ELDER MISTREATMENT

Elder mistreatment means that someone either does something or fails to do something that harms an elderly person or threatens the health and welfare of an elderly person.

Research suggests that 700,000 to 1.2 million elderly people (ie, 4% of all adults older than 65) are subjected to elder mistreatment in the United States and that there are 450,000 new cases annually.

• Elder Mistreatment in the Family, Formal Care Settings, and the Community
• Forms of Elder Mistreatment
• Risk Factors for Elder Mistreatment
• Clues to Possible Elder Mistreatment
• Visible Signs
• Behaviors
• Keeping a Perspective
• What to Expect
• Where to Go for Help

Elder Mistreatment in the Family, Formal Care Settings, and the Community

Elder mistreatment can occur in many environments, including within the family, in formal care settings, or in the community or society at large.

The Family

Within the family, elder mistreatment is often seen in the context of caregiving. For example, a caregiver may be overwhelmed or may not know what is needed or expected in providing care for the elderly person. Sometimes, a caregiver is reluctant to take on the role. Elder mistreatment can also be seen in the family when someone dependent on the older person reacts inappropriately to the older person’s increasing frailty. An example of this situation might be when an adult child with mental illness reacts with anger or anxiety to a parent’s decreased ability to provide care.

Formal Care Settings

Within formal care settings, when elder mistreatment occurs, it is attributable to those on staff who provide direct patient care (ie, are in close contact with patients), but who have not had adequate training.

The Community

Within the community or society at large, the elderly are all too often subject to mistreatment by unscrupulous business people or other criminals.

Forms of Elder Mistreatment

Elder mistreatment can take a number of different forms, including the following:

• physical abuse
• emotional abuse
• neglect(intentional or unintentional)
• financial exploitation
• abandonment
• a combination of these

Risk Factors for Elder Mistreatment

Many factors can increase the risk of elder mistreatment. These risk factors include the following:

Dependency issues	Dependency of the elderly person for caregiving needs Dependency of another person on the elderly person Mental impairment in the dependent person or the caregiver (or both) Isolation of the dependent person, the caregiver (or both) Living arrangements inadequate for the needs of the dependent person Inability to perform daily functions Frailty
Family issues	Family conflict Family history of abusive behavior, alcohol or drug abuse, mental illness, or mental retardation Stressful family events, eg, death of a loved one, loss of employment
Financial issues	Poverty Financial stress or lack of money for new health care needs
Institutional concerns	Socioeconomic factors within nursing homes, including poor working conditions, low salaries, inadequate staff training and supervision, prejudiced attitudes

Frail or debilitated older people may at times be incapable of helping themselves at all. In these situations, they many need more care than the caregiver is able to provide. In particular, mentally disturbed people who may behave in difficult ways (eg, hitting, spitting, or screaming) can greatly add to the stress their caregiver feels, possibly causing the caregiver to respond with some form of elder mistreatment.

Clues to Possible Elder Mistreatment

Both visible signs and certain behaviors by either the elderly person or the caregiver can raise suspicion of elder mistreatment. Watching and talking to both the older person and their caregiver may provide clues that elder mistreatment may be happening. The behavior of victims of elder mistreatment in the presence of the person who might be abusing them may be significant.

Visible Signs that Raise Suspicion of Elder Mistreatment

Type of Mistreatment	Examples
Abandonment	Older person left alone frequently
Abuse	Many trips to the emergency room
	Fractures or bruises, some old and some new, especially bruises on both sides of inner arms and thighs
	Repeated falls
	Unexplained hair loss, possibly from pulling
Exploitation	Evidence that the victim’s possessions are being taken by the caregiver
	Evidence that the victim’s possessions (eg, house, jewelry, car) are being taken over without their consent or approval
	Unexplained loss of Social Security or pension checks
	Dependent person’s living conditions or appearance and his or her financial situation are inconsistent with each other
	Sudden inability to pay for food, health care, or other basic needs
	Unusual interest on the part of caregivers in the patient’s assets
Neglect	Unexplained skin rashes, irritation, or ulcers
	Inappropriate dress
	No energy or spirit
	Malnourishment
	Poor hygiene (eg, dirty, urine or fecal odor)
	Reports of being left in unsafe situation
	Reports of inability to get needed medication

Behaviors that Raise Suspicion of Elder Mistreatment

Possible Behaviors of the Victim	Possible Behaviors of the Caregiver(s)
Avoid eye contact or dart eyes often	May be nervous and fearful, or quiet and passive
Sit a distance away from caregiver	May try to prevent private conversation or examination of the elderly person
Cringe, back off, or startle easily as if expecting to be hit	Gives explanations of elderly person’s injuries that don’t make sense
Allow caregiver to answer for them all the time	May be impatient, irritable, and make negative or demeaning statements about the elderly person

Keeping a Perspective

It is important to remember that signs and symptoms that look like inadequate or neglectful caregiving may in fact be because of the dependent person’s physical or emotional disorders. For example, weight loss may be seen in a person with a history of depression. In addition, in chronic progressive conditions, such as Alzheimer’s disease, deterioration is inevitable, even with the best of care.

It is also important to remember that the relationship of the elderly person with the caregiver(s) can be very complex, and the true cause of the problem may not be obvious. In some cases, the elderly person is truly a victim, while in others, the relationship between the elderly person and the caregiver can be mutually abusive. There are even situations when the elderly person knowingly is part of the reason for the mistreatment. Of course, there are many cases in which the older person and his or her caregivers are making the best of a difficult and sometimes tragic situation.

Where to Go for Help

If you think someone you know is a victim of elder mistreatment, you can ask for help and advice from a number of resources:

• Your family doctor or another knowledgeable health professional
• Social workers, psychologists, or psychiatrists in your community
• Your state’s Adult Protective Services (can provide relevant information and often direct assistance)
• The National Center on Elder Abuse ( a good starting point in the search for information and resources)

Web Link: http://elderabusecenter.org

What to Expect

When you suspect elder mistreatment and visit your doctor or other health care provider, he or she will likely take a number of actions. First, the situation is reported to Adult Protective Services and possibly other public agencies (as required by your state). If the elderly person is in immediate danger, your health care provider will make arrangements for the person’s safety. Possibilities are admitting the person to the hospital (if needed for medical reasons), getting a court protective order, or making sure the person is placed in a safe home. In all cases, the health care provider will make a complete evaluation of the person’s physical, mental, and emotional status as well as the frequency, severity, and intent of the mistreatment.

If the suspicions of maltreatment are determined to be true, your health care provider will coordinate with Adult Protective Services in your state to find the option that least restricts the elderly person’s independence.

If the elderly person is willing to accept voluntary services, he or she can receive several types of including the following:

• education about the tendency for elder mistreatment to happen more often and become more severe over time
• safe home placement, court protective order, hospital admission
• referral to drug or alcohol rehabilitation for the abuser(s) if appropriate
• education, home health, or homemaker services for overburdened families and other caregivers
• referral of the elderly person and family members for social work, counseling services, or legal assistance

If the elderly person is unwilling to accept voluntary services and has the capacity to do make this decision, the health care provider will take the following actions:

• educate the elderly person about the tendency for elder mistreatment to happen more often and become more severe over time
• provide written information on emergency numbers and appropriate referrals
• develop a follow-up plan

If the elderly person is unwilling to accept voluntary services and does not have the capacity to consent, the health care provider and Adult Protective Services will consider the following options:

• financial management assistance
• conservatorship
• guardianship
• committee
• special court proceedings (eg, orders of protection)