How To Prevent Elder Abuse

As our population ages and more stress is placed on families to care or both parents and children at the same time, there is a potential for Elder Abuse by caregivers whether family members or service providers. To understand how Elder Abuse happens we must first define what Elder Abuse is, what are the indicators, who are the perpetrators, what the signs of elder abuse and who is at risk of being a victim.

Elder abuse is defined as any form of mistreatment that results in harm or loss to an older person. It is generally divided into the following categories:

Physical Abuse

Physical abuse is physical force or violence that results in bodily injury, pain, or impairment. It includes assault, battery, and inappropriate restraint.

Who are the perpetrators?

Perpetrators may be acquaintances, sons, daughters, grandchildren, or others. Perpetrators are likely to be unmarried, to live with their victims, and to be unemployed. Some perpetrators have alcohol or substance abuse problems. Some are caregivers for those they abuse.

Who is at risk?

As a group, victims of physical abuse do not differ significantly from seniors who are not abused.

What are the indicators?

Indicators are signs or clues that abuse has occurred. Physical indicators may include injuries or bruises, while behavioral indicators are ways victims and abusers act or interact with each other. Many of the indicators listed below can be explained by other causes (e.g. a bruise may be the result of an accidental fall) and no single indicator can be taken as conclusive proof. Rather, one should look for patterns or clusters of indicators that suggest a problem.

Physical indicators

* Sprains, dislocations, fractures, or broken bones

* Burns from cigarettes, appliances, or hot water

* Abrasions on arms, legs, or torso that resemble rope or strap marks

* Internal injuries evidenced by pain, difficulty with normal functioning of organs, and bleeding from body orifices

* Bruises. The following types of bruises are rarely accidental:

o Bilateral bruising to the arms (may indicate that the person has been shaken, grabbed, or restrained)

o Bilateral bruising of the inner thighs (may indicate sexual abuse)

o “Wrap around” bruises that encircle an older person’s arms, legs, or torso (may indicate that the person has been physically restrained)

o Multicolored bruises (indicating that they were sustained over time)

o Injuries healing through “secondary intention” (indicating that they did not receive appropriate care)

o Signs of traumatic hair and tooth loss

Behavioral indicators

* Injuries are unexplained or explanations are implausible (they do not “fit” with the injuries observed)

* Family members provide different explanations of how injuries were sustained

* A history of similar injuries, and/or numerous or suspicious hospitalizations

* Victims are brought to different medical facilities for treatment to prevent medical practitioners from observing a pattern of abuse

* Delay between onset of injury and seeking medical care

Sexual Abuse

Sexual abuse is any form of non-consensual physical contact. It includes rape, molestation, or any sexual conduct with a person who lacks the mental capacity to exercise consent.

Who are the perpetrators?

Perpetrators of sexual abuse include attendants, employees of care facilities, family members (including spouses), and others. Facility residents sometimes assault fellow residents.

Who is at risk?

* The majority of identified victims are women, however older men have been sexually abused in both domestic and institutional settings.

* Persons with physical or cognitive disabilities

* Persons who lack social support and are isolated

What are the indicators?

Indicators are signs or clues that abuse has occurred. Physical indicators may include injuries or bruises, while behavioral indicators are ways victims and abusers act or interact with each other. Some of the indicators listed below can be explained by other causes (e.g. inappropriate or unusual behavior may signal dementia or drug interactions) and no single indicator can be taken as conclusive proof. Rather, one should look for patterns or clusters of indicators that suggest a problem.

Physical indicators

* Genital or anal pain, irritation, or bleeding

* Bruises on external genitalia or inner thighs

* Difficulty walking or sitting

* Torn, stained, or bloody underclothing

* Sexually transmitted diseases

Behavioral indicators

* Inappropriate sex-role relationship between victim and suspect

* Inappropriate, unusual, or aggressive sexual behavior

Domestic violence

Domestic violence is an escalating pattern of violence or intimidation by an intimate partner, which is used to gain power and control. Several categories of domestic violence against the elderly have been identified:

“Domestic violence grown old” is when domestic violence started earlier in life and persists into old age

“Late onset domestic violence” begins in old age. There may have been a strained relationship or emotional abuse earlier that got worse as the partners aged. When abuse begins or is exacerbated in old age, it is likely to be linked to:

* Retirement

* Disability

* Changing roles of family members

* Sexual changes

Some older people enter into abusive relationships late in life

Who are the perpetrators?

* Perpetrators are spouses or intimate partners

* The majority are men

* Some perpetrators abuse drugs or alcohol.

Who is at risk?

* Older women whose relationships with their spouses or intimate partners were abusive or strained when they were younger.

* Older women who enter into intimate relationships late in life

What are the indicators?

Indicators of domestic violence are similar to those associated with physical abuse and/or sexual abuse (see physical abuse and sexual abuse). The following additional patterns are also characteristic:

* The frequency and severity of injuries are likely to increase over time

* Victims often experience intense confusion and disassociation

* Violent incidents are often preceded by periods of intensifying tension and followed by periods of apparent contrition on the part of perpetrators

Psychological abuse

Psychological abuse is the willful infliction of mental or emotional anguish by threat, humiliation, or other verbal or nonverbal conduct.

Cultural values and expectations play a significant role in how psychological abuse is manifested and how it affects its victims.

Who are the perpetrators?

Perpetrators may be family members, caregivers, or acquaintances.

Who is at risk?

Persons who are isolated and lack social or emotional support are particularly vulnerable.

What are the indicators?

Indicators are signs or clues that abuse has occurred. Physical indicators may include somatic changes or decline, while behavioral indicators are ways victims and abusers act or interact. Some of the indicators listed below can be explained by other causes and no single indicator can be taken as conclusive proof. Rather, one should look for patterns or clusters of indicators that suggest a problem.

Physical indicators

* Significant weight loss or gain that is not attributed to other causes

* Stress-related conditions, including elevated blood pressure

Behavioral indicators

The perpetrator:

* Isolates the elder emotionally by not speaking to, touching, or comforting him or her

The elder:

* Has problems sleeping

* Exhibits depression and confusion

* Cowers in the presence of abuser

* Is emotionally upset, agitated, withdrawn, and non responsive

* Exhibits unusual behavior usually attributed to dementia (e.g., sucking, biting, rocking)

Financial Abuse

Elder financial abuse spans a broad spectrum of conduct, including:

* Taking money or property

* Forging an older person’s signature

* Getting an older person to sign a deed, will, or power of attorney through deception, coercion, or undue influence

* Using the older person’s property or possessions without permission

* Promising lifelong care in exchange for money or property and not following through on the promise

* Confidence crimes (“cons”) are the use of deception to gain victims’ confidence

* Scams are fraudulent or deceptive acts

* Fraud is the use of deception, trickery, false pretense, or dishonest acts or statements for financial gain

* Telemarketing scams. Perpetrators call victims and use deception, scare tactics, or exaggerated claims to get them to send money. They may also make charges against victims’ credit cards without authorization

Who are the perpetrators?

1. Family members, including sons, daughters, grandchildren, or spouses. They may:

* Have substance abuse, gambling, or financial problems

* Stand to inherit and feel justified in taking what they believe is “almost” or “rightfully” theirs

* Fear that their older family member will get sick and use up their savings, depriving the abuser of an inheritance

* Have had a negative relationship with the older person and feel a sense of “entitlement”

* Have negative feelings toward siblings or other family members whom they want to prevent from acquiring or inheriting the older person’s assets

2. Predatory individuals who seek out vulnerable seniors with the intent of exploiting them. They may:

* Profess to love the older person (“sweetheart scams”)

* Seek employment as personal care attendants, counselors, etc. to gain access

* Identify vulnerable persons by driving through neighborhoods (to find persons who are alone and isolated) or contact recently widowed persons they find through newspaper death announcements

* Move from community to community to avoid being apprehended (transient criminals)

3. Unscrupulous professionals or business persons, or persons posing as such. They may:

* Overcharge for services or products

* Use deceptive or unfair business practices

* Use their positions of trust or respect to gain compliance

Who is at risk?

The following conditions or factors increase an older person’s risk of being victimized:

* Isolation

* Loneliness

* Recent losses

* Physical or mental disabilities

* Lack of familiarity with financial matters

* Have family members who are unemployed and/or have substance abusers problems

Why are the elderly attractive targets?

* Persons over the age of 50 control over 70% of the nation’s wealth

* Many seniors do not realize the value of their assets (particularly homes that have appreciated markedly)

* The elderly are likely to have disabilities that make them dependent on others for help. These “helpers” may have access to homes and assets, and may exercise significant influence over the older person

* They may have predictable patterns (e.g. because older people are likely to receive monthly checks, abusers can predict when an older people will have money on hand or need to go to the bank)

* Severely impaired individuals are also less likely to take action against their abusers as a result of illness or embarrassment

* Abusers may assume that frail victims will not survive long enough to follow through on legal interventions, or that they will not make convincing witnesses

* Some older people are unsophisticated about financial matters

* Advances in technology have made managing finances more complicated

What are the indicators?

Indicators are signs or clues that abuse has occurred. Some of the indicators listed below can be explained by other causes or factors and no single indicator can be taken as conclusive proof. Rather, one should look for patterns or clusters of indicators that suggest a problem.

* Unpaid bills, eviction notices, or notices to discontinue utilities

* Withdrawals from bank accounts or transfers between accounts that the older person cannot explain

* Bank statements and canceled checks no longer come to the elder’s home

* New “best friends”

* Legal documents, such as powers of attorney, which the older person didn’t understand at the time he or she signed them

* Unusual activity in the older person’s bank accounts including large, unexplained withdrawals, frequent transfers between accounts, or ATM withdrawals

* The care of the elder is not commensurate with the size of his/her estate

* A caregiver expresses excessive interest in the amount of money being spent on the older person

* Belongings or property are missing

* Suspicious signatures on checks or other documents

* Absence of documentation about financial arrangements

* Implausible explanations given about the elderly person’s finances by the elder or the caregiver

* The elder is unaware of or does not understand financial arrangements that have been made for him or her

Neglect and Self-Neglect

“Active” neglect refers to behavior that is willful – that is, the caregiver intentionally withholds care or necessities. The neglect may be motivated by financial gain (e.g. the caregiver stands to inherit) or reflect interpersonal conflicts.

“Passive” neglect refers to situations in which the caregiver is unable to fulfill his or her care giving responsibilities as a result of illness, disability, stress, ignorance, lack of maturity, or lack of resources.

“Self neglect” refers to situations in which there is no perpetrator and neglect is the result of the older person refusing care.

Who are the perpetrators?

* Perpetrators may be paid attendants, family members, employees of long- term care facilities, or others

* Caregivers who lack adequate skills, training, time, or energy

* Caregivers who are mentally ill, or who have alcohol, substance abuse or other mental health problems

* In self-neglect cases, there are no perpetrators

Who is at risk?

* Persons with physical or mental disabilities who depend on others for care

* Persons with high care needs. The literature on care giving suggests that certain conditions are particularly stressful to caregivers. These include fluctuations in the older person’s need for care, disturbed sleep, incontinence, and lack of support from other family members.

* Self-neglect is often associated with mental health problems, including substance abuse, dementia, and depression.

What are the indicators?

Indicators are signs or clues that neglect has occurred. Indicators of neglect include the condition of the older person’s home (environmental indicators), physical signs of poor care, and behavioral characteristics of the caregiver and/or older person. Some of the indicators listed below may not signal neglect but rather reflect lifestyle choices, lack of resources, or mental health problems, etc. One should look for patterns or clusters of indicators that suggest a problem. Signs of neglect observed in the home

* Absence of necessities including food, water, heat

* Inadequate living environment evidenced by lack of utilities, sufficient space, and ventilation

* Animal or insect infestations

* Signs of medication mismanagement, including empty or unmarked bottles or outdated prescriptions

* Housing is unsafe as a result of disrepair, faulty wiring, inadequate sanitation, substandard cleanliness, or architectural barriers

Physical indicators:

* Poor personal hygiene including soiled clothing, dirty nails and skin, matted or lice infested hair, odors, and the presence of feces or urine

* Unclothed, or improperly clothed for weather

* Decubiti (bedsores)

* Skin rashes

* Dehydration, evidenced by low urinary output, dry fragile skin, dry sore mouth, apathy, lack of energy, and mental confusion

* Untreated medical or mental conditions including infections, soiled bandages, and unattended fractures

* Absence of needed dentures, eyeglasses, hearing aids, walkers, wheelchairs, braces, or commodes

* Exacerbation of chronic diseases despite a care plan

* Worsening dementia

Behavioral indicators:

Observed in the caregiver/abuser

* Expresses anger, frustration, or exhaustion

* Isolates the elder from the outside world, friends, or relatives

* Obviously lacks care giving skills

* Is unreasonably critical and/or dissatisfied with social and health care providers and changes providers frequently

* Refuses to apply for economic aid or services for the elder and resists outside help

Observed in the victim:

* Exhibits emotional distress such as crying, depression, or despair

* Has nightmares or difficulty sleeping

* Has had a sudden loss of appetite that is unrelated to a medical condition

* Is confused and disoriented (this may be the result of malnutrition)

* Is emotionally numb, withdrawn, or detached

* Exhibits regressive behavior

* Exhibits self-destructive behavior

* Exhibits fear toward the caregiver

* Expresses unrealistic expectations about their care (e.g. claiming that their care is adequate when it is not or insisting that the situation will improve)