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Dependent Adult Abuse (Elder Abuse) for CNAs, HHAs, and MAs

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This peer reviewed course is applicable for the following professions:
Certified Nursing Assistant (CNA), Home Health Aid (HHA), Licensed Nursing Assistant (LNA), Medical Assistant (MA), Medication Aide
This course will be updated or discontinued on or before Saturday, November 22, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


≥92% of participants will know the signs of dependent adult abuse and what to do.


After completing this course, the learner will be able to:

  1. Define dependent adult.
  2. Identify cultural beliefs about dependent adult.
  3. List types of dependent adult abuse.
  4. Identify signs of abuse.
  5. Describe what to do if you see signs of abuse.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Dependent Adult Abuse (Elder Abuse) for CNAs, HHAs, and MAs
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Julia Tortorice (RN, MBA, MSN, NEA-BC, CPHQ)

Definition of Dependent Adult

A dependent adult is defined as an adult at least eighteen years of age who cannot protect their interests or perform or get the care needed to meet basic needs on their own. The term elder abuse has been used because elderly adults make up most of the dependent adult population. Dependent adults include those who are physically or mentally impaired.

The World Health Organization has defined dependent adult abuse as a single or repeated action or lack of needed action. About one in ten older adults are abused or neglected (Eliopoulos, 2022). Many victims are afraid or unable to report abuse. Many dependent adults are subjected to more than one type of abuse (DOJ, 2019).

Cultural Beliefs

The National Center on Elder Abuse (NCEA) says that beliefs about dependent adults are different in different cultural groups.

Indigenous Dependent Adults

The National Elder Mistreatment Study (NEMS) showed that dependent adults among the tribal communities and Alaskan indigenous groups reported an abuse rate of 33%. That is almost twice as many for whites (Crowder et al., 2021). An Indigenous dependent adult may not report abuse out of shame, feeling at risk, fear of retaliation, and concerns about getting family members into trouble (National Indigenous Elder Justice Initiative, 2020).

Black Dependent Adults

Black dependent adults have high rates of poverty, disability, and living alone. For many dependent black adults, a lifetime of dealing with racism and segregation leads to a bigger risk of abuse. Many live in poor urban areas with poor social services and high crime rates. It is a normal place that leaves dependent adults at a bigger risk for mistreatment. That abusive action will not be reported. Black dependent adults have a distrust of government agencies which presents another block to reporting. There is a willingness to put up with an abusive home rather than risk being sent to a nursing home (NCEA, 2020a).

Latinx Dependent Adults

Latinx describes persons of Latin American cultural or ethnic origin who reside in the US. It includes Cuban, Mexican, Puerto Rican, South or Central American, or other Hispanic origins. Latinx is the biggest ethnic minority. About 40% of dependent Latinx adults experienced at least one type of abuse, and 21% experienced multiple types of abuse. The family, 'la Familia.' is very important. The needs of the family are more important than those of the individual members. Dependent adults in these communities do not think providing money for their adult children and grandchildren is mistreatment. Isolation and being excluded from family activities is the worst type of abuse. Blocks to reporting abuse include language, fear of how they will be treated, and a need to defend family members even if they are abusers (NCEA, 2020b).

Chinese Dependent Adults

Studies show that dependent adult abuse is widespread within the Chinese community. Emotional and psychological abuse has the greatest impact. The abuse often happens in the form of the silent treatment, where the dependent adult member is ignored. It is seen as humiliation and punishment. Financially supporting adult children is not seen as abuse in this community. Studies show that a tightly knit family helps fight dependent abuse. Dependent adult abuse can lead to higher suicidal thoughts (NCEA, 2020c).

Lesbian, Gay, Bisexual, and Transgender (LGBT) Dependent Adults

About 68% of LGBT-dependent adults have been subjected to verbal harassment. Around 43% have been threatened with violence. Black LGBT adults reported lifetime discrimination. Studies show that LGBT-dependent adults may go to great lengths to hide their sexual orientation. This action prevents them from seeking help. Many find themselves in situations where the abuser will use the threat to 'out' the dependent LGBT adult to control the abusive situation. 52% of LGB-dependent adults worried that they would have to hide their identity if they had to be in long-term residential care. 67% stated they were concerned about neglect, and 60% had concerns about verbal and physical abuse (NCEA, 2020d).


Ageism is the beliefs about older adults. For example, the idea that older adults are cranky, contrary, resistant to change (Eliopoulos, 2022). Ageism can put dependent adults in a less favorable light and increase their risk of abuse (Phelan, 2020). Ageism is prejudice based on discrimination by younger adults against older adults. Part of ageism is the worry of younger adults about their aging (Donizetti, 2019).

Healthcare workers experience ageism. Studies show bias against older adults among all healthcare workers. These attitudes lower the quality of patient care and increase the risk of death. Dependent adults who had lower levels of education were more at risk for the bad health effects of ageism (NCEA, 2021a).

Dependent Adult Abuse

The six types of dependent adult abuse are:

  1. Physical Abuse
  2. Sexual Abuse
  3. Emotional Abuse
  4. Neglect
    • Physical
    • Spiritual
  5. Abandonment
  6. Financial Abuse

Physical Abuse

Physical abuse is a physical act that may result in acute or chronic bodily injury, physical pain, problems, distress, or death (Carney, 2020). This abuse includes striking, hitting, beating, shoving, pushing, shaking, slapping, kicking, pinching, and burning. Physical abuse also includes restraining a dependent adult with drugs or physical restraints and forcing them to eat or drink against their will. It often begins with small things that slowly happen more often and more serious attacks.

Look for signs of physical abuse, document these signs, and report them immediately to your supervisor. Possible signs of physical abuse include (Carney, 2020):

  • Bruises, black eyes, lacerations, restraint/ rope marks
  • Broken bones and fractures, or skull fractures
  • Sprains, dislocations, or internal injuries/bleeding
  • Open wounds, cuts, punctures, or untreated injuries in various stages of healing
  • A dependent adult's report of being hit, slapped, kicked, or mistreated
  • A dependent adult's change in action
  • The caregiver's refusal to allow visitors to see the dependent adult alone

Accidental falls of dependent adults showed differences between accidental injuries and physical abuse. These differences include (Rosen et al., 2020):

  • Those physically abused were more likely to have bruising than those who accidental fall
  • Physical abuse victims had more injuries on the face, mouth, and neck than accidental falls
  • Victims of abuse did not have leg fractures as often as an accidental fall

Sexual Abuse

Sexual abuse is any sexual act performed with a dependent adult who does not agree to the sex or who is not able to agree to sexual acts. This abuse can include unwanted touching, rape, sodomy, coerced nudity, or sexually explicit photography (Carney, 2020). Although the dependent adult population is sexually active, everyone involved should agree upon these acts. Signs of sexual abuse that need investigation include (Phelan, 2020):

  • Bruises in various stages around the breasts or genital area
  • Unexplained vaginal or anal bleeding
  • Unexplained genital infections or venereal disease
  • Torn, stained, or bloody underwear
  • Difficulty in walking, standing, or sitting
  • Changes in the person's normal action
  • Panic attacks
  • Social isolation or emotional withdrawal
  • Suicide attempts
  • A dependent adult reports being sexually raped or assaulted

When dealing with possible sexual abuse with dependent adults, the healthcare workers must use great care with this sensitive subject. The healthcare worker may see signs but not know what may have happened in the patient's earlier life. Suppose the victim of sexual abuse experienced abuse or rape as a child or young adult. In that case, they might relive these past events, and the effects of sexual abuse as a dependent adult will have a bigger effect (Carney, 2020).

Emotional or Psychological Abuse

Emotional or psychological abuse is causing anguish, emotional pain, or distress with verbal or nonverbal acts, including harassment, verbal assaults, threats of harm or restraint, intimidation, humiliation, and treating a dependent adult as if they were an infant. Isolating a dependent adult from others is emotional abuse because social interaction is one of the most basic human needs (Carney, 2020).

Healthcare workers may mistake simple arguments or disagreements as innocent, but they could be signs of a bigger problem. Signs of emotional or psychological abuse include:

  • Being withdrawn and non-communicative or non-responsive
  • Being emotionally upset
  • Unusual action that is common for dementia, like sucking, biting, or rocking
  • A dependent adult's report of being mistreated

Psychological or emotional abuse may leave a dependent adult with feelings of shame and a low sense of self-worth. It may cause them to doubt their own abilities. It can lead to physical decline and higher death rates (Carney, 2020).

Physical Neglect

Neglect is a major problem with frail and dependent adults because they need more care and help. As people age, they become less able to do activities of daily living by themselves, and their actions become slower. This disability can lead their caretakers to neglect the dependent adult. Neglect is the refusal or failure to provide for needs (Carney, 2020). These needs include food, water, and shelter. Neglect also involves not providing medications. Signs of neglect include (Pennsylvania Office of Victim Care, 2021):

  • Dehydration, malnutrition, untreated bedsores, or poor personal hygiene
  • Unattended or untreated health problems
  • Over-medicated, confused, or lethargic
  • Withdrawn, refusing to interact, depressed
  • A dangerous or unsafe living place like bad wiring, no heat, or running water
  • An unclean living place like dirt, fleas, lice on person, soiled bedding, fecal and urine smell, or does not have correct cloths
  • A dependent adult's report of being mistreated

Neglect may be deliberate or accidental. The caregiver may be physically disabled, too frail, or have a psychiatric illness that prevents them from meeting the needs of the dependent adult (Elder, 2021).

Spiritual Neglect

Spiritual abuse or neglect restricts or prevents a dependent adult from engaging in their usual spiritual activities, customs, or traditions. This abuse can take the form of preventing the dependent adult from attending their place of worship or refusing to take them there. Religious or spiritual beliefs can be used to take advantage or exploit an at-risk dependent adult. Making fun of or attacking the person's beliefs can be abuse (Government of Canada, 2017).


Abandonment is when someone responsible for a dependent adult leaves them. Abandoned dependent adults may be confused, unable to call for help, and left without money. If you see a dependent adult abandoned, take responsibility to get them help. Suspect abandonment if (Carney, 2020):

  • The dependent adult has been deserted at a hospital, a nursing facility, or other institutions
  • The dependent adult has been left at a shopping center or other public location
  • A dependent adult reports being abandoned

Healthcare workers need to know the fear and sense of loss that abandoned dependent adults may experience. They are suddenly separated from their familiar situation, personal belongings, and photos. This sudden change in their lives can make health problems worse. Remember that the dependent adult may be a victim of other types of abuse (Carney, 2020).

Financial Abuse

Financial abuse is common. It is under-reported and under prosecuted (Phelan, 2020). Financial abuse is stealing, misusing, or hiding a dependent adult's money or property (DOJ, 2020). This abuse happens when someone cashes a dependent adult person's check without their permission, forges their signature, steals money or valuable belongings, or tricks or forces them to sign contracts or wills (DOJ, 2020).

Many dependent adults do not work, and live off retirement funds, Social Security, or personal savings. So being careful with money is important. Financial responsibility is sometimes given to those who care for the dependent adult. This lack of control puts the dependent adult at risk for abuse and mismanagement of funds. Signs of financial abuse include (DOJ, 2020):

  • The sudden unexplained movement of money or property to a family member or someone outside the family
  • Unexplained loss of funds or valuable belongings
  • Unauthorized cash is taken out of the dependent adult's funds using the dependent adult's ATM card
  • Sudden changes in a bank account or normal bank activity, including an unexplained large amount of money taken out by a person with the dependent adult
  • A dependent adult's report of financial abuse
  • Poor care being provided or bill unpaid despite the availability of good financial resources
  • Forged signatures
  • Names added on a dependent adult's bank signature card
  • Sudden changes in a will, property, or financial documents
  • Relatives who have not been involved claiming control of the dependent adult's decisions and belongings
  • Getting care that is not needed

Financial abuse of dependent adults is getting bigger. Some of the problems are (NAPSA 2021):

  • Dependent adults who are victims of financial abuse have a higher death rate, and they are four times more likely to look for nursing home care.
  • 90% of abusers are family members or others that the dependent adult trusts.
  • Around one in ten victims of financial abuse will make Medicaid nursing home funds because their money is stolen.
  • Individuals with mental problems and those who make help with activities of daily living are at an increased risk for financial abuse

Age-related changes to the brain can bigger risk of financial abuse. Dependent adults are at larger risk from scams that include telephone calls and the internet. Healthcare workers need to remind dependent patients to never give out private information to anyone over the phone or the internet. That includes credit card and banking information, social security number, and Medicare number. Data shows that almost 900,000 persons in this country had thief by criminals impersonating Internal Revenue Officials. At least 26 million dollars has been lost to this crime (Wright, 2017).

An example is a call saying they are from the Medicare office. The dependent adult has an outstanding medical bill that must be paid immediately or lose their Medicare benefits. Medicare and other government agencies do not make these kinds of telephone calls. They always use written letters. Healthcare workers should tell patients to hang up and call the customer service number on the back of their Medicare card or call their healthcare provider's office. Healthcare workers can also help by writing important numbers for patients on 4 x 4 index cards that are big enough to be read.

Long Distance Caretaking

Many dependent adults live alone with their family living a long way away. About 11% of family caretakers live an hour or more away from their aging family members (AARP, 2020). This distance can cause problems. The dependent adult may not let their family know about their problems, and family members may not know who is involved in their day-to-day lives. Having good communication between the patient, healthcare provider, and distant caretaker is important.

The Abuser

The reasons for dependent adult abuse are complicated. Caring for frail, dependent adults is a hard, stressful job. If a dependent adult is mentally or physically impaired, they are likely to need more care from their caregiver. Depending on others can lead to dependent adult abuse. Those who are dependent on others may be unable to report that they are being abused.

The caregiver may not perform needed care for the dependent adult because of physical or financial problems. These problems cause frustration and stress, leading to abuse (Administration for Community Living, 2019). Dependent adults in poor health are more likely to be abused than those in good health because of the greater need for care by others.

The abuser is almost always a family member when the abuser is known. The abuser is typically a child or spouse. Data shows that family members do 90% of dependent adult abuse (National Care Planning Council, 2016).


Everyone working with dependent adults must know they want to make their own decisions and do not want change (Kutame, 2021). Dependent adults have the right to make decisions about themselves. If they choose to be neglectful, they have that right to be competent (mentally able). Healthcare providers and the courts determine competence.

Self-neglect is refusing or being unable to care for their health or safety. Mental problems, physical disability, and distress lead to self-neglect (Dong, 2017). One out of every nine dependent adults has some self-neglect (Kutame, 2021). Signs of self-neglect include (Carney, 2020; Kutame, 2021):

  • Not eating enough food
  • Wearing dirty clothes, torn
  • Wearing clothes that are not correct for the weather
  • Living in an unclean or dangerous place
  • Not getting needed medical care

Risks for people who neglect themselves include (Phelan, 2020; Kutame, 2021):

  • Living alone
  • Women (possibly because more women live alone than men)
  • Depressed or getting more confusion
  • Frail and dependent adult
  • Alcohol and drug problems
  • History of poor personal hygiene or bad living place

Signs to look for in the home and on the person include the following:

The Home (Lambert, 2020):

  • Not enough food, water, or heat
  • Unclean or dangerous living place
  • Major repairs are needed and not done
  • Human or animal feces
  • Hoarding: nothing is thrown away, stacks of papers and magazines
  • Overrun with unwanted animals or insects

The Person (Phelan, 2020; Kutame, 2021):

  • Poor personal hygiene (dirty hair, nails, skin)
  • Smells of feces or urine
  • Unclothed or not correctly dressed for the weather
  • Skin rashes or bedsores
  • Dehydrated, malnourished, or weight loss
  • Lack of needed dentures, eyeglasses, hearing aids, walkers, wheelchairs braces, or a commode
  • Higher dementia, confusion, or disorientation
  • A sudden lower level of health or living place
  • Spending too much time alone or isolated from former activities
  • Lack of interest or concern about life
  • Untreated medical problems
  • Self-destructive actions
  • Changes in normal activity
  • Hallucinations or delusions
  • Misusing drugs or alcohol
  • Higher use of hospital care

Support by family, friends, community members, and healthcare workers is important to help dependent adults be safe. Family and friends can help by (Lambert, 2020):

  • Helping the adult to less isolation by regularly visiting, telephone calls, and volunteering to events, church, or shopping
  • Learning the signs to look for
  • Staying in contact with the adult
  • Listening to and talking to adults regularly, showing caring, and helping them to fix problems
  • Help the person to think about options and to make their choices
  • Help the person agree to help and to get needed care
  • Getting others to help by finding volunteer groups
  • Getting help from Adult Protective Services (APS)

Neighbors can help by (Lambert, 2020):

  • Looking for changes that might show a problem with an aging neighbor
  • Looking for signs of changes in well-loved animals once well cared for and now losing weight and neglected
  • Looking for newspapers or mail piling up or a change in routine
  • When concerned, neighbors can knock on their door and check to see if they need help
  • They can listen, offer support, and call APS if concerned about self-neglect
  • 911 can be called if the person needs immediate medical help and is in danger of harm

Public Service Workers can help by (Kutame, 2021):

  • Look for any changes that may show a problem with an aging customer. They may see mail or newspapers piling up
  • They may see a bad change in the personality of the dependent adult
  • Lower risks and act right away if there is danger

Actions need to be based on the person knowing that they are neglecting themselves and their mental ability to make decisions about self-care and safety (Dong, 2017). A team of healthcare workers is needed to help a person who is neglecting themselves (Kutame, 2021). Dependent adults have an attachment to their normal place. Even if they know the place is no longer safe for them, they may not want to leave (Kutame, 2021).

Institutional Abuse

Institutional abuse is abuse that happens at a facility or organization that gives dependent adult care. These include assisted living facilities, intermediate care facilities, community living centers, rehabilitation facilities, and nursing homes. Institutional abuse includes all types of abuse. Reasons for institutional abuse are:

  • Being female
  • Having a disability or mental problems
  • Being dependent than 74 years of age

In the US, four out of every five residents in nursing homes are women. Often abuse is seen in an institutional because of the misuse of drugs or physical restraints. Misuse means that restraints are used more than the physician ordered or in the wrong ways. Examples are over-medicating residents to keep them quiet or workers not loosening the restraints often enough (Carney, 2020).

Outside facts that affect patient care at institutions include:

  • Demand for facility beds
  • The unemployment rates
  • The physical layout of the building
  • Cost of good care
  • Number of workers for each patient

Resident-to-resident aggression is a problem. This abuse includes a resident's physical violence, sexual assault, verbal abuse, humiliating treatment, and social isolation against another resident (Phelan, 2020). About 20% of nursing home residents have this abuse. Healthcare worker actions to deal with resident-to-resident aggression include stopping opportunities and situations that trigger aggressive actions. It also includes managing tense situations and mediation (Phelan, 2020).

Resident-to-resident abuse includes:

  • Shouting, screaming, or cursing the victim
  • Physical attacks, biting, hitting, kicking
  • Sexual abuse
  • Financial abuse
  • Entering the room or personal space of another individual without permission and snooping in their personal belongings

In the institutional setting, the typical abusers are often the lowest paid and most uneducated people in healthcare facilities. This abuse or neglect can lead to disasters. Residents can suffer from falls, the development of painful decubitus ulcers, malnutrition, and sometimes death. Studies show that usually, the abuser is male, young, and lacks experience. He often is poorly educated and suffers from job burnout. This burnout leads to a loss of caring about the patients. Studies show that workers who reported themselves for abuse thought they were emotionally exhausted (Yon et al., 2018; NCEA, 2021b).

Dependent adult prisoners are a problem. Because of limited resources in the prison system, some dependent adult prisoners may not receive good treatment for health problems (ODPHP, 2020).

Patients, family members, and healthcare workers can report complaints about poor care in a facility. States have laws protecting workers from revenge from management, so workers feel safe to make reports. Nursing homes can implement actions to prevent dependent adult abuse, including regular worker training about abuse and neglect. Some states have registries to track workers that commit abuse.

Social service and law enforcement agencies can investigate reports, act, and remove dependent adult victims from abusive places. Laws criminalizing abuse of the dependent adult change from state to state. Depending on the abuse, it may be a misdemeanor, a felony, or a lower murder charge. Punishment can be done when the abuser's act is evil and willful. There are also civil legal suits that the person or their family can bring for financial damages. Many states have passed residents' bills of rights that prohibit mental and physical abuse of patients and ask for abuse reports. Based on the problems, the institution in question may have its permits or licenses revoked, suspended, or denied. This denial is one of the many ways states are trying to improve dependent adult care in facilities.

Reporting Abuse

Most states make certain groups of workers report suspected abuse and neglect. The most common groups are medical workers, healthcare workers, mental health counselors, service workers, and government agents who see the dependent adults. Make a report of the signs that made you think there was abuse. Some states have established 24- hour hotlines to make reporting easier and secure the safety of the victim as soon as possible. There is punishment for those who fail to report. There is immunity from civil suits or prosecution to those who make reports in good faith, even if those reports did not prove abuse.

The APS is the main public agency that investigates reported cases of dependent adult abuse. It gives victims and their families treatment and protective care. Reports can be made to APS either in-person, online, by phone call, or fax (ALTSA, 2021). All calls to APS are private. The APS checks the report and decides if the situation needs to be investigated. If it is an emergency, APS acts within 24 hours to give emergency care. If it is not an emergency, the APS works with other agencies to give the dependent adult social services and health care (ALTSA, 2021). Many other public and private organizations protect at-risk, dependent persons from abuse, neglect, and abuse. These agencies include:

  • The state agency on aging
  • The law enforcement agencies
  • The police department
  • The district attorney's office
  • The court system
  • The sheriff's department
  • The medical examiner/coroner's office
  • Hospitals and medical clinics
  • The state long term care Ombudsman's office
  • The public health agency
  • The area agency on aging
  • The mental health agency
  • The facility licensing/certification agency

The power of each agency changes by state. Use this internet site to find local agencies— or call 1-800-677-1116.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


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