As hidden as the other forms of family violence may be, domestic elder abuse is even more concealed within our society. As the baby boomers age, the number of elders in the United States will continue to increase. The societal cost for the identification and treatment of elder abuse is also projected to rise as the baby boomers enter the elder years. Elder abuse is now recognized as a pervasive and growing problem. Vastly underreported, for every case of elder abuse and neglect that is reported to authorities, as many as five cases are not reported.
Many physicians feel ill-equipped to address this important social and medical problem. The most common reporters of abuse are family members (17%) and social services agency staff (11%). Physicians reported only 1.4% of the cases. Healthcare professionals consistently underestimate the prevalence of elder abuse. Concerns for patient safety and retaliation by the caregiver, violation of the physician-patient relationship, patient autonomy, confidentiality, and trust issues are quoted as reasons for low reporting. Studies have shown that healthcare professionals attest to viewing cases of suspected elder abuse but yet fail to report them. One study revealed that physicians report only 2% of all suspected cases.
Older victims who suffer from neglect or physical abuse are likely to seek care from their primary care physician or gain entry into the medical care system through an emergency department. Except for the older person’s caregivers, physicians may be the only ones to see an abused elderly patient.
G. Knowledge detection and reporting of abuse by health and social care professionals: a systematic review. Am J Geriatr Psychiatry
. 2009; 17(10):826–838.
et al.. Health care professionals’ perspectives on barriers to elder abuse detection and reporting in primary care settings. J Elder Abuse Negl
. 2012; 24(1):17–36.
A. Definition and Types of Abuse
Elder abuse encompasses all types of mistreatment and abusive behaviors toward older adults. The mistreatment can be either acts of commission (abuse) or acts of omission (neglect). The National Center on Elder Abuse (NCEA) describes seven different types of elder abuse: physical abuse, sexual abuse, emotional abuse, financial exploitation, neglect, abandonment, and self-neglect (Table 43-1). Self-neglect is defined as the behavior of an elderly person that threatens her/his own health and safety. Labeling a behavior as abusive, neglectful, or exploitative is difficult and can depend on the frequency, duration, intensity, severity, consequences, and cultural context. Currently, state laws define elder abuse and definitions vary considerably from one jurisdiction to another.
Table 43–1.Elder abuse: definitions. ||Download (.pdf) Table 43–1.Elder abuse: definitions.
|Physical abuse ||Use of physical force that may result in bodily injury, physical pain, or impairment |
|Sexual abuse ||Nonconsensual sexual contact of any kind with an elderly person |
|Emotional abuse ||Infliction of anguish, pain, or distress through verbal or nonverbal acts |
|Financial/material exploitation ||Illegal or improper use of an elder’s funds, property, or assets |
|Neglect ||Refusal, or failure, to fulfill any part of a person’s obligations or duties to an elderly person |
|Abandonment ||Desertion of an elderly person by an individual who has physical custody of the elder or who has assumed responsibility for providing care to the elder |
|Self-neglect ||Behaviors of an elderly person that threaten the elder’s health or safety |
EF. The Availability and Utility of Interdisciplinary Data on Elder Abuse: A White Paper for the National Center on Elder Abuse. American Bar Association Commission on Law and Aging for the National Center on Elder Abuse. National Center on Elder Abuse at American Public Human Services Association; 2006.
It is estimated that 4% of adults aged > 65 years are subjected to mistreatment in the United States. In almost 90% of cases the perpetrator of the abuse is known, and in two-thirds of cases the perpetrators are spouses or adult children. Because of underreporting, poor detection, and differing definitions, the true estimate of elder abuse may be far greater. In a nationally representative survey of almost 6000 subjects, the prevalence of elder abuse was 0.6% for sexual abuse, 1.6% for physical abuse, 4.6% for emotional abuse, 5.1% for neglect, and 5.2% for financial abuse by a family. Psychological abuse is more prevalent than physical abuse. Neglect—the failure of a designated caregiver to meet the needs of a dependent elderly person—is the more common form of elder maltreatment. The prevalence of elder financial abuse is difficult to gauge. One researcher estimates that for every known case of financial exploitation, 24 go unreported. Elder self-neglect is an important public health concern that is the most common form of elder abuse and neglect reported to social services.
et al.. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health
. 2010; 100(2):292–297.
et al.. Assessing knowledge of elder financial abuse: a first step in enhancing prosecutions. J Elder Abuse Negl
. 2013; 25(2):162–182.
Several explanations have been proposed to explain the origins of elder mistreatment. These explanations have focused on overburdened or mentally disturbed caregivers, dependent elders, a history of childhood abuse and neglect, and the marginalization of elders in society. Abuse among older adults with cognitive impairment is markedly higher than for unimpaired adults. In a recent systematic review, caregiver burden/stress was a significant risk factor. Care setting also seems to influence risk of elder abuse. Most elder abuse and neglect occur in the home. Paid home care has a relatively high rate of verbal abuse, and assisted-living settings have an unexpectedly high rate of neglect. Moving from paid home care to nursing homes has been shown to more than triple the odds of the elder experiencing neglect. In one study >70% of nursing home staff reported that they had behaved at least once in an abusive or neglectful way toward residents over a one-year period. Risk factors commonly cited for elder mistreatment are listed in Table 43-2.
Table 43–2.Risk factors for elder abuse. ||Download (.pdf) Table 43–2.Risk factors for elder abuse.
Lower levels of social network and social support
Lower household income
Need for ADL assistance
Characteristics of perpetrators of elder abuse can be seen in Table 43-3.
Table 43–3.Characteristics of perpetrators of elder abuse. ||Download (.pdf) Table 43–3.Characteristics of perpetrators of elder abuse.
|Relationship ||Percentage (%) |
|Family member ||89.7 |
|Adult child ||47.3 |
|Spouse ||19.3 |
|Other relatives ||8.8 |
|Friend ||6.2 |
|Home service provider ||2.8 |
|Out-of-home service provider ||1.4 |
A typology of abusers has also been suggested to better delineate who may perpetrate abuse. Five types of offenders have been postulated:
Overwhelmed offenders are well intentioned and enter caregiving expecting to provide adequate care; however, when the amount of care expected exceeds their comfort level, they lash out verbally or physically.
Impaired offenders are well intentioned, but have problems that render them unqualified to provide adequate care. The caregiver may be of advanced age, have physical or mental illness, or have developmental disabilities.
Narcissistic offenders are motivated by anticipated personal gain and not the desire to help others. These individuals tend to be socially sophisticated and gain a position of trust over the vulnerable elder. Maltreatment is usually in the form of neglect and financial exploitation.
Domineering or bullying offenders are motivated by power and control and are prone to outbursts of rage. This abuse may be chronic and multifaceted, including physical, psychological, and even forced sexual coercion.
Sadistic offenders derive feelings of power and importance by humiliating, terrifying, and harming others. Signs of this type of abuse include bite, burn, and restraint marks and other signs of physical and sexual assault.
et al.. Elder abuse: a systematic review of risk factors in community-dwelling elders. Age Ageing
. 2013; 42(3):292–298.
et al.. Institutional abuse of older adults: what we know, what we need to know. J Elder Abuse Negl
. 2012; 24(2):138–160.
et al.. The effect of care setting on elder abuse: results from a Michigan survey. J Elder Abuse Negl
. 2009; 21(3):239–252.
H. Elder-abuse offenders: a typology. Generations. 2000; 24:17.