Contact Hours: 2
This online independent study activity is credited for 2 contact hours at completion.
The purpose of this course is to provide an overview of elder abuse, including the various types, signs of abuse, and reporting requirements.
Elder abuse is described as intentional actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver or other trusted person. The abuse can lead to an increased risk of morbidity, mortality, institutionalization, and hospital admission, negatively affecting families and society. Thus, it is important to be aware of signs and report suspicions of elder abuse. This independent study provides an overview of elder abuse, the signs of abuse, and reporting requirements.
Upon completion of the independent study, the learner will be able to:
- Define elder abuse
- Describe the various forms of elder abuse
- Recognize the signs of elder abuse
- Understand common characteristics of a perpetrator of abuse.
- Understand the requirement of reporting elder abuse
This activity has been planned and implemented in accordance with the policies of FastCEForLess.com.
Fast CE For Less, Inc and its authors have no disclosures. There is no commercial support.
|Abandonment||To cease to support or look after someone.|
|Abuse||To treat a person with cruelty or violence, especially regularly or repeatedly.|
|Caregiver||A family member or paid helper who regularly looks after a child or a sick, elderly, or disabled person.|
|Elder Abuse||Intentional actions that cause harm or create a serious risk of harm (whether intended or not) to a vulnerable elder by a caregiver or other person who stands in a trusting relationship.|
|Emotional Abuse||Any act including confinement, isolation, verbal assault, humiliation, intimidation, infantilization, or any other treatment which may diminish the sense of identity, dignity, and self-worth.|
|Failure to Act||When a person or party has a duty to perform a certain act but does not end up doing so.|
|Financial Abuse||To wrongfully take, appropriate, obtain, or retain, or assist in taking, appropriating, obtaining, or retaining, real or personal property of an elder.|
|Neglect||Fail to care for properly.|
|Physical Abuse||Any nonaccidental physical injury and can include striking, kicking, burning, or biting, or any action that results in a physical impairment.|
|Self-Neglect||An extreme lack of self-care, it is sometimes associated with hoarding and may be a result of other issues such as addictions.|
|Sexual Abuse||Unwanted sexual activity, with perpetrators using force, making threats, or taking advantage of victims not able to give consent.|
Approximately 4 million American adults are subjected to physical, psychological, and other forms of abuse and neglect every year.1 Elder abuse is an intentional act that causes or creates a risk of harm to older adults aged 60 or above.2 Elder abuse and failure to act can occur at the hands of a caregiver or a trusted person and leads to poor life quality where the functional and financial status of the individual is severely jeopardized.1,2 It can be the result of injury, deprivation, and other dangers from a caregiver or trusted person that intended to harm or failed to prevent it.3
According to the U.S. National Academy of Sciences, elder abuse can be defined as:3
- Intentional actions that cause harm or create a serious risk of harm (whether intended or not) to a vulnerable elder by a caregiver or other person who stands in a trusting relationship.
- A caregiver fails to satisfy the elder’s basic needs or protect the elder from harm.
Understanding elder abuse’s magnitude and risk factors are the first steps toward developing interventions.4 However, there is a lack of consensus in defining and measuring elder abuse and its major subtypes, resulting in wide variations in reported prevalence rates.4
Despite what you may think, elder abuse is not limited to adults in nursing homes.1 In fact, most elder abuse cases do not happen in nursing homes or older residential settings. Usually, family members and caregivers are the abusers.1 Moreover, elder abuse does not follow a single pattern and is brought about by changes in living conditions due to an elder or an elder’s dependency on other individuals.1 Whatever the case, elder abuse is a human rights violation that requires urgent action.4
Elder abuse can lead to an increased risk of morbidity, mortality, institutionalization, and hospital admission, negatively affecting families and society.4 Even in the absence of chronic conditions or life-threatening diseases, abused elders die earlier than those who are not.1 Thus, it is important to be aware of signs and report suspicions of elder abuse to reduce the risk.1
Elder abuse is a common and serious problem in the United States.2 From 2002 to 2016, more than 643,000 older adults were treated in emergency departments for nonfatal assaults, and over 19,000 homicides occurred.2 But the statistics don’t show the whole story because, for every case of elder abuse and neglect reported to authorities, experts estimate as many as 23 cases go undetected.1
Moreover, some groups of adults face higher abuse rates than others.2 For instance, from 2007 to 2016, the rate of nonfatal assaults increased by more than 75% among men (2002–2016) and more than 35% among women.2 Most elder abuse and neglect studies are unclear and follow questionable evidence-based methods.3 Moreover, research is subdivided into typologies based on community or institutional living older adult populations.3 However, as stated above, long-term care facilities and nursing homes are rarely the places where elder abuse takes place; thus, it is necessary to direct the attention elsewhere and find out the risk factors, patterns, and warning signs to identify elders at risk and provide the care they need.1
Elder abuse can take many forms, and according to the National Center on Elder Abuse (NCEA), it is broken down into seven different types.5
Physical abuse in elders is the most measured mistreatment type.3 Several cases show one or more events with a designated prevalence period.3 Elder physical abuse includes slapping, hitting, beating, shoving, pushing, burning, and restraining with ropes and chains.1,2 The abusive act is done by a caregiver or trusted individual and can lead to death, functional impairment, illness, pain, and injury.2 The act is either done intentionally or with the intent to help the elder. Still, even then, it is considered abusive. 1,2
Physical elder abuse also includes inappropriate use of medication and physical punishment of any kind.1
Elder neglect can be defined as a caregiver failing to meet an older adult’s basic needs.2 These needs can range from emotional and physical to social tasks, and neglect can be in the form of a caregiver intentionally withholding proper attention to fulfill the needs of the older adult.1
Neglect includes food, medication, water, shelter, clothing, hygiene, and assistance with daily activities.1,2 Neglect leads to harm, injuries, and severe illnesses in older adults.5 Studies show that prevalence in such cases ranges from 0.2% to 5.5%.3 Elder neglect is a less frequent form of abuse because sometimes, the elderly neglect themselves, which is known as self-neglect.1
Elder self-neglect is a type of elder abuse in which the older adult is no longer able to meet their basic daily needs, which leads to harm, injury, and illness.5 Elders can experience self-neglect by:1
- Not eating
- Not going to the doctor for needed care
- Compulsive hoarding
- Alcohol or drug abuse
Older adults with dementia may become abusive as the disease progresses. As a result, they can abuse other adults, family members, caregivers, or whomever they interact with.
The elderly can also abuse other individuals by hitting, gripping too hard, or causing hazards.1
Another reason elder self-neglect happens is that the family or caregiver cannot achieve the balance between respecting an elder adult’s autonomy and intervening before self-neglect occurs.1 Elder self-neglect happens because of changes in cognitive abilities and is triggered by abuse from a caregiver, but it is still dangerous and unacceptable.1
Elder sexual abuse includes forced sexual act of any kind.1,2 Sexual acts can include unwanted sexual contact, penetration, non-contact sexual acts like photographing the person in suggestive poses, forcing adults to look at pornography, or any unwanted sexual behavior. 1,2 These sexual interactions are with older adults with conditions like Alzheimer’s, dementia, or other cognitive disabilities that prevent them from giving consent.5 Sexual elder abuse can also include rape, sodomy, or coerced nudity.1 It is the least reported type of elder abuse.
Emotional abuse in the elder refers to verbal and nonverbal behaviors that lead to anguish, mental distress, fear, or pain in an older adult.1,2 The emotional and psychological abuse acts can range from name calling or giving the “silent treatment” to intimidating and threatening the individual.1
Verbal actions include shouting, swearing, and making insulting or disrespectful comments.1 In contrast, physical or non-verbal actions include threatening and manipulating behavior that establishes a power difference between the older adult and the caregiver, interpersonal isolation, and harassment.1,2
Elder abandonment is like elder neglect.5 It occurs when a caregiver, trusted family member, or the individual responsible for the older adult intentionally deserts them.5 The responsible caregiver can leave the older adult at a nursing facility, long-term institutional management, or with other relatives that did not agree to be their caregivers.5
The elder can appear confused, in pain, malnourished, or have poor overall hygiene.5
Financial elder abuse is the illegal, improper, and unauthorized use of older adults’ money and assets.1,2 Financial abuse can range from fraud, forced property transfers, and taking someone’s money forcefully to buying something expensive under pretenses or without consent.1 It includes the improper use of legal guardianship arrangements, powers of attorney, or conservatorships.1 As you can see, elder abuse can take on many forms and types, but the result is the same.1 The older adult feels isolated, worthless, and finds themselves in dangerous situations.1
As an individual or a medical professional, it is your responsibility to recognize the signs of elder abuse and report it to the appropriate authorities or take immediate action when necessary. Most of the signs of elder abuse could be related to a medical condition or disease; thus, further inspection is required.1 Below are the common signs of elder abuse based on the type.
Table 1: Signs of elder abuse based on type 1,5
|Abuse type||Abuse signs|
|Physical abuse||Unexplained or poorly explained injuries Bruises or grip marks on necks and arms Delayed medical care for an injury or illness Hospitalization pattern for similar injuries Dismissive attitude regarding injuries Refusal to go to the emergency room for injuries|
|Neglect||Untreated injuries Weight loss Dehydration or malnutrition Lack of appropriate clothing, basic hygiene, or clean food and water Lack of medical aids like walking stick, glasses, etc. Unpaid bills Unsafe environment|
|Self-neglect||Cannot dress themselves Cannot maintain basic hygiene Cannot maintain their home and bills Cannot address their medical needs|
|Sexual abuse||Unexplained vaginal and anus bleeding Unexplained vaginal diseases Bruised genitals or inner thigh Torn or bloody underwear Difficulty in walking or sitting New sexually transmitted diseases or infections (STDs/STIs)|
|Emotional abuse||Unexplained or uncharacteristic changes in behavior Lack of interest in social contact or gatherings Frequent mood swings Isolated from friends and family Appearing withdrawn, depressed, or scared Unresponsive and uncommunicative Changes in sleeping or eating patterns Low self-esteem|
|Abandonment||Appear malnourished and dehydrated Have poor hygiene Appear confused, lost, or scared|
|Financial abuse||Signatures on documents do not match the older adult Changes in older adult’s power of attorney or bank accounts Lifestyle does not match the financial assets Pattern of missing belongings and property Unusual activity and large withdrawals from bank Eviction notices and unpaid bills|
The only way effective interventions can be made against elder abuse is by understanding the common risk factors. Elder abuse is a complex problem and is caused by multiple factors.1 These factors are divided based on strong, potential, and contested risk factors.3 Strong risk factors have substantial evidence, potential risk factors have limited evidence, and contested risk factors lack evidence.3 These risk factors are reviewed in detail below.
Table 2: Individual-level risk factors3
|Level||Evidence Strength||Risk factors||Description|
|Individual||Strong||Poor physical health||Is continuously associated with elder abuse across multiple countries, such as financial abuse, physical, sexual, and emotional abuse.|
|Individual||Strong||Functional dependence or disability||Older adults that are dependent on others or have a disability are at a greater risk of elder abuse.|
|Individual||Strong||Poor mental health||Studies have found a relationship between poor mental/emotional health of the victim and elder abuse|
|Individual||Strong||Low income||Low income can lead to aggregated elder abuse.|
|Individual||Strong||Dementia||Cognitive impairment is defined as a strong risk factor as many cases depict mistreatment committed by dementia caregivers.|
|Individual||Potential||Age||Younger age of the caregiver is associated with a great risk of elder abuse.|
|Individual||Potential||Gender||The risk of abuse varies within communities and cultures.|
|Individual||Potential||Ethnicity||Compared with Caucasians, African American older adults may be at increased risk of financial abuse and psychological abuse.|
|Individual||Potential||Financial dependence||Financial dependence is linked to elder abuse and neglect.|
Table 3: Individual-Level Risk Factors (Perpetrator)3
|Level||Evidence Strength||Risk factors||Description|
|Perpetrator||Strong||Substance misuse||Drug and substance abuse is common among elder abuse perpetrators. It has been linked with verbal and financial abuse.|
|Perpetrator||Strong||Abuser dependency||Elder abuse perpetrators are abusers who are dependent on their victims for emotional support, financial help, housing, and/or other assistance.|
|Perpetrator||Strong||Mental illness||Depression, anxiety, and other mental illnesses are also common among elder abuse perpetrators.|
It is important to study individual-level perpetrator risk factors to identify individuals who have abuser characteristics and are placed in trusted relationships or caregiving facilities around older adults.3
Table 4: Victim–Perpetrator Relationship-Level Risk Factors3
|Level||Evidence Strength||Risk factors||Description|
|Victim–Perpetrator||Potential||Relationship type||Perpetrator relationship type appears to vary according to mistreatment type and culture.|
|Victim–Perpetrator||Potential||Marital status||Some studies indicate that marriage is associated with aggregated elder abuse. While other studies show that being single, widowed, or separated increases your risks of aggregated elder abuse.|
Table 5: Other risk factors3
|Level||Evidence Strength||Risk factors||Description|
|Community||Potential||Geographical location||Elders living in urban areas are at a greater risk of elder abuse.|
|Societal||Contested||Social and cultural norms||Scholars speculate that the normalization of violence may further perpetuate violent behavior toward older people.|
|Societal||Contested||Ageism||Ageism refers to negative reviews on aging. Negative attitudes and stereotypes about elders might lead to social acceptance of elder abuse.|
Despite the pressing nature of the problem, the biggest gap in the knowledge about elder abuse lies in the prevention.3 It is crucial that interventions are developed to prevent the mistreatment of older adults.3 The effort to prevent elder abuse starts from the front line of care, and nurses are among the group of mandatory reporters.6 Nurses are trained to recognize the signs and symptoms of elder abuse and are required by law to report it, even if they just suspect it.6 Failure to report can result in fines and incarceration.6 Thus, it is crucial that nurses are aware of all types of elder abuse, risk factors, and prevention and intervention measures.6
According to the International Council of Nurses, the role of nurses in terms of safeguarding can be summarized as follows, “Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles.”7
This means that nurses are regulated to offer protection to the public and protection of the profession.7 Many regulatory bodies and professional organizations have specific guidance on older adult care or have integrated such guidance into codes of conduct.7 Nurses must understand these codes of conduct both on a personal and professional level.7 Moreover, nurses are not confined to their own practice but also need to report abusive behavior of fellow healthcare professionals that results in poor care practices and incidents.7
As stated above, reporting elder abuse is mandatory for nurses, but effective elder abuse interventions are complex and require interprofessional communication and support from various specialties and resources.6 In such cases, when elder abuse is reported, a representative from the adult protective services visits the home or facility and inspects the mistreatment.6 The resulting intervention is highly individualized based on the specific case.6
Remember that abuse does not need to be proven to provide or initiate a notification of suspicion, home health care, mental health services, physical therapy, or any other form of treatment.6 Regardless of the situation, detecting elder abuse requires multiple fundamental assumptions.7 Nurses must be conscious of the conditions of the possibility of detection.7
Recognizing elder abuse can be challenging because of the cultural and societal norms and the existing values, practices, and power relations.7 Despite the challenges, multiple approaches and assessment tools have been developed to detect different types of elder abuse.7
Screening is not solely used when detecting elder abuse because it is a multifaceted issue that has many diverse influences from the macro-perspective of society to the micro-perspective of the older person’s immediate environment.7
A literature review recommends two screening tools for detecting elder abuse, the Elder Abuse Suspicion Index (EASI) and the Older Adult Financial Exploitation Measure.7 The EASI is supported by the World Health Organization (WHO) and has been translated into many languages.7 The EASI comprises six questions with yes, no, or did not answer responses. Five questions are directed at the older person based on the types of elder abuse perpetration. The final question is based on the subjective assessment of the clinician.7
The simple act of asking a question can lead to abuse disclosure by the older adult.7 It is the duty of nurses to build up trust through communication and enable the disclosure of abuse.7 Many reasons prevent elders from disclosing abuse, such as feelings of shame, worthlessness, or minimizing the impact of the abuse.7 In a study on older people’s experiences of elder abuse, participants described a lack of knowledge of the presence of or how to access helping agencies as well as feeling they would not be believed.7 Nurses need to understand the challenges of disclosure and different victim-perpetrator relationship scenarios and overcome reporting barriers by building strong relationships and providing unparalleled support.7
Following the detection of abuse, it is mandatory for nurses to act.7 But nurses might feel futile as the older adult has decision-making capacity and wishes to retain the situation as-is.7 In such cases, it is important for nurses to provide continued support, especially in a community setting where the perpetrator has continued access to the victim.7
Depending on the context of abuse and the immediacy of intervention, careful deliberation must be made to conclude whether to refer to protective services or not.7 In all cases, the older adult’s voice is paramount, and case management should consider the impact on the older person.7
There are many protective authorities available that can help prevent elder abuse. The most widely used intervention is telephone “helplines,” which allow individuals to seek advice and assistance regarding elder abuse.3 Helplines help with early elder abuse detection and can forestall mistreatment.3 According to the CDC; you can use the National Center on Elder Abuse Listing of Stated Elder Abuse Hotlines at ncea.acl.gov to find your state’s reporting numbers, government agencies, state laws, and other resources.2
Other protective services and resources include emergency shelters, multi-disciplinary teams, and caregiver interventions.3
How To Follow-Up
As stated above, elder abuse is a complex situation, and the first step is reporting it to the appropriate authorities.7 If the elderly wants to remain in the situation, you can follow up and continue to offer support, should they change their mind.
A nurse has a duty to report suspected abuse.7 The elderly population is growing, which means more older adults are susceptible to the risks of elder abuse.2 Elders may face communication and time challenges that may prevent them from recognizing that abuse is occuring.7 Elder abuse is a problem whose type, prevalence, and manifestations occur in different variations and nurses must be able to detect its occurrence and initiate appropriate responses.7 In order to report abuse, nurses should have a clear understanding of what elder abuse is, the various forms of elder abuse, their signs, and reporting laws.7
1. Elder abuse and neglect: In search of solutions. https://www.apa.org. https://www.apa.org/pi/aging/resources/guides/elder-abuse. Published 2012.
2. Centers for Disease Control and Prevention. Preventing elder abuse. www.cdc.gov. Published 2020. https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html
3. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies. The Gerontologist. 2016;56(Suppl 2): S194-S205. doi:10.1093/geront/gnw004
4. Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community settings: a systematic review and meta-analysis. The Lancet Global Health. 2017;5(2):e147-e156. doi:10.1016/s2214-109x(17)30006-2
5. Nursing Home Abuse Center. Types of Elder Abuse – Learn About the Different Types of Elderly Abuse. Nursing Home Abuse Center. Published 2016. https://www.nursinghomeabusecenter.com/elder-abuse/types/
6. Reporting Elder Abuse: The Responsibility of Nurses | Duquesne University. Duquesne University School of Nursing. Published December 1, 2017. https://onlinenursing.duq.edu/blog/reporting-elder-abuse/
7. Phelan A. The role of the nurse in detecting elder abuse and neglect: current perspectives. Nursing: Research and Reviews. Published September 10, 2018. https://www.dovepress.com/the-role-of-the-nurse-in-detecting-elder-abuse-and-neglect-current-per-peer-reviewed-fulltext-article-NRR