Dependent Adult Abuse (Elder Abuse)

The United States Department of Justice defines a dependent adult as a person who has a “physical or mental condition” that significantly limits their ability to maintain their daily care (U. S. Department of Justice, 2025a). The term elder abuse has been the most frequently discussed form of abuse because older adults make up a large percentage of the dependent adult population. However, dependent abuse comprises all dependent adults who are 18 years of age and older. The focus of this course will be on elder abuse, which was first presented in 1975 as “Granny Battering” (OJP, n.d.).

In the United States, in 2020, individuals aged 65 and older accounted for 16.8% of the population (Caplan, 2023). The areas of the older population that have experienced the highest growth rates are those in the 65-74 age sector and among those aged 95 years and over (Caplan, 2023).

The World Health Organization has defined dependent adult abuse as ‘a single or repeated act or lack of appropriate action’ that happens within a relationship where trust should be the norm. This adverse behavior results in physical or emotional harm, or both, to the victim. Dependent adult abuse is a human rights violation. Worldwide, the prevalence of dependent adult abuse is expected to increase due to several countries having rapidly ageing populations (World Health Organization [WHO], n.d.).

When examining elder abuse in the United States, the data have shown that pre-COVID pandemic figures indicated that around 1 in 10 older adults were subjected to some type of abuse. However, more up-to-date studies indicate that 1 in 5 older adults reported incidences of abuse during the COVID-19 pandemic. Other sources of data have shown that only 1 in 24 incidences of abuse are reported to authorities (National Council on Aging [NCOA], 2024).

Elder abuse includes any of the following, either singly or in combination. It’s important to keep in mind that victims may experience many types of abuse simultaneously.

• Physical abuse: this includes actions such as hitting, kicking, and punching that cause pain or injury.
• Sexual Abuse: Acts that include touching, caressing, or intercourse, or any type of sexual action, that is not consensual and includes physical force or threats.
• Emotional and psychological abuse: This can include verbal attacks, insults, name-calling, threats, harassment, or coercion. It can also include ‘silent treatment,’ refusing to communicate or interact with the older adult.
• Confinement: Restricting movements and isolating a person, other than for a health-related concern.
• Passive Neglect: The older adult is denied adequate accommodation, nutrition, clothing, or access to medical care.
• Willful Deprivation: These are actions that deprive the individual of medications, medical care, and assistive devices and subject the older adult to possible physical or psychological harm.
• Financial Abuse: This occurs when the older adults’ resources are withheld from them or misused by someone else (NCOA, 2024).

Compared to a decade ago, more older Americans are living independently. The availability of assistive devices and home modifications has allowed older adults to remain independent. Statistical evidence shows that more older women live alone. In 2023, 27% of women in the 65-74 age group lived alone. This number increases to 39% for women between the ages of 75 and 84 and rises to 50% for women aged 85 and older (Mather & Scommegna, 2024).

90% of elder abuse happens in the victim’s residence (Clark, 2025). Data on elder abuse shows that the type of abuse is often related to the setting. For older adults living in the community, psychological abuse is the most common form of abuse. This is followed by financial abuse and neglect (Burba, 2025). Reports show that financial abuse is now the most rapidly increasing type of elder abuse, with scammers playing a major role in these schemes (Hellwig, 2023).

Since the 1980s, more research has been done on the various factors that contribute to elder abuse. Ethnicity and culture can have an impact on elder abuse. However, it is essential to recognize that substantial diversity exists within specific cultural and racial groups. Older adults who grew up overseas and witnessed the close-knit family bonds and care afforded to seniors may have similar expectations for their own older years. This conflict between the norms of another culture and time and the realities of contemporary American life can be a source of anguish for elderly family members and their younger relatives.

Traditions and practices change over time, often in response to changes in society. Studies have shown that the weakening of family ties can increase the likelihood of elder abuse occurring. There is often an imbalance of power between the victims of elder abuse and the perpetrator. Most instances of elder abuse are invisible to society. The following brief overview will look at issues of elder abuse in different racial populations in the United States.

Martha brings her mother to the clinic for her checkup. The clinician notices that Martha’s mother is more confused and has difficulty following instructions. Martha appears to be anxious and irritated, frequently shouting instructions at her mother. Martha is also limping and using a walking stick. She explains to the clinician, “I hurt my back trying to get my mother out of the shower.”  At the end of the visit, the clinician asks the medical technician to sit with the patient while she talks to Martha alone in the office. The clinician enquires, “How are things going at home?” Martha begins by saying, “Fine,” and then bursts into tears. “I promised my mother we would never put her in a nursing home, but she needs to be watched 24 hours a day. My brother and sister don’t help. I don’t mean to lose patience with her, but it’s so hard.”  The clinician commends Martha for taking care of her mother and then discusses residential care for older people with memory problems. Martha is hesitant, but she agrees to visit some of the facilities that the clinician offers. A few weeks later, Martha calls the clinic to say that she has found “a wonderful place” for her mother, where she is getting the care she needs, and Martha can visit anytime. She admits to having a great deal of guilt for being verbally aggressive with her mother and is seeing a therapist.

Ageism can be defined as the labels that are applied to older people based solely on their age. It also describes how older adults see themselves and other older people. For example, the stereotype that older people are irritable, difficult, and resistant to change (Eliopoulos, 2022). Ageism and the attitudes associated with it are of concern as they are considered to play a significant part in the perpetration and acceptance of elder abuse (Storey et al., 2024).

Unfortunately, healthcare professionals are not immune to ageism. Studies have highlighted bias against older adults among physicians, medical students, and nurses. These mindsets can compromise the quality of patient care and lead to an increased risk of mortality. One study showed that older adults with lower levels of education were more at risk for the negative health effects of ageism (NCEA, 2021).

As healthcare professionals, we must be aware of the signs of abuse that patients may present with, document these signs, and report them to the appropriate agencies. To successfully address potential abuse, the clinician must first establish rapport with the patient. They must employ emphatic listening skills and observe the patient’s body language. When asked if they feel safe in their home environment, a patient may respond yes, but at the same time drop their gaze and clench their fists. This important body language will be missed if the clinician is busy typing and watching the computer screen.

During a physical assessment, the possible signs of physical abuse to be aware of include:

• Bruising, black eyes, cuts, scratches, and marks on the skin that may have been left by using restraints.
• Fractures, sprains, or dislocated joints.
• Internal injuries with possible hemorrhaging.
• Wounds, or untreated injuries, in different stages of healing.
• Laboratory results indicating medication overdose or under-utilization of prescribed medications.
• A dependent adult stating that they are being abused. This reporting of abuse should be taken seriously regardless of the patient’s cognitive status. A clinician should never dismiss a patient’s complaint of abuse because they have memory problems, or because a caretaker states that the patient is confused and “doesn’t know what they are saying.”
• A noticeable change in the behavior and interactions of the dependent adult.
• The caregiver limiting, or preventing, the dependent adult from having visitors or insisting on being present during all interactions with the dependent adult, including visits with health care professionals (U.S. Department of Justice, 2025b).

A study reviewing elderly patients seen in emergency departments found significant differences between those who experienced unintentional falls and those who were subjected to physical abuse. These findings include:

• Those who experienced physical abuse were younger compared to fall victims. The average age of physical abuse victims was 68.5 years, whereas the average age of unintentional fall victims was just over 77 years.
• Bruising and abrasion were the most frequent findings in elder abuse victims, accounting for over 38% of diagnoses. Whereas the most frequent diagnosis in the unintentional fall group was fracture. 
• Among abuse victims, the face was the most common location of injury, with over 32% of facial injuries. In comparison, a little over 4.5% of fall victims had facial injuries.
• Comparing the location of fractures, there were also notable differences between the groups. Neck fractures were a common finding in the fall patients, whereas abuse victims had a significant finding of finger fractures. In fractures of the lower extremities, abuse victims had a higher incidence of toe fractures compared to fall victims. Over 11.5% in the first group compared to 3.3% in the latter. Pelvic and hip fractures were the most frequent finding in the fall group.

Other findings from this study were that elder abuse victims have a lower hospital admission rate in comparison to fall patients. Awareness of clinical findings of abuse, such as facial, upper body, and upper extremity injuries, is essential in emergency room settings to ensure that these patients get needed support and help (Khurana et al., 2024).

Many elderly adults find themselves alone when adult children move away from home. Awareness of dependent adult abuse can be difficult in these situations. From a distance, it can be challenging to determine the adequacy of the care an older adult is receiving. When interviewing a patient, healthcare professionals should note that the primary caretaker lives at a distant location. During patient interviews, they need to enquire how this is working out for the older adult, and if there is a friend or neighbor locally that they can turn to. Awareness of possible self-neglect is critical in these circumstances (National Institute on Aging, 2023b).

Self-neglect has been defined as "an extreme lack of self-care” to the point that it endangers an individual’s health and safety (Social Care Institute for Excellence [SCIE], 2024). There are many reasons why self-neglect may happen, including physical and emotional health concerns. Physical illness can deplete energy reserves, which can limit self-care and environmental care. Depression, traumatic life changes, lack of motivation, decreased attention span, and confusion can also be causes of self-neglect (SCIE, 2024).

Signs of self-neglect include:

• Poor nutritional intake.  Infrequent purchasing of food supplies.
• Clothing is not suitable for the weather conditions, such as wearing a heavy jacket in the summer months.
• Severe neglect of the home environment, where it becomes a health and safety hazard.
• Lack of adequate medical care, unfilled prescriptions, and missed appointments with healthcare providers.

Addressing self-neglect in elderly adults can be challenging. They may refuse help and state that they do not need it. Family members, friends, and healthcare professionals play an important role in mitigating self-neglect. However, if the elderly person has the mental capacity to be their own decision maker, there are limitations on what outside help can do.

Legally, safeguarding duties, included under The Care Act (2014) Statutory Guidance, aim to provide care and support to individuals who are at risk of self-neglect. In most instances, the intervention focuses on minimizing the risks while showing regard for the individuals’ preferences.

Research indicates that when working with individuals who self-neglect, a person-centered, empathetic approach is essential. Changing a person’s behavior may not be feasible, and a more realistic approach may be a good risk management strategy. Building trust and realizing that change may be a slow process is part of the course. The patient may fear losing self-control, which can lead to resistance to change. Help the patient explore alternatives that they are more comfortable with, and, with the patient’s consent, include family members and friends they trust (SCIE, 2024).

Dependent elderly adults who need assistance with self-care rely on nursing homes, community living centers, and other long-term care facilities to provide services. Depending on the level of care needed, these institutions can range from assisted living facilities to nursing homes.

Institutional abuse occurs at a location that provides dependent adult care. These facilities include:

• Assisted living communities
• Intermediate care facilities
• Community living facilities
• Nursing homes

This mistreatment can include any of the previously discussed forms of abuse. Research indicates that the major risk factors for institutional abuse are:

• Women are more frequently abused than men.
• Having disability or cognitive impairment places residents at higher risk for abuse.
• Being older than 74 years of age (Nursing Home Abuse Center, 2025b).

Key statistics related to nursing home abuse include:

• 2 out of 3 staff members confessed to committing abuse of elderly nursing home patients in the previous year.
• Around 1 in 10 residents in nursing homes are subjected to abuse.
• Almost 50% of nursing home residents with dementia experience abuse and neglect (Nursing Home Abuse Center, 2025a).

Nursing homes have a legal responsibility to protect residents from all types of abuse, including resident-to-resident abuse. The most predominant types of elder abuse in nursing homes are physical, emotional, and sexual abuse. Federal and state laws mandate care facilities to ensure safe surroundings for residents and to have in place policies and procedures to prevent abuse and neglect. The Centers for Medicare and Medicaid Services (CMS) has established comprehensive rules that nursing homes must follow to maintain their licensure and certification. These rules highlight the facilities’ duty to keep residents safe from all forms of abuse. All new residents must have a complete assessment, during which any potential behavioral or safety concerns are identified. Long-term care facilities are required to develop a care plan for each resident that addresses their individual needs and risks. When a facility fails to adequately assess residents or to apply necessary safety measures, it can be held accountable for subsequent harm. All incidents of resident abuse must be reported to the appropriate authorities, and this includes resident-to-resident abuse (Senior Advocate Center, n.d.).

Federal and state laws exist to protect dependent adults from abuse. Laws and definitions can differ from state to state, but all states have reporting systems in place. Adult Protective Services (APS) responds to reports of suspected dependent adult abuse. APS investigates reported allegations of abuse and works with other agencies to ensure the care and safety of the dependent adult (Adult Protective Services [APS], n.d).

Frequent reports of abuse prompted policymakers to enact a series of laws aimed at protecting dependent adults. Some important, landmark legislation is the ‘Federal Older Americans Act of 1965 (OAA)’ and the creation of the ‘Vulnerable Dependent Adult Rights Protection Program 42 USC 3058’, et seq. in 1992. These acts were the impetus for the creation of state laws to address the needs and interests of dependent adults. The OAA has been amended several times since its inception. On March 25, 2020, the President of the United States signed the Supporting Older Americans Act of 2020, which provided funding for OAA programs. One of these programs is the National Center on Elder Abuse, which provides information on dependent adult abuse to the public and healthcare providers. It also offers training and technical resources to state-dependent adult abuse agencies and community-based organizations.

The Vulnerable Elderly Rights Protection Program legislation endorsed the following (Congressional Research Service, 2021):

• Advocacy efforts through the ombudsmen services.
• Prevention programs to address abuse, neglect, and exploitation of dependent adults.
• Provide legal assistance to older adults.
• Federal funding initiatives made it possible for states to create and sustain programs intended to assist dependent adults (Congress.Gov, 2021).

Reporting suspected elder abuse is an important first step in the detection and prevention of further harm. There is also a legal requirement to report abuse or suspect abuse. The laws governing mandatory reporting can vary from state to state, but those typically designated as mandatory reporters include all healthcare professionals. It should be noted that someone does not have to be a mandated reporter to report abuse or suspected abuse. Anyone can report abuse, and in several states, non-mandated reporters can make a report anonymously.

Failing to report suspicions of abuse is regarded in most states as a misdemeanor and has certain consequences. It is essential to note that reporting should occur even if one is uncertain about the veracity of the allegation. Mandatory reporters cannot be punished for making a report in good faith. The same applies to individuals who are not designated mandatory reporters.

Mandated reporters can also be exposed to civil lawsuits for failure to protect a vulnerable individual. In certain states, there is no statute of limitations on the failure to report abuse, which allows victims of abuse to instigate charges against a mandated reporter regardless of the length of time since the abuse took place (Marschall, 2024).

You are the new Nurse Manager of a nursing home. One of your first tasks is to review the personal files of all employees. While doing this, you notice that several healthcare workers do not have background checks in their files. How should you respond to this:

1. These employees were hired before you took this position, so it is not your responsibility.
2. Since you are now the Nurse Manager, the safety and well-being of the residents is your responsibility.

The answer is “b”. As the Nurse Manager, you are responsible for patient care. You will create a list of all caregivers who do not have background checks and present it to the nursing home administrator. You will request that background checks be done immediately. Once the background checks are completed, you will review them to ensure that there are no employees who are excluded from patient care. If there are, you will bring this to the immediate attention of the facility administrator.

You will ensure that the facility has a policy in place for completing background checks when required. You will also ensure that the administrative and human resources staff involved in the new hiring process are aware of this policy and follow it. The policy should also specify the frequency of background checks, and you will periodically review employee files to confirm that this is being done.

Preventing elder abuse requires the involvement of elderly adults and the communities they live in. Increasing awareness and understanding of elder abuse can help prevent it from occurring. Some interventions that can be put in place include:

• Encourage family, friends, and neighbors to regularly check in with elderly adults. This can include visiting them at home or in care facilities. For older adults who move to residential care, these communications can help maintain the bond with the community they lived in and still be a part of it. Neighbors, who an elderly person has known for a lifetime, may be the first to notice subtle clues that all is not well and ask open-ended questions about how they are doing.
• Older adults should receive education on their right to be free from all forms of abuse and neglect. They should also be provided with information, both verbal and written, about the resources available to them, including ombudsman services, adult protective services, and hotlines for reporting financial abuse. Knowledge empowers older adults to advocate for themselves and to know that help is there for them.
• Caregivers require adequate support and training to carry out what is often a very demanding role. Resources that help caregivers manage stress and navigate difficult situations are vital. Many caregivers will confess that they didn’t know what they were committing to when they took on the role, and they can feel trapped and guilty. Healthcare professionals may be the first to detect caregiver stress or burnout, and they should provide empathetic listening and access to resources that can help the caregiver, including counseling services and caregiver support groups.
• Promoting open communication between older adults and family members. Healthcare professionals, including social workers, counselors, and elder care advocates, among others, can play a pivotal role in creating a safe environment where issues can be openly discussed and solutions considered. The older adult and the caregiver may both be unhappy with the care arrangements, but neither feels comfortable voicing their concerns. A non-judgmental environment can allow both parties to express their feelings and consider other solutions.
• Advising and, when requested, assisting older adults to put in place mechanisms to protect their resources. Competent older adults are capable of informed decision-making and have full access to their resources. Older adults should be advised to plan for a time when they may not be able to make their own decisions and to choose a trusted person to manage their affairs if that time comes (Renneisen, 2024).

As a society, we must recognize that we all have a responsibility to protect our dependent elderly population by actively sharing our knowledge, experience, and resources. Our goal should be to ensure that elder abuse does not occur and that the elderly members of our community have the opportunity to live safe and productive lives. Over the coming years, as the adult population continues to grow, there is also the likelihood that dependent elder abuse will increase. We must inform our political representatives about the needs of older adults and advocate for adequate funding to address these needs. Nurses, along with other healthcare professionals, have consistently been at the forefront in advocating for their patients' needs. Healthcare professionals will continue to play a role of advocacy for the elderly members of our communities.

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