After completing this course, the learner will be able to:
There are nearly 6 million cases of elder abuse every year. That is approximately one case every five seconds. Unfortunately, many of these cases will go unreported. The Affordable Care Act defines elder abuse as the knowing infliction of physical or psychological harm or the knowing deprivation of goods or services that are necessary to meet essential needs or to avoid physical or psychological harm to a vulnerable older adult.
Elder abuse or maltreatment is a significant public health problem. Each year, hundreds of thousands of adults over the age of 60 are abused, neglected, or financially exploited. In the United States alone, over 500,000 older adults are believed to be abused or neglected each year. These statistics are likely an underestimate because many victims are unable or afraid to tell the police, family, or friends about the violence (CDC, 2012).
U.S. Elder Abuse Statistics
Every five seconds, an elderly person is abused.
|State / Region||Elderly Population*||Cases of Elder Abuse**|
|District of Columbia||98,977||10,933|
* Elderly defined as 60 years of age and older.
** Estimated # of reported and unreported cases of elder abuse
Mistreatment of the elderly is a complex issue because of the varied forms it takes and because of the growing number of vulnerable seniors and care givers both in community settings and in institutions (CDC 2012a; CDC 2012b).
There are six forms of abuse that occur in people over the age of 60. These include:
Physical abuse is the use of physical force that may result in bodily injury, physical pain, or impairment. This includes acts of violence like striking, hitting, beating, shoving, pushing, shaking, slapping, kicking, pinching, and burning. The inappropriate use of drugs and physical restraints, force-feeding, and physical punishment of any kind also are some examples of physical abuse. It often begins with what is excused as trivial contact escalating into more frequent and serious attacks (CDC, 2012a; CDC 2012b).
Signs of physical abuse are the following:
Sexual abuse is nonconsensual sexual contact. Sexual contact with any person incapable of giving consent is also considered sexual abuse. It includes, but in not limited to unwanted touching; and all types of sexual assault or battery, such as rape, sodomy, coerced nudity or sexually explicit photography (CDC 2012a; CDC 2012b).
Signs and symptoms of sexual abuse include:
Emotional/psychological abuse can include constant harassment, verbal abuse, and humiliation, isolation from friends and family or deprivation of physical and economic resources (CDC 2012a; CDC 2012b).
Signs and Symptoms of emotional/psychological abuse include:
Neglect is a major problem with the frail and elderly. Neglect is the refusal or failure to fulfill any part of a person's obligations or duties to an elder. This includes the refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, or other essentials included in an implied or agreed upon responsibility to an elder. Neglect includes failure of a person who has fiduciary responsibilities to provide care for an elder or failure on the part of an in-home service provider to provide necessary care.
Signs and symptoms of neglect include: (NCEA, 2003, CDC, 2012).
Abandonment is the desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.
Signs and symptoms of abandonment include: (NCEA, 2003, CDC, 2012).
Financial exploitation includes illegal taking, misuse, or concealment of funds, property, or assets of a vulnerable elder (NCEA 2011a; NCEA 201b). This can include, but is not limited to cashing an elderly persons check without authorization; forging an older persons signature, misusing or stealing an older persons money or possessions; coercing or deceiving an older person into signing any document like contract or a will. This is also the improper use of conservatorship, guardianship, or power of attorney. Signs and symptoms of financial or material exploitation include: (CDC, 2012).
The Washington State Department of Social and Health Services (DSHS) has determined that vulnerable adults such as senior citizens, who neglect themselves, are unwilling or unable to do needed self-care suffer from self- neglect ( DSHS, 2012) This can include such things as:
Common characteristics of people who neglect themselves are the following:
Signs to look for in the home and on the person include the following:
Poor personal hygiene (dirty hair, nails, skin).
Smells of feces or urine.
Unclothed, or improperly dressed for weather.
Skin rashes or bed sores (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 (DSHS, 2012).
Self-destructive behaviors or significant behavior changes.
Misusing drugs or alcohol (DSHS, 2012)
The definition of self-neglect excludes a decision by a mentally competent older person to engage in acts that threaten his health or safety, as a matter of personal choice. The term mentally competent assumes that an individual understands the consequences of his decisions and makes conscious and voluntary choices.
Social support by family, friends, and members of the community and services providers is extremely important in helping vulnerable adults to remain safe in our communities.
Family and friends can assist by:
Neighbors can help by:
Public Service Providers can:
Working together community members can help our elders remain safe and live fruitful lives.
As the baby boomer generation reaches retirement age and improved health care allows more Americans to live longer, the difficult questions of who will care for our elderly citizens and how they will afford the cost of such care have challenged our society.
Consequently many elderly Americans who can no longer care for themselves are relying upon 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 full nursing home care.
Institutional abuse is abuse found at a facility or organization that provides elder care. These include assisted living facilities, intermediate care facilities, community living centers, rehabilitation facilities and nursing homes. This abuse can include any of the previously mentioned types of abuse.
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 residents' behavior by inappropriate use of drugs (McDaniel, 1997; Acierno, et al. 2009). This can lead to wounds in areas that restraints have been placed and eventually if not treated to infections and even death.
Factors external to the facility that may lead to abuse are the supply and demand of facility beds and the unemployment rate. A surplus of beds may cause patients to be accepted without adequate assessment, resulting in misplacement. A shortage of beds may force patients into facilities with reputations for poor care. Unemployment rates and pay rates affect the staffing levels (McDaniel, 1997; Acierno, et al. 2009).
Nursing homes oriented toward custodial care often experience more abusive situations. Other environmental factors that may affect abuse include the physical design of the building, the level of care, size, cost of care, staff-to-patient ratio, and the turnover rate of both patients and staff (McDaniel, 1997; ACA 2010).
As in the domestic setting, patients who are mentally or physically incapacitated are more likely to be the victims of abuse. Additionally, patients who lack regular visitors who can watch for abusive situations are more likely to be victimized (McDaniel, 1997; ACA 2010).
Long-term care for the elderly is typically extremely expensive (well over $5,000 per month in many places), the vast majority of residents go through most, if not all, of their assets in a matter of months and then become eligible for federal Medicaid benefits. This process is known as spending down. The cost of over 90% of nursing home residents is paid by Medicaid. Consequently almost all nursing home facilities receive Medicaid funds.
Facilities accepting Medicare or Medicaid funds must abide by government regulations setting minimum standards for the care of residents in such facilities. Many of these regulations are promulgated by the Centers for Medicare and Medicaid Services (CMS). CMS regulations set guidelines for the evaluation, care and treatment of residents, aimed at maximizing the quality of each resident's daily life and minimizing abuse and neglect.
Many of the institutions that provide long-term care for the elderly are owned by for-profit corporations. In an effort to maximize profits, a lot of institutions have cut back on staff or hired less qualified workers for lower salaries in an attempt to decrease costs. Often times, elderly and or disabled residents of long-term care facilities are not getting the attention they require and often times have to compete with dozens of other residents for the attention of too few staff. As a result, all too often residents who require assistance in activities of daily living (ADL) such as feeding, bathing, toileting, and walking, are not receiving adequate care.
Most often in the institutional setting, the typical abusers are nursing aides. These are often the lowest paid and most uneducated positions in health care 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 a 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 (McDaniel, 1997; Acierno, et al. 2009).
Many states have created distinct measures to address abuse in institutional settings. Authorities are granted special powers to investigate reports of abuse in nursing homes and care facilities, and to revoke or deny operating permits to institutions which violate laws or allow their employees to commit offenses against the elderly in their care. Provisions to protect employees who report institutional abuse from retaliation by their employers are becoming more common. All states and the District of Columbia have established ombudsman programs to receive, investigate, and resolve the grievances of patients residing in long-term care facilities.
Some states have establishing registries of caregivers and medical personnel convicted of elder abuse to allow potential employers to conduct more complete criminal history background checks of applicants for positions involving care of the elderly. Missouri maintains an employee disqualification list of persons who have misappropriated funds or property of a resident while employed in a long-term care facility.
A lot of states have passed residents' bills of rights which prohibit mental and physical abuse of patients and encourage the filing of 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.
In an effort to deter crimes against elderly victims, and to express society's abhorrence toward such offenses, many state legislatures have created special offenses involving crimes against the elderly. All 50 states have passed some form of elder 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 elder abuse. The rights and services 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 elderly 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 policy makers to pass a series of laws intended to protect elderly victim. The passage of the Federal Older Americans Act of 1965 (OAA), and the creation of the Vulnerable Elder Rights Protection Program 42 U.S.C. '' 3058, et seq. in 1992 were instrumental in promoting state laws to address the needs and concerns of the elderly.
The Vulnerable Elder Rights Protection Program legislation promoted the following: (National Center for Victims of Crime, 2012).
State elder abuse laws are patterned after legislation designed to address the problem of child abuse and neglect, and, like the response to child maltreatment, often involve the combined efforts of both criminal justice officials and social services staff (National Center for Victims of Crime, 2012).
Laws criminalizing abuse of the elderly generally define the conduct which constitutes a specific form of abuse, and may make a distinction between abuses committed in a domestic, as opposed to an institutional, setting.
States such as Massachusetts and North Carolina developed laws which subject anyone over the age of 18 who has sufficient means, but neglects or refuses to support a parent who is unable to support him/herself due to age or disability, to a fine or imprisonment. (Massachusetts Code ' 273-20; North Carolina Code ' 14-326.1).
In some states, elder abuse laws are incorporated into assault, battery, domestic violence or sexual assault statutes, and a sentencing enhancement imposed if the victim is over a specified age. Illinois uses a combination approach, enacting separate crimes for aggravated battery of a senior citizen and for criminal neglect or financial exploitation of an elderly person, but including the age of the victim as a special classification under its aggravated criminal sexual assault and abuse laws (National Center for Victims of Crime, 2012).
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 health care programs which participate in Medicaid, including home health care services (NCEA, 2003).
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 U.S.C. 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. Most physical, sexual, and financial/material abuses are considered crimes in all states. However, elder abuse may or may not be a crime, depending on the statutes of a given state. Self- neglect is not a crime in all states (NCEA, 2003).
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 than there is a balance between a person's right to independence verses his safety and well-being. Family, friends and service providers can work together to help this individual. It is vital that everyone stay involved and support the vulnerable adult as much as possible.
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, health care providers, mental health counselors, service providers, and virtually all government agents who come in contact with the elderly. Most require such individuals to report evidence that leads them to "reasonably believe" that the elderly person in question is the victim of abuse or neglect.
Some states have established 24 hour hotlines in an attempt to make reporting of abuse easier in order 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 elder abuse -- up 150 percent from 1986 to 1996 -- it is still believed to be widely under reported (National Center on Elder Abuse Incidence Study Executive Summary 1996).
The Adult Protective Services (APS) is the principal public agency responsible for both investigating reported cases of elder abuse and for 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 departments of social services (NCEA, 2003, CDC, 2012). Many other public and private organizations are actively involved in efforts to protect vulnerable older persons from abuse, neglect, and exploitation.
These agencies include:
The power each agency has is dependent upon the state law enacted to protect elders. There is an internet site to find local reporting agencies. Use the eldercare locator at www.eldercare.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 further promote reporting of elder abuse.
Many states have prevention activities which include:
The Administration on Aging is a federal agency dedicated to policy development, planning, and the delivery of supportive home and community-based services to elders and care givers. This agency provides critical information, assistance and programs that protect the rights of vulnerable, at risk older individuals, through the national aging network. The administration does not have oversight responsibility for APS.
All calls to APS are confidential. The APS screens calls for seriousness and decides if the situation is a possible violation of state elder 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.
Most states empower both social service and law enforcement agencies to investigate reports, intervene, and even remove elderly 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 better evaluate an elderly victim's needs. Appropriate protective services can then be offered to elder abuse victims. In some states, such as Colorado, a restraining order may be imposed to prohibit further emotional abuse of an elderly victim.
Tennessee has created an innovative Victimization Prevention Program, an extension of the Tennessee State University's Center for Aging's program on the prevention and treatment of elder abuse, neglect and criminal victimization.
This prevention program is designed to: collect data on the problems of elderly 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 elderly 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 the development of stronger assistance and prevention initiatives designed specifically to aid elderly victims (Tennessee Code ' 49-8-803).
Special classifications for elderly victims are often included in a state's robbery, assault, battery, murder, and even carjacking statutes. A few states, such as Iowa and Oregon, have chosen to include age as a hate violence characteristic. States are also starting to address telemarketing schemes and consumer fraud crimes which often seem to target especially vulnerable victims, including the elderly (National Center for Victims of Crimes, 2012).
Other states impose sentencing enhancements -- increased penalties -- when the victim is elderly. In Nevada, an offender who commits a crime against a person over the age of 60 is subject to a prison term twice as long as that normally allowed for the same offense. A Louisiana law mandates that all violent crimes against the elderly be punished by a minimum of five years imprisonment with no opportunity for parole. Georgia imposes an enhanced penalty for unfair or deceptive business practices directed toward the elderly. A number of states consider the victim's advanced age to be an aggravating factor to be taken into account when determining a sentence (National Center for Victims of Crimes, 2012).
Healthcare professional often times are the first to see signs and symptoms of elder 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 elder abuse will note the following:
Healthcare professionals should document all subjective and objective findings. This includes the patients and care givers 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 (Gray-Vickrey, 1999).
As a society we all have to take responsibility in protecting our aging population by actively sharing our knowledge, experience, and resources which will help keep our elders safe and productive. We must all help our political representatives to understand the needs of our aging population and the funds required. At times we must assist them in developing laws to prevent elder abuse.
Acierno, Ron; Melba Hernandez-Tejada; Wendy Muzzy, and Kenneth Steve, National elder mistreatment study, Retrieved September 3, 2012 from NCJRS.Gov, March 2009.
Administration on Aging, Department of Health and Human Services (DHHS). (2003). The National Elder Abuse Incidence Study, Final Report, September 1998.
Administration on Aging, Department of Health and Human Services (DHHS). (2012) Aging Statistics Retrieved September 6, 2012 from the Administration for Community Living.
Bonnie, Richard, and Robert Wallace, Elder mistreatment, abuse, neglect and exploitation in an aging America. Retrieved September 5, 2012 from The National Academies Press, 2003.
California Nursing Homes: Federal and State Oversight Inadequate to Protect Residents in Homes with Serious Care Violations, Op. Gen. Accounting Off. /T-HEHS98-219 (July 28, 1998).
Center for Disease Control (CDC), Elder Maltreatment, Retrieved September 5, 2012 from The CDC, 2012a
Center for Disease Control (CDC), Elder Maltreatment: Additional Services. Retrieved September 6, 2012 from The CDC, 2012b
The Elder Justice Coalition. One Year Anniversary of the Elder Justice Act. Retrieved September 6, 2012 from The Elder Justice Coalition.
Environmental Protection Agencys Aging Initiative, Aging Initiative Home, Retrieved September 6, 2012 from The EPA.
Florida Code ' 400.023. Retrieved September 6, 2012 from Statutes.Law.Com.
Gray-Vickrey, P. (1999). Recognizing Elder Abuse, Springhouse Corporation.
Massachusetts Code ' 273-20; North Carolina Code ' 14-326.1. Retrieved September 5, 2012 from Statutes.Law.Com.
National Center on Elder Abuse. National Elder Abuse Incidence Study, Executive Summary (1996). Retrieved September 6, 2012 from The Administration for Community Living.
National Center on Elder Abuse (NCEA), Administration on Aging, Risk Factors for Elder Abuse, Retrieved September 5, 2012 from The NCEA.
National Committee for the Prevention of Elder Abuse, Financial Abuse, NCPEA.
Patient Protection and Affordable Care Act (ACA) of 2010. Subtitle H. Elder Justice Act, Administration for Community Living.
The Older Americans Act of 1965 (42 U.S.C. 3001 et seq.) Retrieved. September 6, 2012 from The Department of Labor.
State Long Term Care Ombudsman program 42 U.S.C. '' 3058, et seq. Retrieved September 6, 2012 from Cornell University Law School.
Tennessee Alliance: Factsheets: Elder Abuse and the Law. Retrieved September 6, 2012 from New York City Alliance Against Sexual Assault.
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Certified Nursing Assistant (CNA), Clinical Nurse Specialist (CNS), Home Health Aid (HHA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Registered Nurse (RN)
CPD: Practice Effectively, Domestic Violence, Geriatrics, Medical Surgical, Texas Requirements/Recommendations