when older people
Live alone and isolate themselves
Have a disorder that impairs their judgment and memory (such as Alzheimer’s disease)
Have several chronic disorders
Have severe depression
However, some people have no particular medical problems. Why such people neglect themselves is unclear.
Self-neglect can range from not keeping themselves or their clothing clean to not paying bills to not seeing a doctor when they have a life-threatening condition. People may eat too little and may become dehydrated and malnourished. If they see a doctor, they may refuse treatment, not fill their prescriptions, or skip follow-up visits. Their home may be filthy, in hazardous disrepair, or infested by animal or insect pests. Sometimes self-neglect endangers public health, for example, when people’s behavior causes risk of fire.
Knowing where to draw the line between self-neglect and the right to autonomy and privacy can be very difficult for family members, friends, and health care practitioners. Older people may be making informed and capable choices. They may simply have decided to live in a way that others find undesirable. Often, a social worker is in the best position to make such a determination and can intervene if alerted by family members or friends.
If intervention is thought to be needed, help can be just a phone call away. Contacting the person’s primary care doctor is a good way to start. Adult Protective Services or the state unit on aging (whose numbers are available through the Eldercare Locator at 800-677-1116) can also be contacted.
Responding to Mistreatment
Older people should never think that mistreatment is part of being old or dependent. Being mistreated threatens their personal dignity and sense of well-being and can even cost people their life.
Detecting mistreatment of older people can be difficult. Older people may be reluctant to tell others about it, or they may be unable to tell others because the perpetrator limits phone calls or access to visitors and health care practitioners.
If older people believe they are in danger, they can call an elder abuse hotline for immediate help. Such hotlines are listed in the local phone book, usually in the Blue Pages, or can be provided by a phone operator. A list of all state laws about elder mistreatment and telephone numbers to call to report mistreatment are available at the web site of the National Center for Elder Abuse. The local Area Agency on Aging is another good source of information and referral. If older people do not feel endangered but still want help, they can try talking about it with their doctor or other health care practitioner. However, many health care practitioners are unfamiliar with how to handle elder mistreatment because the topic has not traditionally been part of medical training and education.
Because mistreatment and its effects can vary greatly, interventions need to be tailored to each person’s situation. Interventions may include the following:
Medical assistance
Education, such as information about mistreatment and available options, as well as help with devising safety plans
Psychologic support, such as psychotherapy and support groups
Law enforcement and legal intervention, such as arrest of the perpetrator, orders of protection, and legal advocacy
Arrangement for alternative housing, such as housing that provides safe shelter with protection from the perpetrator
Relatives, friends, and acquaintances have a responsibility to help if they know of or strongly suspect mistreatment, as do health care practitioners. Directly confronting the perpetrator is not recommended because it can worsen mistreatment. Instead, the situation should be reported. Reporting suspected or confirmed abuse or neglect is mandatory in all states if the mistreatment occurs in an institution and in most states if it occurs in a home. Every state has laws that protect and provide services for vulnerable, incapacitated, or disabled people. Every state also has laws protecting people who report suspected mistreatment from being sued for doing so. To report mistreatment, people can contact the following:
In most states: The state social service department (Adult Protective Services)
In a few states: The state unit on aging
For abuse within an institution: The local longterm care ombudsman’s office or the state department of health
Telephone numbers for these agencies and offices in any part of the United States can be found by calling the Eldercare Locator (800-677-1116) or the National Center on Elder Abuse (202-682-2470) and giving the person’s county and city of residence or zip code.