Sign Up
For the best experience, choose your profession & state.
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Dependent Adult Abuse (Elder Abuse)

2 Contact Hours
Does NOT satisfy Iowa Requirements.
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Registered Nurse Practitioner, Respiratory Therapist (RT)
This course will be updated or discontinued on or before Thursday, November 16, 2023

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.


CEUFast, Inc. is an AOTA Provider of professional development, Course approval ID#03885. This distant learning-independent format is offered at 0.2 CEUs Intermediate, Categories: Professional Issues and Foundational Knowledge. AOTA does not endorse specific course content, products, or clinical procedures. AOTA provider number 9575.


FPTA Approval: CE22-467198. Accreditation of this course does not necessarily imply the FPTA supports the views of the presenter or the sponsors.
Outcomes

≥92% of participants will know how to identify dependent adult abuse and respond appropriately.

Objectives

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

  1. Characterize unique aspects of dependent adult abuse occurring in different ethnic and racial minorities.
  2. Recognize physical trauma that is highly indicative of physical abuse.
  3. Relate the characteristics commonly found in those who use abuse tactics.
  4. Describe interventions that can be put in place to prevent abuse.
  5. Outline findings that are suggestive of dependent adult abuse, both subjective and objective findings.
  6. Describe when and how to report suspected abuse and what channels to follow.
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.

Last Updated:
CEUfast OwlGet one year unlimited nursing CEUs $39Sign up now
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:    Maryam Mamou (BSN, RN, CWOCN)

Introduction

USLegal.com (2021) defines a dependent adult as “a person of eighteen years of age or older who is unable to protect the person’s own interests or unable to adequately perform or obtain services necessary to meet essential human needs.” Traditionally, the term elder abuse has been used due to older adults make up a large percentage of the dependent adult population. In practice, dependent abuse includes all dependent adults, including those physically or mentally impaired. Please note that the term elder abuse may be used to maintain consistency with the research used through this activity.

Prevalence

In the United States, those over 65 years of age presently make up more than 16% of the population (Eliopoulos, 2022). By 2060, this number is expected to double. It is important to note that dependent adult persons, over 85 years of age, are anticipated to double by 2040 (Eliopoulos, 2022). Due to advancements in healthcare, better exercise and dietary practices, and new technologies, individuals continue to live longer and healthier lives. As our population ages, it is our responsibility to ensure we protect geriatric individuals. This responsibility includes understanding how to recognize and report suspected dependent adult abuse.

The World Health Organization has defined dependent adult abuse as a single or repeated act or lack of appropriate action occurring within any relationship. There is an expectation of trust that causes harm or distress to a dependent adult person (Phelan, 2020). Approximately one in ten elderly individuals are abused or neglected annually (Eliopoulos, 2022). However, according to the United States Department of Justice, this figure does not accurately capture the extent of elder abuse due to many victims being afraid or unable to report abuse. It is also important to note that many older adults are subjected to more than one type of abuse, and these multiple forms of abuse usually happen simultaneously (DOJ, 2019).

United States Elder Abuse Statistics

Table 1: Prevalence According to the Type of Abuse
Type of AbusePrevalence
Financial Fraud and Exploitation5.2%
Caregiver Neglect5.1%
Psychological Abuse4.6%
Physical Abuse1.6%
Sexual Abuse0.6%
Statistics from the United States Department of Justice, 2017
  • Since 90% of older adults live in the community, dependent adult abuse has the highest concentration in this population.
  • Statistics from July 2017 show that 19% of the United States rural population were 65 years of age or older, compared with 15% in urban locations.
  • Older adults dwelling in rural areas are more likely to present with risk factors related to dependent adult abuse—the most significant of these being dementia.
  • Evidence suggests that reporting Elder adult abuse in rural communities is less than in urban settings.
  • Dependent adult abuse in rural America and within the tribal nations is complex and understudied.

Recent research shows that the values of respect and reverence ingrained in tribal cultures appear to afford scant protection from elder abuse. An analysis of the National Elder Mistreatment Study (NEMS) demonstrated that older adults among the tribal communities and Alaska Native population reported an accumulative abuse prevalence of 33% - nearly twice that of the overall previous study for white respondents (Crowder et al., 2021). Dependent adult members may not report abuse out of a sense of shame, heightened vulnerability, fear of retaliation, and concerns about getting family members into trouble (National Indigenous Elder Justice Initiative, 2020).

The National Center on Elder Abuse (NCEA) has presented interesting research on mistreatment and abuse of various groups within the larger population. One of the findings from NCEA research is that the perception of dependent adult abuse and how it is reported and responded to varies among different cultural groups.

Black Older Adults

In 2018, the population of older African Americans was estimated to be around 4.5 million adults, 65 years and older. By the year 2060, the number of older African Americans is predicted to reach over 12 million. In 2018 the poverty rate among this group was 18.9%, almost double that for all older American adults. Also, in 2018, data showed that 39% of older African Americans lived alone. Statistics from 2017 indicated that 39% of this population were coping with one or more disabilities. For many older African Americans, a lifetime of dealing with racism, and segregation, increase cumulative stress levels leading to greater vulnerability to abuse. Older African Americans frequently reside in poor urban areas with inadequate social services and high crime rates. It is an environment that leaves older adults at greater risk for mistreatment and a greater likelihood that abusive behavior will not be reported. There is also a lingering distrust of government agencies which presents another barrier to reporting dependent adult abuse. There is a significant fear of institutionalization among older African Americans, which leads to a willingness to put up with an abusive home rather than risk being sent to a nursing home (NCEA, 2020a).

Latinx Older Adults

Latinx is used to describe persons of Latin American cultural or ethnic origin who reside in the United States. It includes Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish origins. Latinx adults are the United States' largest ethnic minority and comprise approximately 17% of the total population of this country. Few studies of dependent adult abuse among this population have been conducted. One study found that 40% of older Latinx adults experienced at least one type of abuse, and 21% experienced multiple types. Strong emphasis is put on the value of the family, 'la familia,' and in many instances, the demands of the family unit surpass those of the individual members. Dependent adult members of these communities often do not regard financial abuse, providing their adult children and grandchildren with money, as a type of mistreatment. Isolation and being excluded from family activities is seen as one of the worst types of abuse. Hindrance to reporting abuse includes language barriers, fear of how professionals will be treated, and a need to defend family members, even those that are abusive (NCEA, 2020b).

Chinese Older Adults

Data from 2018 indicated that approximately 5.2 million persons of Chinese descent live in the United States. They form the biggest group with the Asian and Pacific Island population. Research shows that dependent adult abuse is widespread within the Chinese community. The rate of abuse is considered to be between 10% to 25.8%. Dependent adult adults identified emotional and psychological abuse as having the greatest impact. A form of abuse specific to this community is the 'silent treatment,' where the dependent adult member is ignored. It is regarded as an intense type of psychological humiliation and punishment. Financially supporting adult children was generally not considered dependent adult abuse by older adults in this community. Research indicates that a tightly knit family unit affords protection to older adults from exploitation and abuse. Over time, it has also been found that dependent adult abuse contributes to mortality in this population. A study found that dependent adult abuse was related to an increased risk for suicidal ideation (NCEA, 2020c).

Lesbian, Gay, Bisexual, and Transgender (LGBT) Elderly

Currently, it is projected that there are close to 3 million lesbian, gay, bisexual, and transgender persons in the United States who are fifty years of age or older. This figure is projected to rise to about 7 million by the year 2030. Little research has been done on dependent adult abuse among this population. Data indicates that around 68% of LGBT older adults have been subjected to verbal harassment, and around 43% have been threatened with violence. Black LGBT adults reported the most significant levels of lifetime discrimination.

Research also found that LGBT older adults may go to great lengths to hide their sexual orientation. For older LGBT adults who are the victims of abuse, this may prevent them from seeking help. Many may find themselves in situations where the abuser will use the threat to 'out' the older LGBT adult to control the abusive situation. 52% of LGB older adults worried that they would have to hide their identity if they had to find long-term residential care. 67% stated they were concerned about neglect, and 60% had concerns about verbal and physical abuse (NCEA, 2020d).

The Relationship Between Ageism and Elder Abuse

Ageism can be described as the stereotypes that are applied to older adults based purely on their age. It also describes how older people view themselves and other older people. For example, the idea that older adults are cranky, contrary, resistant to change (Eliopoulos, 2022). Ageism can create a generational barrier, place older adults in a less favorable light, and increase their vulnerability to abuse (Phelan, 2020). Ageism is a unique form of prejudice; it is based on discrimination by members of one group, younger adults, against those in a second group, older adults, that those in the first group will one day be a part of. One key finding considered a part of ageism concerns one's future aging process (Donizzetti, 2019).

Unfortunately, healthcare providers are not immune to ageism. Studies have found bias against older adults among physicians, medical students, and nurses. These attitudes compromise the quality of patient care and result in an increased risk of mortality. One study found that older adults who had lower levels of education were more at risk for the negative health effects of ageism (NCEA, 2021a).

Six Forms of Abuse

The six forms of abuse that can occur with dependent adults include:

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

Physical Abuse

Physical abuse is a physical force that may result in acute or chronic bodily injury, physical pain, impairment, distress, or death (Carney, 2020). This abuse includes striking, hitting, beating, shoving, pushing, shaking, slapping, kicking, pinching, and burning. In addition, utilizing drugs or physical objects to restrain a patient or forcing them to eat or drink against their will is also classified as physical abuse. It often begins with what is excused as trivial contact escalating into more frequent and serious attacks.

As healthcare providers, we must diligently assess our patients for signs of physical abuse, document these signs, and report them to the appropriate individuals. A thorough physical assessment, such as a comprehensive geriatric assessment, increases the likelihood of timely identification and intervention of dependent adult abuse. Be aware of possible signs of physical abuse, including:

  • 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
  • Laboratory findings of medication overdose or under-utilization of prescribed drugs
  • A dependent adult’s report of being hit, slapped, kicked, or mistreated
  • A dependent adult’s change in behavior
  • The caregiver's refusal to allow visitors to see the dependent adult alone (Carney, 2020).

A study that examined unintentional falls in older adults found that several clinically significant differences may exist between unintentional injuries and those that result from physical abuse. These findings include:

  • Those subjected to physical abuse were more likely to have bruising than those who experienced an unintentional fall (78% of those physically abused, compared to 54% of those with unintentional falls).
  • 67% of physical abuse victims had injuries on the maxillofacial, dental, and neck areas, compared to 28% of those who had an unintentional fall.
  • Victims of abuse did not exhibit lower extremity fractures as often as those who experienced an unintentional fall. The data showed an 8% fracture rate for abuse victims compared to 22% for unintentional falls (Rosen et al., 2020).

Sexual Abuse

Sexual abuse is classified as any sexual act performed with a dependent adult who does not consent to the act or who is incapable of giving consent to sexual acts. This abuse can include unwanted touching, rape, sodomy, coerced nudity, or sexually explicit photography (Carney, 2020).

Although the elderly population still is very involved in sexual activities, as sex is a natural part of human life, we must ensure these acts are consensual for all parties involved. Signs of sexual abuse that warrant further investigation include:

  • 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 behavior
  • Panic attacks
  • Social isolation or emotional withdrawal
  • Suicide attempts
  • A dependent adult’s report of being sexually raped or assaulted (Phelan 2020)

When dealing with possible sexual abuse with dependent adults, the healthcare professional must use great sensitivity. The clinician is dealing with the here and now and presenting symptoms; however, the clinician rarely knows about what may have happened in the patient’s earlier life. If the victim of sexual abuse experienced abuse or rape as a child or young adult, they might relive these past events, and the effects of sexual abuse as an older adult will have a more profound effect. This experience may be especially poignant in patients with progressive dementias (Carney, 2020).

Emotional/Psychological Abuse

Emotional or psychological abuse is "the infliction of anguish, pain, or distress through verbal or nonverbal acts," including constant harassment, verbal assaults, threats of harm or restraint, intimidation, and humiliation, treating an older adult as if they were an infant. Furthermore, isolating a dependent adult individual from others is also classified as emotional abuse, as social interaction is one of the most basic human needs (Carney, 2020).

We may mistake "simple arguments" or disagreements as innocent, but they could be signs of a larger problem. Regardless of the amount of abuse, any act listed above can cause severe emotional harm and distress. Signs that one may suffer from psychological abuse include:

  • Being extremely withdrawn and non-communicative or non-responsive
  • Being emotionally agitated and upset
  • Unusual behavior usually attributed to dementia, like sucking, biting, or rocking
  • A dependent adult's report of being mistreated

Psychological abuse may leave an older adult with feelings of shame and a diminished sense of self-worth. It may cause them to doubt their own ability to function successfully in their community. Ultimately it can lead to physical decline and an increase in morbidity and mortality rates (Carney, 2020).

Neglect

Physical Neglect

Neglect is a major problem with frail and dependent adults due to older individuals often needing more care and assistance. As people age, they become less able to do activities of daily living independently, and their actions become much slower. This disability can lead their caretakers to neglect the dependent adult. Neglect is "the refusal or failure to fulfill any part of a person's obligations or duties to a dependent adult," including refusing to provide necessities (Carney, 2020). These necessities are things Maslow's Hierarchy of Needs defines as physiological and most important, including food, water, and shelter. Neglect also involves not providing necessary medications to a dependent adult individual under one's care, which can be detrimental to their health.

Signs and symptoms of neglect include (Pennsylvania Office of Victim Services, 2021):

  • Dehydration, malnutrition, untreated bedsores, or poor personal hygiene
  • Unattended or untreated health problems
  • Over-medicated, confused, or lethargic
  • Withdrawn, refusing to interact, depressed
  • Hazardous or unsafe living conditions/arrangements like improper wiring, no heat, or no running water
  • Unsanitary and unclean living conditions like dirt, fleas, lice on person, soiled bedding, fecal/urine smell, or inadequate clothing
  • A dependent adult's report of being mistreated

Neglect may be an intentional act when a caregiver deliberately withholds food or medicine from an older adult. However, at times the neglect may be unintentional. In these instances, the caregiver may be physically disabled, too frail, or have a psychiatric illness that prevents them from meeting the needs of the older adult (Elder Abuse.org, 2021).

Spiritual Neglect

Spiritual abuse or neglect refers to restriction or preventing an older adult from engaging in their usual spiritual activities, customs, or traditions. This abuse can take the form of preventing the older 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 a vulnerable older adult. Ridiculing or attacking the person's beliefs can be used as a means of subjugation (Government of Canada, 2017).

Abandonment

Abandonment is when someone who has responsibility for a dependent adult individual leaves them. This abandonment can happen when the dependent adult individual is deserted at a facility, putting the dependent adult individual at risk. Abandoned dependent adults may be confused, unable to call for assistance, or left without money or a phone.

If you see a dependent adult left alone, it is your responsibility to ensure unharmed care. You should suspect abandonment if (Carney 2020):

  • The dependent adult has been deserted at a hospital, a nursing facility, or other similar institution
  • The dependent adult has been left at a shopping center or other public location
  • A dependent adult's report of being abandoned

Nurses need to be aware of the fear and sense of loss that older abandonment adults may be experiencing. They are suddenly separated from their familiar environment, personal effects, and photos that may have been gathered over a lifetime. This sudden, traumatic change in their lives can worsen existing health conditions, such as depression and confusion. It is also important to remember that the dependent adult may have been subjected to other forms of abuse (Carney, 2020).

Financial Abuse

Research has found that financial abuse is the first or second most pervasive form of dependent adult abuse. It was also found to be under-reported and under prosecuted (Phelan, 2020). Financial exploitation includes "illegal taking, misuse, or concealment of funds, property, or assets of a vulnerable dependent adult" (DOJ, 2020). This exploitation happens when someone cashes a dependent adult person's check without their permission, forges their signature on financial forms or checks, steals money or valuable possessions, or coerces them into signing contracts or wills (DOJ, 2020).

As many dependent adult individuals do not work and may be living off retirement funds, Social Security, or personal savings, being fiscally responsible is exceedingly important. At times, this responsibility is given to those who care for the dependent adult, which puts the dependent adult at risk for exploitation and mismanagement of funds. Signs and symptoms of financial or material exploitation include (DOJ, 2020):

  • The unexplained sudden transfer of assets to a family member or someone outside the family
  • Unexplained disappearance of funds or valuable possessions
  • Unauthorized withdrawal of the dependent adult's funds using the dependent adult's ATM card
  • Sudden changes in a bank account or banking practice, including an unexplained withdrawal of large sums of money by a person accompanying the dependent adult
  • A dependent adult's report of financial exploitation
  • Substandard care being provided or bill unpaid despite the availability of adequate financial resources
  • Discovery of a dependent adult's signature being forged for financial transactions or the titles of his possessions
  • The inclusion of additional names on a dependent adult's bank signature card
  • Abrupt changes in a will or other financial documents
  • The sudden appearance of previously uninvolved relatives claiming their rights to a dependent adult's affairs and possessions
  • The provision of services that are not necessary

The financial exploitation of older adults is on the increase. The National Adult Protective Services have reported that the frequency and complexity of financial abuse of vulnerable and older adults have increased extensively over the past decade. Some of the research findings related to financial abuse of older adults include (NAPSA 2021):

  • Older adults who are victims of financial abuse have an increased mortality rate, and they are 4-times more likely to seek nursing home care.
  • 90% of abusers are family members or other individuals that the older adult trusts.
  • Around one in ten victims of financial abuse will require Medicaid assistance due to their finances being stolen.
  • Individuals with cognitive impairment and those who require assistance with activities of daily living are at greater risk for financial abuse.

Research has found that certain age-related changes to the brain can increase vulnerability to financial abuse. The anterior insula of the brain, located with the brain's lateral sulcus, among other functions, is involved in decision making. Deterioration of the anterior insula can lead to impaired judgment, inability to pick on cues to fraudulent situations, and untrustworthy individuals, a diminished 'gut feeling' to when something isn't right (Master Class 2021; Phelan, 2020).

Older adults are increasingly at risk from schemes that include telephone calls from fraudsters and internet scams. The golden rule that nurses and healthcare professionals need to re-enforce with older patients is never, under the circumstances, 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 have been targeted by fraudsters impersonating Internal Revenue Officials. At least 26 million dollars has been lost to this particular fraud (Wright, 2017).

An example is a call purporting to come from the Medicare office stating that the older adult has an outstanding medical bill that must be paid immediately or will lose their Medicare benefits. It cannot be said often enough that Medicare, or any government agency, will make these kinds of telephone calls. Nurses re-enforce with patients to hang up and call the customer service number on the back of their Medicare card or call their healthcare provider's office. Nurses can also help by writing important numbers for patients on 4 x 4 index cards to be large enough to be read.

Long Distance Caretaking

Many older adults find themselves alone when adult children move away. A study found that 11% of family caretakers live an hour or more away from their aging family members. In these circumstances, being aware of dependent adult abuse can be a challenge. The older adult may not burden their adult children with their problems, and family members may not fully know who is involved in the older adult's day-to-day life. In these circumstances establishing good communication between the patient, healthcare provider, and distant caretaker is essential (AARP, 2020).

Who is the Abuser?

As our dependent adult population increases, more family members become caregivers, and more healthcare workers must care for aging individuals. As with all cases of abuse, the reasons for dependent adult abuse are complex. However, there are some special considerations in dependent adult abuse.

Caring for frail, dependent adults can be a stressful and challenging job. If a dependent adult individual is mentally or physically impaired, they will likely depend on their caregiver. Dependence on others is sometimes a contributing factor to dependent adult abuse, and those who are dependent on others may be unable to report that they are being abused. This dependence includes those who are physically or mentally impaired. Furthermore, if the caregiver cannot perform certain tasks for the dependent adult due to physical or financial constraints, they may become frustrated and more likely to abuse. Lastly, if the resources necessary to provide care are unavailable, caregivers may be unable to provide basic needs, leading to increased stress.

Those in poor health are more likely to be abused than those in good health, possibly due to the increased dependence on others. Abuse tends to occur when the caregiver's stress level increases due to a worsening of the dependent adult's impairment (Administration for Community Living, 2019).

The abuser is a family member in almost all abuse cases in which the perpetrator is known. The abuser is typically a child or spouse. Data indicates that family members carry out 90% of dependent adult abuse (National Care Planning Council, 2016).

What is Self-neglect?

Self-neglect has been defined as "refusal or being unable to care about own health or safety." Studies demonstrate that cognitive impairment, physical disability, and psychological distress are associated with increased self-neglect (Dong, 2017). The Chicago Health and Aging Project study indicated that 1 out of every 9 older adults, who reside in the community, have some type of self-neglect (Kutame, 2021). Several elements included in self-neglect (Carney, 2020; Kutame, 2021):

  • Not eating enough food to the point of malnourishment
  • Wearing filthy clothes, torn or not suited for the weather
  • Living in filthy, unsanitary, or hazardous conditions
  • Not getting needed medical care

Common characteristics of people who neglect themselves are the following (Phelan, 2020; Kutame, 2021):

  • Live alone
  • Women (possibly because more women than men live alone)
  • Depressed or increasingly confused
  • Frail and dependent adult
  • Alcohol and drug problems
  • History of poor personal hygiene or living conditions

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

The Home (Lambert, 2020):

  • Not enough food, water, heat
  • Filth or bad odors, hazardous, unsafe, or unclean living conditions
  • Major repairs are needed and not done
  • Human or animal feces
  • Hoarding: nothing is thrown away, stacks of papers and magazines
  • Animal or insect infestation

The Person (Phelan 2020; Kutame 2021):

  • Poor personal hygiene (dirty hair, nails, skin)
  • Smells of feces or urine
  • Unclothed or improperly dressed for the weather
  • Skin rashes or bedsores (pressure ulcers)
  • Dehydrated, malnourished, or weight loss
  • Absence of needed dentures, eyeglasses, hearing aids, walkers, wheelchairs braces, or a commode
  • Increased dementia, confusion, disorientation
  • Unexpected or unexplained worsening of health or living conditions
  • Spending too much time alone or isolated from former activities
  • Lack of interest or concern about life
  • Untreated medical conditions
  • Self-destructive behaviors or significant behavior changes
  • Hallucinations, delusions
  • Misusing drugs or alcohol
  • Increased use of hospital services

Social support by family, friends, members of the community, and healthcare providers are extremely important in helping vulnerable adults to remain safe.

Family and friends can assist by (Lambert, 2020):

  • They are helping the adult to reduce isolation as much as possible. Possible community services are regularly visiting, telephone calls, and volunteering to events, church, or shopping.
  • Learning the signs and symptoms to look for.
  • Staying in contact with the adult.
  • Listening to and talking to adults regularly, showing concern, and helping them to find solutions. Help person to consider options and to make his own choices.
  • Helping the person accept help from others and to get services needed.
  • Getting others involved by contacting faith-based volunteer groups or other volunteer groups to help with unmet needs.
  • Getting help from Adult Protective Services if an adult is showing signs of self-neglect.
  • Allowing an adult to have control of his destiny, remembering if they choose to be neglectful, he has the right to do so if he is competent.

Neighbors can help by (Lambert 2020):

  • Staying alert and aware of changes that might indicate a problem with an aging neighbor.
  • Noting signs of changes in well-loved animals once well cared for and now losing weight and neglected.
  • Noting whether newspapers are piling up on the porch and if there is a change in routine.
  • When concerned, neighbors can knock on their door and check to see if they need help.
  • They can listen and offer support and call Adult Protection Services if concerned about self-neglect.
  • 911 can be called if the person needs immediate medical help and is in danger of harm.

Public Service Providers can help by (Kutame 2021):

  • Stay alert to any changes that may indicate a problem with an aging customer. They may see mail or newspapers piling up.
  • They may note a significant, negative change in the personality of the dependent adult.
  • Focus efforts to reduce risks, deal with situations that require immediate interventions, and work towards establishing long-term stability.

A specific challenge to addressing self-neglect behavior in an older adult is that person's resistance to help and care. Interventions on all levels need to be individualized, based on the person's level of self-awareness of self-neglecting behaviors and their capacity to make decisions that ensure their self-care and protection (Dong, 2017). Assessment will be needed to establish the older adult's capacity for decision-making and establish the risk of harm to the older adult. These assessments will require the input of several different professionals, including nursing (Kutame, 2021). It is important to recognize that older adults have developed an attachment to their environment, especially if it's one that they have lived in for the greater part of their lives. Even if they know that it is no longer safe for them, they often do not want to leave (Kutame, 2021). All professionals working with older adults, especially those at risk for self-neglect, must recognize and respect their need for independence and continuity (Kutame, 2021).

Institutional Abuse

As the "baby boomer" generation reaches retirement age, and improved healthcare allows Americans to live longer, the difficult questions of who will care for our dependent adult citizens and how they will afford the cost of such care have challenged our society.

Consequently, many dependent adult Americans who can no longer care for themselves rely on nursing homes, community living centers, and other long-term care facilities to provide such care. Depending on the level of care required, these institutions can range from an assisted living environment to total nursing home care.

Institutional abuse is abuse found at a facility or organization that provides dependent adult care. These include assisted living facilities, intermediate care facilities, community living centers, rehabilitation facilities, and nursing homes. This mistreatment can include any of the previously mentioned types of abuse. Research shows that the predominant risk factors for institutional abuse are:

  • Being female
  • Having a disability or cognitive impairment
  • Being older than 74 years of age

In the United States, statistics show that four out of every five residents in nursing homes are women. One of the main reasons for this is that in the advanced dependent adult, those over 80 years, the ratio of women to men is higher.

Frequent abuse seen in an institutional setting is the misuse of chemical or physical restraints. Misuse means that restraints are used beyond what the physician ordered or is not within accepted medical practice. Examples are staff failing to loosen the restraints within adequate time frames or attempting to cope with a resident's behavior by inappropriate use of drugs (Carney, 2020). This failure can lead to wounds in areas that restraints have been placed and eventually, if not treated, to infections and even death.

Another area of institutional abuse gaining more attention is abuse among residents, referred to as 'resident-to-resident aggression.' This abuse includes physical violence, sexual assault, verbal abuse, humiliating treatment, and social isolation (Phelan, 2020). The rate of occurrence of resident-to-resident abuse is hard to determine, but current research estimates that it affects about 20% of nursing home residents. Nursing interventions to deal with resident-to-resident aggression include eradicating opportunities and factors that trigger aggressive behaviors. It also includes managing tense situations and mediation (Phelan, 2020).

A study showed that the types of resident-to-resident abuse include:

  • 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

A program developed in 2014 is aimed at decreasing resident-to-resident abuse. It has the acronym SEARCH, which stands for Support, Evaluate, Report Care plan and Help to avoid abuse. The SEARCH program aims to train staff members on how to more quickly identify resident-to-resident abuse that often goes unnoticed (Intriago, 2021).

Another recommendation is to encourage nursing home facilities to put in place programs that encourage the reporting of abusive incidents and provide the option for anonymous reporting (Intriago, 2021).

Most often, in the institutional setting, the typical abusers are nursing aides. These are often the lowest paid and most uneducated positions in healthcare facilities. This neglect can lead to disastrous consequences. Residents can suffer from debilitating falls, the development of painful and immobilizing decubitus ulcers, malnutrition, and sometimes death. Typically, the staff member is male, young, and often lacks experience. He often is poorly educated and suffers from job burnout, leading to a loss of concern for the patients. Research findings indicate that staff who self-report carrying out abuse label themselves as emotionally exhausted. Another research finding is a noteworthy relationship between abuse and a high ratio of residents to RN's. It found that a greater number of licensed nurses in a facility was linked with a reduction in resident abuse (Yon et al., 2019; NCEA, 2021b).

Special Provisions for Institutional Abuse

As our dependent adult population grows, states are attempting to address institutional abuse by healthcare workers better. Various authority figures, such as Adult Protective Services (APS), can investigate reports of abuse or neglect in nursing homes or other dependent adult care facilities. The institution in question may have its permits or licenses revoked, suspended, or denied based on the findings. This denial is one of the many ways that states are attempting to strengthen laws and regulations surrounding how the dependent adult population is treated within facilities.

Aside from patients or family members, workers are also one of the ways that complaints may be received about poor care within a facility. States have enacted provisions protecting employees from retaliation to help motivate employees to report concerns within their work environments.

In addition to investigations by authorities, Ombudsman programs have been established in each state. The purpose of these programs is to advocate for dependent adult patients in long-term care facilities and attempt to change laws so that dependent adult patients receive better care (NCEA, 2021b).

Nursing homes can implement interventions to prevent dependent adult abuse, including regular staff training about abuse and neglect issues.

To help decrease the number of convicted dependent adult abuse offenders hired into healthcare roles, certain states have registries to alert potential employers of these prior offenses. When used correctly before employment, similarly to a background check, these registries help ensure facilities do not risk their patients' safety by hiring someone known to abuse dependent adult individuals. For example, Missouri has an Employee Disqualification List (EDL), which includes individuals who have abused or neglected patients, exploited patients through mismanagement of their funds or property, or falsified documentation (Missouri Department of Mental Health, 2021).

The Centers for Medicare and Medicaid Services (CMS) report awarded more than $65 million to 28 States to create a comprehensive national background check program for direct patient access staff. CMS has committed to providing technical assistance to the States taking part in the program (CMS, 2020).

Unfortunately, depending on the setting, not all healthcare organizations require background checks on their employees. Because of the increase in chronic disease and the need for home health management, many dependent adult individuals who live independently or within assisted living areas see home health agents frequently. This frequent interaction creates a space for potential dependent adult abuse. These patients are often alone with their providers, and abuse may be less likely to be noticed by others or reported. For some healthcare agencies, having to run a background check on every employee appears to be unreasonable. However, background checks are the only way to ensure that an agency hires staff to provide safe, reliable care to their patients. Healthcare background checks should include the following items:

  • A National Criminal Search
  • National Sex Offender Search
  • Identification Verification Check
  • Drug Screen

CMS regulations $483.12(a) states that 'The facility must not employ or otherwise engage individuals who:

  • Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law;
  • Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or
  • Have a disciplinary action in effect against their professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of residents property' (CMS, 2021).

Office of the Inspector General (OIG) Exclusion List of Excluded Individuals and Entities (LEIE):

  • The Department of Health and Human Services Office of Inspector General keeps and implements the LEIE list. It is a database of those who are not allowed to provide services, either directly or indirectly, that receive federal funding as a result of offenses related to fraud or abuse. The list is updated monthly. Data indicates that nurses, nurse aides, personal care providers, home healthcare aides, and doctors accounted for nearly two-thirds of all LEIE exclusions over five years. All new employees must be checked against the LEIE list (Willard, 2021; Exclusion Screening, 2019).
  • Many states have passed residents' bills of rights that prohibit mental and physical abuse of patients and encourage filing grievances or complaints by or on behalf of the resident. Some states also authorize the commencement of a civil action for the violation of a resident's rights. A successful plaintiff may be awarded punitive damages when the respondent's conduct was a malicious, willful disregard of the older patient's rights.

Abuse of dependent adult prison inmates:

  • A growing number of dependent adult prisoners is becoming an issue in most States. The reality is that most prisons were not designed for older inmates, and there is a lack of facilities to accommodate the needs of an aging prison population. Frail, older prisoners are vulnerable to abuse by younger prisoners. Due to limited resources in the prison system, some older inmates may not receive adequate treatment for health conditions, notably mental health illness (ODPHP, 2020).

Is Dependent Adult Abuse Illegal?

To deter crimes against dependent adult victims and express society's abhorrence toward such offenses, many state legislatures have created certain offenses involving crimes against dependent adults. All 50 states have passed some form of dependent adult abuse prevention laws. Laws and definitions vary from state to state, but all states have reporting systems. Adult Protective Services (APS) receive and investigate reports of suspected dependent adult abuse. The rights and services are generally available to all crime victims by statute. Legislators at both the federal and state levels have enacted laws that provide special protections and privileges to dependent adult victims of crime. Much of this legislation simply modifies or extends existing general victims' rights legislation to address the special needs of older victims.

Numerous accounts of maltreatment led policymakers to pass a series of laws intended to protect the dependent adult victim. The passage of 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 were instrumental in promoting state laws to address the needs and concerns of the dependent adult. The OAA has been amended several times over the years. On March 25, 2020, the President signed the Supporting Older American Act of 2020, providing funding for OAA programs. One such program is The National Center on Elder Abuse, which provides information on dependent adult abuse to the general public and healthcare providers and training and technical assistance to state-dependent adult abuse agencies and community-based organizations.

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

  • Advocacy efforts through ombudsmen offices
  • Abuse, neglect, and exploitation prevention programs
  • Legal assistance on behalf of older Americans
  • Federal funding incentives made it possible for states to develop and maintain programs designed to assist dependent adults. Criminal Elder Abuse Laws

Laws criminalizing abuse of the dependent adult generally define the conduct that constitutes a specific form of abuse and may distinguish between abuses committed in a domestic, as opposed to an institutional, setting.

States are different in how they approach dependent adult abuse. Some states have enacted laws that specifically address crimes against older persons. For example, California Penal Code 368(b)(1), (2) (3) deals with the abuse of elders and dependent adults. A description of the code states: "Abuse of Elders and Dependent Adults - Likely to Produce Great Bodily Harm or death.' Under this code, a misdemeanor conviction results in one-year county jail or a $6,000 fine. A Felony conviction will lead to 2, 3, or 4 years of State prison time(California Department of Justice, 2021).

Colorado, on the other hand, does not have laws that deal specifically with dependent adult abuse. However, the State law allows for 'penalty enhancement,' which is a more severe sentence if the victim of the offense is 70 years of age or older (Denver Criminal Defense Attorneys, 2021).

Every state has a long-term care ombudsman program to investigate and resolve nursing home complaints. State Attorney General's Office is required by Federal law to have a Medicare Fraud Control Unit to investigate and prosecute Medicaid provider fraud and patient abuse or neglect in healthcare programs that participate in Medicaid, including home healthcare services (US Department of Health and Human Services, 2021).

In 1987, President Ronald Reagan signed into law the first major revision of the Federal standards for nursing home care since the 1965 creation of both Medicare and Medicaid 42 U.S.C1396r,42 USC 1395i-3,42 CFR 483. This legislation changed society's legal expectations of nursing homes and their care. Long-term care facilities wanting Medicare or Medicaid funding are to provide services so that each resident can "attain and maintain her highest practicable physical, mental, and psycho-social well-being.

CMS provided revised federal nursing home regulations in October 2016. These regulations were activated in stages between November 2016 and November 2019. Some areas covered in the revised regulations include:

  • The right of the resident to be informed of and participate in their treatment
  • The right to personal privacy
  • The right to visitor access
  • Right to be free from chemical restraints
  • Freedom from abuse, neglect, and involuntary seclusion
  • Safe/clean/comfortable/homelike environment
  • Care provided by qualified persons
  • Sufficient 24-hour staffing per Care Plans
  • Proficiency of nurse aides (The Long Term Care Community Coalition, 2018)

Adult Protective Services (APS) can be a part of a community's involvement in aiding a self-neglecting vulnerable adult. Once self-neglect is reported, the individual needing help has to give their consent for help. If an individual refuses assistance, there is a balance between a person's right to independence versus safety and well-being. Family, friends, and service providers can work together to help this individual. Everyone must stay involved and support the vulnerable adult as much as possible.

Reporting Dependent Adult Abuse

A majority of states now require certain classes of professionals to report suspected abuse and neglect. The most common categories of mandatory reporters are medical professionals, healthcare providers, mental health counselors, service providers, and virtually all government agents who contact the dependent adult. Most require such individuals to report evidence that leads them to "reasonably believe" that the dependent adult person in question is the victim of abuse or neglect.

Some states have established 24- hour hotlines to make reporting of abuse easier to secure the safety of the victim as quickly as possible. While most statutes establish penalties for those who fail to report, many also provide immunity from civil suits or prosecution to those who make reports in "good faith" -- even if those reports cannot be substantiated, to further encourage reporting of suspected abuse.

Laws have helped to increase the reporting of dependent adult abuse. However, a report in 2019 from the Office of Inspector General of the U. S. Department of Health and Suman Services found in their investigation that nursing homes failed to report nearly 1 in 5 cases of potential abuse to the State agencies responsible for investigating them (OIG, 2019).

The Adult Protective Services (APS) is the principal public agency responsible for investigating reported cases of dependent adult abuse and providing victims and their families with treatment and protective services. An APS is usually located within the Human Service Agency as part of the county social services departments. Reports can be made to APS either in-person, online, by phone call, or fax (ALTSA, 2021). Many other public and private organizations are actively protecting vulnerable older persons from abuse, neglect, and exploitation.

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 each agency has is dependent upon the state law enacted to protect dependent adults. There is an internet site to find local reporting agencies. Use the eldercare locator at www.eldercare.acl.gov or call 1-800-677-1116.

Nationwide training programs to increase public awareness and better prepare those required by law to report have been implemented in California, Florida, and Mississippi, in an attempt to promote reporting of dependent adult abuse further.

Many states have prevention activities which include:

  • Professional training workshops for adult protective services personnel and other professional groups; statewide conferences open to all service providers with interest in dependent adult abuse; and development of training manuals, videos, and other materials
  • Coordination among state service systems and service providers; creation of dependent adult abuse hotlines for reporting; formation of statewide coalitions and task forces; and creation of local multidisciplinary teams, coalitions, and task-forces
  • Technical assistance in the development of policy manuals and protocols that outline proper and preferred procedures
  • Development of dependent adult abuse prevention education campaigns for the public, including media public service announcements, flyers, posters, and videos

The Administration on Aging is a federal agency dedicated to policy development, planning, and delivering supportive home and community-based services to dependent adults and caregivers. This agency provides critical information, assistance, and programs that protect vulnerable, at-risk older individuals' rights through the national aging network. The administration does not have oversight responsibility for APS (ALTSA, 2021).

What Happens After you Report Dependent Adult Abuse?

All calls to APS are confidential. The APS screens call for seriousness and decide if the situation is a possible violation of state dependent adult abuse laws. If so, the APS assigns a caseworker to conduct an investigation, usually within 24 hours if it is an emergency. Crisis intervention services are utilized as warranted. If it is not an emergency, the APS agencies work with other community agencies to obtain social and health services that the older person needs (ALTSA, 2021).

Most states empower social service and law enforcement agencies to investigate reports, intervene, and even remove dependent adult victims from abusive circumstances. In some jurisdictions, multidisciplinary teams are being used -- combining the knowledge of medical, mental health, social service, legal, and law enforcement professionals to evaluate a dependent adult victim's needs better. Appropriate protective services can then be offered to dependent adult abuse victims.

Tennessee has created an innovative Victimization Prevention Program, an extension of the Tennessee State University's Center for Aging's program on preventing and treating dependent adult abuse, neglect, and criminal victimization.

This prevention program is designed to: collect data on the problems of dependent adult abuse, neglect, and criminal victimization; engage in prevention activities through presentations at churches, community centers, schools, and senior citizen centers; conduct workshops for government employees and police, as well as for the dependent adult and their families; and implement an advocacy program to assist victims in responding to and recovering from abuse, neglect and criminal victimization. This program's research findings will provide the basis for developing more substantial assistance and prevention initiatives designed specifically to aid-dependent adult victims (Tennessee Code ' 49-8-802 Justia US Law, 2016).

What is the Role of Healthcare Professionals?

Healthcare professionals often are the first to see signs and symptoms of dependent adult abuse and neglect. Their observations are crucial in substantiating that abuse and or neglect has been occurring. They are in a key position to help because of the trust and respect the patients often have for their healthcare providers.

Healthcare professionals evaluating patients for dependent adult abuse will note the following:

  • Somatic signs and symptoms of abuse.
  • Question the plausibility of explanations given for common injuries and conditions.
  • Provide expert testimony on what was seen.
  • Treat injuries or health factors that result from abuse.
  • Perform abuse screenings.
  • Encourage clinics, hospitals, health maintenance organizations, or other medical providers to develop or adopt screening protocols, respond to abuse, and learn more about Dependent Adult Abuse.

Healthcare professionals should document all subjective and objective findings. This documentation includes the patient's and caregiver's explanations of the injuries. Quotation marks should be placed around their remarks and note any discrepancies in their stories. They should photograph injuries and document injury sites on a body map (Carney, 2020).

Case Study

You are the Nurse Manager of a nursing home. You have recently begun interviewing candidates for charge nurse, and you have selected an applicant you believe best fits your needs and qualifications. What is your duty/responsibility before allowing the newly hired nurse to contact your dependent adult patients?

  • Answer: It depends on the state's laws. Some healthcare settings do not require background checks on employees, and some allow them to start working while background checks are pending. However, as a nurse manager, these may be conditions you want to consider in your role. Many states require either a statewide background check or an FBI background check before allowing patient contact. Furthermore, some states have "Employee Disqualification Lists (EDLs)" or registries that should be checked for potential employees' names. These lists contain names of those who have abused, neglected, or exploited patients. Above everything else, as the Nurse Manager, you are expected to uphold your facility's policies and ensure your patients' safety.

Conclusion

As a society, we all have to take responsibility for protecting our dependent adult population by actively sharing our knowledge, experience, and resources which will help keep these individuals and productive. Over the coming years, the dependent adult population will continue to grow, likely that dependent adult abuse will become one of the United States' major social issues. We must all help our political representatives understand our aging population's needs and the funds required. At times we must assist them in developing laws to prevent dependent adult abuse. Currently, APS is described as a 'stretch to breaking point’ requiring more professional staff and more funding. Nurses have always been on the front line when it comes to advocating for their patients. We will continue to do that for the dependent adult members of our communities.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
Reflect on Practice ImpactDescribe how this course will impact your practice.   (No Test)

References

  • Administration of Community Living (2019) What is Elder Abuse?Visit Source.
  • Aging and Long-Term Support Administration (ALTSA) (2021) Adult Protective Services (APS). Visit Source.
  • American Association of Retired Persons (AARP) (2020) Long-Distance Caregiving: 5 Key Steps to Providing Care From Afar.Visit Source.
  • California Department of Justice (2021) Elder Abuse Laws (Criminal). Visit Source.
  • Carney, A., (2020) Elder Abuse, Forensic, Legal and Medical Aspects, Academic Press, Elsevier Publications, 50 Hampshire Street, 5th floor, Cambridge, MA 02139.
  • Centers for Medicare and Medicaid Services (CMS) (2020) CMS National Background Check Program. Visit Source.
  • Centers for Medicare and Medicaid Services (CMS) (2021) Abuse, Neglect, and Exploitation. Division of Nursing Homes.Visit Source.
  • Congressional Research Service (2021) Older Americans Act: Overview and Funding. Visit Source.
  • Crowder, J., Carson, L., Kuehn, K., Baldridge, D. Elder Abuse Project, International Association for Indigenous Aging.Visit Source.
  • Denver Criminal Defense Attorneys (2021) Elder Abuse Colorado -A Guide to The Laws and Penalties. Visit Source.
  • Dong, X. (2017) Elder Self-Neglect: Research and Practice. Visit Source.
  • Donizetti, A. R., (2019) Ageism in an Aging Society: The Role of Knowledge, Anxiety about Aging, and Stereotypes in Young People and Adults. Visit Source.
  • Elder Abuse.org (2021) What is Elder Neglect? Visit Source.
  • Exclusion Screening (2019) A Provider's Guide to OIG Exclusions. Visit Source.
  • Eliopoulos, C., (2022) Gerontological Nursing 10th Edition Wolters Kluwer Publishers, Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103.
  • Government of Canada (2017) How You Can identify Abuse and Help Older Adults at Risk. Visit Source.
  • Intriago, J. (2021) Resident-to-Resident Abuse within Nursing Homes. Seniors Matter.com. Visit Source.
  • Justia US Law (2016) 2016 Tennessee Code 49-8-802 Center on Aging – Victimization Prevention Program.Visit Source.
  • Kutame, M., (2021) Self-Neglect Among Older Adults: Is it a 'Lifestyle' Choice? Visit Source.
  • Lambert, A., (2020) What's Self-Neglect in Older Adults? 9 Signs. Cake.com Visit Source.
  • Master Class (2021) How the Insular Cortex Works: 7 Functions of the Insular-Cortex. Visit Source.
  • Missouri Department of Mental Health (2021) Employee Disqualification List. Visit Source.
  • National Adult Protective Services Association (NAPSA) (2021) Elder Financial Exploitation. Visit Source.
  • National Care Planning Council (NCPC) (2016) Perpetrators of Elder Abuse Are Usually Family Members. Visit Source.
  • National Center on Elder Abuse (2020a) Mistreatment of African American Elders.Visit Source.
  • National Center on Elder Abuse (2020b) Mistreatment of Latinx Older Adults. Visit Source.
  • National Center on Elder Abuse (2020c) Mistreatment of Chinese Elders. Visit Source.
  • National Center on Elder Abuse (2020d) Mistreatment of Lesbian, Gay, bisexual and Transgender (LGBT) Elders.Visit Source.
  • National Center on Elder Abuse (2021a) Ageism. Visit Source.
  • National Center on Elder Abuse (2021b) Research Statistics and Data. Visit Source.
  • National Indigenous Elder Justice Initiative, (n.d.) Center for Rural Health University of North Dakota, School of Medicine and Health Sciences. Visit Source.
  • Office of Disease Prevention and Health Promotion (ODPHP) (2020) Social Determinants of Health. Visit Source.
  • Office in Inspector General, Department of Health and Human Services (2019) CMS Could Use Medicare Data to Identify Instances of Potential Abuse or Neglect. Visit Source.
  • Pennsylvania Office of Victim Services (2021) Signs and Symptoms of Elder Abuse and Neglect. Visit Source.
  • Phelan, A., (2020) "Advances in Elder Abuse Research: Practice, Legislation, and Policy," Springer Publications Gewerbestrasse 11, 6330 Cham, Switzerland.
  • Rosen, T., LoFasco V.M., Bloeman, E. M., Clark, S., McCarthy, T. J., Reisig, C., Gogia, K., Elman, A., Markarian, A., Flomenbaum, N.E., Sharma, R., Lachs, M. S., (2020) Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases. Ann Emerg Med. 2020 Sept;76(3):266-276. Visit Source.
  • United States Department of Justice (2019) Elder Justice. Visit Source.
  • United States Department of Justice (2017) Elder Abuse Statistics. Visit Source.
  • United Sates Department of Justice (2020) Red Flags of Elder Abuse: Warning Signs of Financial Exploitation. Visit Source.
  • US Department of Health and Human Services, Office of Inspector General (2021) Medicaid Fraud Control Units. Visit Source.
  • The Long Term care Community Coalition, (2018) Nursing Home Quality Standards: A Primer for Residents, Families, Ombudsmen, and Advocates. Visit Source.
  • Willard, J., (2021) An In-Depth Look at the OIG Exclusion List. Verisys. Visit Source.
  • Wright, T. L., (2017) The Family Guide to Preventing Elder Abuse.' Skyhorse Publishing Inc., 307 West 36th Street, 11th Floor, New York, NY 100018.
  • Yon, Y., Ramiro-Gonzalez, M., Mikton, C. R., Huber, M., & Sethi, D., (2018) The Prevalence of Elder Abuse in Institutional Settings: A Systemic Review and Meta-Analysis. Eur J Public Health. Feb 1:29(1):58-67. Visit Source.