Elder Abuse

By Julie A. Fusco, Pharm.D., BCPS, CGP

Reviewed by Patricia W. Slattum, Pharm.D., Ph.D., CGP; Anne L. Hume, Pharm.D., FCCP, BCPS;
and Samantha Karr, Pharm.D., BCPS

Learning Objectives
1. Analyze the scope of elder abuse in the United States.
2. Distinguish signs and symptoms for each category of
elder abuse.
3. Evaluate a patient or caregiver for risk factors associated with elder abuse.
4. Discuss the outcomes of elder abuse and penalties
for abusers.
5. Analyze the reasons for the low reporting rate of
abuse by professionals and victims.
6. Evaluate the process and outcomes that occur after a
suspicion of elder abuse is reported.

(72.1 million) of the U.S. population in 2030, up from

12.6% (37.9 million) in 2007. In particular, the number
of individuals 85 years and older is projected to rapidly
increase. An obvious implication of this future growth
is the health care and assistance these older adults may
require, especially if they have chronic medical problems and disability. Family or non-family caregivers may be responsible for providing their basic needs.
Longer life expectancy and limited functional capacity
may also heighten the likelihood of institutional placement with each decade of life. Elder abuse can take place
regardless of the living arrangement.

Introduction

Laws
The primary responses of states to elder abuse have
been statutes modeled after child abuse and domestic
violence statutes. Every state has enacted legislation
aimed at protecting the elderly population. Foremost,
states mandate the implementation of Adult Protective
Services (APS) agencies. State APS programs typically
receive reports of domestic elder abuse and neglect,
investigate such reports to determine their validity, and
intervene by providing services to the victims. The APS
laws vary from state to state, including who may be the
subject of a report, types of action that are covered, and
types of services an agency may make available if a complaint is substantiated. States have also taken action
against elder abuse through the use of criminal laws that
set punishments for certain types of conduct. State laws
covering crimes such as assault, battery, theft, and rape
may also apply to situations of elder abuse.

The discovery of elder abuse by the medical community is a relatively recent event. A public health issue, like
child abuse and domestic violence, elder abuse requires
both attention and research. The term granny battering
was first referenced in British scientific journals in 1975.
The U.S. House of Representatives heard testimony on
parent battering at a subcommittee hearing on family violence in 1978. Today, more than 30 years later, elder abuse
is known internationally as a growing medical and social
problem. June 15 marks World Elder Abuse Awareness
Day, a day set aside for communities to raise awareness of
the human rights violation that elder abuse constitutes.
Elder abuse occurs in both developed and developing countries. It is present in all racial and ethnic backgrounds, as well as in all socioeconomic classes. The
number of people subject to elder abuse will likely rise
as the population ages. The elderly will make up 19.3%

Baseline Review Resources

The goal of PSAP is to provide only the most recent (past 35 years) information or topics. Chapters do not provide an overall review. Suggested resources for background information on this topic include:
Lachs MS, Pillemer K. Elder abuse. Lancet 2004;364:126372.

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problem, but with some variation. Age 60 is the beginning of old age by federal designation, but state laws covering elder abuse refer to ages 60, 62, or 65 years. Most
definitions include the infliction of some type of harm
or deprivation and the responsibility of a specific person for the situation. Elder mistreatment takes many
forms. In general, the six major types of elder abuse are
categorized as physical, sexual, psychological, financial,
neglect, and self-neglect.
The definition adopted by the World Health Organization (WHO) stipulates that a trusting relationship
exists between the abused and abuser. According to the
definition of WHO, elder abuse is a single, or repeated
act, or lack of appropriate action, occurring within any
relationship where there is an expectation of trust which
causes harm or distress to an older person. If such a relationship (e.g., spouse, family member, friend, service
provider) is required, elder abuse is distinct from criminal violence by strangers. Of course, distinguishing
strangers from non-strangers is not always simple. The
National Academy of Sciences has defined elder abuse
as follows: (1) intentional actions that cause harm or
create a serious risk of harm (whether or not harm is
intended) to a vulnerable elder by a caregiver or other
person who stands in a trust relationship to the elder
or (2) failure by a caregiver to satisfy the elders basic
needs or to protect the elder from harm. By this definition, the abusive conduct must be deliberate. Reckless behavior is excluded, as are acts by individuals considered incapable of intent. Vulnerability as a defining
feature is introduced, thereby suggesting the victim is a
weaker person mistreated by a stronger one. For example, the older adult may depend on someone for care or
have a diminished capacity for self-protection.
Controversies about defining elder abuse have stirred
debate among clinicians, researchers, and policy-makers. Some variations in how abuse is defined include the
requirement for special relationship, intentionality, or
vulnerability. Other issues in the field include whether
a single act counts or whether the abuse must be repetitive; and whether the conduct has to result in harm or
whether it is the conduct that matters. The inclusion of
victim vulnerability often appears in state statutes covering elder abuse, but vulnerability is not easily defined.

Abbreviations in This Chapter

APS
EJA
NEAIS

Adult Protective Services

Elder Justice Act
National Elder Abuse Incidence
Study

Federal law addresses elder abuse and neglect, but not

to the extent of the states. The Older Americans Act of
1965 established state agencies on aging to help respond
to the social services needs of the growing number of
older adults. In 1978, Congress required each state to
establish and operate an ombudsman program for longterm care facilities. The functions of the ombudsman
include identifying, investigating, and resolving complaints made by and on behalf of facility residents. A 1992
amendment to the original legislation authorized funding for elder abuse awareness, training, and coordination
activities; however, most APS agencies continue to be
supported primarily by state and local funding sources.
The Elder Justice Act (EJA), signed into law on
March 23, 2010, represents the first legislation to specifically provide, among other things, federal resources
to combat elder abuse. Although no appropriation has
yet been provided, the EJA has authorized $777 million
over 4 years for various activities and programs. One
key provision establishes an Elder Justice Coordinating
Council of government officials. The Councils purpose is to make recommendations to the Secretary of
Health and Human Services on how to coordinate the
elder justicerelated work of different agencies. The EJA
also authorizes grants to state and local APS agencies to
support their activities. The allocation of funds to each
state would be based on the proportion of residents age
60 and older who live in the state compared with all
states. For long-term care facilities, the EJA authorizes
grants to strengthen ombudsman activities and provide
incentives for the training of direct care workers. A companion bill, the Elder Abuse Victims Act of 2011, has not
yet been passed by the U.S. Senate. Among other things,
this piece of legislation would create an Office of Elder
Justice within the Department of Justice. Likewise,
the End Abuse Later in Life Act of 2011 has also been
referred to a congressional committee for consideration.
One specific aim of this Act is to fund training programs
for law enforcement personnel and prosecutors who are
confronted with cases of abuse late in life.

Epidemiology
Incidence
The National Elder Abuse Incidence Study (NEAIS)
collected data on domestic abuse and neglect among
adults age 60 and older across 20 counties in 15 states.
Of the almost 450,000 substantiated reports in 1996,
only 16% were in APS files. This finding revealed that,
for every case of abuse or neglect reported to authorities, about five more were unreported to APS. Other
reports deemed substantiated in NEAIS were received

Definitions
Consensus is lacking with respect to what constitutes elder abuse. The term does not have a universally
accepted definition. Many organizations, legislative
bodies, and health care disciplines have identified the
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in the past year. Verbal abuse emerged as the most

widespread form of mistreatment; 9% reported being
insulted or put down by a family member. Financial
and physical abuse was reported by 3.5% and 0.2% of
respondents, respectively.
A prevalence rate of 32 abused elderly per 1000 was
found in a population-based survey of more than 2000
older adults in the Boston metropolitan area. The study
collected data in the domains of physical and psychological abuse, as well as neglect. Respondents having
suffered at least one act of violence since turning 65
years of age were at greatest risk of physical abuse. The
most common form of physical abuse was being pushed,
grabbed, or shoved.
In a 1999 telephone survey of family violence in
Canada, 7% of older adults reported experiencing emotional abuse by a child, caregiver, or spouse in the past 5
years. The types of emotional abuse varied but the most
common was being put down or called names; the next
most common type was having contact with family or
friends limited. One percent of the sample population
reported physical or sexual assault in the 5 years before
the survey. In both the Boston and Canadian surveys,
the results relied on victims disclosure of events, and
not all individuals would admit to being mistreated.
When people in national samples from Denmark
and Sweden were interviewed by telephone, 8% of
respondents reported knowledge of specific cases of
elder abuse occurring in the past year. This study used
a more liberal definition of abuse (theft was included)
and required the event to come to the attention of the
respondents. Of note, surveying by telephone has weaknesses including a lack of visual support. Victims may
be afraid to answer openly or at all because the abuser
is in the household. This method also lacks the ability
to reach at-risk elderly who have dementia or who live
in facilities as well as those who do not have a telephone.
In one study of people with dementia who lived at home,
the mistreatment rate by admission of their caregivers
was 47%. The majority of victims (88.5%) suffered psychological abuse; 31.0% experienced more than one
mistreatment type.
Prevalence has also been calculated based on surveys
of professional caregivers. The administrators and directors of nursing of 409 Iowan Medicare-certified nursing
homes were surveyed in 2003 about the incidents of
abuse observed or reported to them in the past year; 355
of the respondents provided data on both abuse numbers and outcomes. The incident rate of abusive events
was 20.7 per 1000 nursing home residents. Of the cases
then reported to state authorities, 29% were substantiated. A 1987 telephone survey of staff from 31 nursing
home facilities in one state revealed that 36% had seen at
least one incident of physical abuse by other staff members in the past year. Nurses and nursing aides cited the
use of restraint beyond what was thought necessary at

from specially trained individuals having frequent contact with older adults in community agencies such as
police departments, hospitals, or banks.
In 2003, a national survey gathered APS data on
reports of elder and vulnerable adult abuse for individuals of all ages in all 50 states plus the District of Columbia
and Guam. Of interest, not all states were able to provide
data for victims age 60 years and older. A total of 192,243
cases of alleged elder abuse were investigated by APS (29
states). Self-neglect was the most common category of
investigated reports, followed by caregiver neglect, and
financial exploitation (19 states). For states that made
available both investigated and substantiated reports,
the average substantiation rate was 46% (24 states). The
home setting served as the location for 89.3% of substantiated reports (13 states). About 6.2% of substantiated
reports occurred in long-term care facilities; however,
the actual incidence might be higher because not all APS
agencies investigate abuse in this setting. Medicaid Fraud
Control Units respond to allegations of abuse among
nursing home residents in many states.
Ombudsmen handle many different types of complaints in areas including, but not limited to, residents
rights, care, and quality of life. A database of more
than 200,000 complaints received by long-term care
ombudsmen in 2008 revealed that failure to respond
to requests for assistance was the most common complaint that staff worked to resolve. Of the 12,916 complaints of abuse, gross neglect, or exploitation, the most
common grievance was physical abuse.
Another source of data on the quality of care in U.S.
nursing facilities is the On-line Survey, Certification and
Reporting System. State survey agencies enter facilitylevel information in the On-line Survey, Certification
and Reporting System database after an on-site evaluation. In 2009, 16.78% of facilities were cited for poor
facility practices for reasons of chemical and physical
restraints, abuse, and staff treatment of residents. The
highest percentage of deficiencies in this category was
for improper physical restraint (10.78%). Almost 25% of
facilities received one or more deficiencies that caused
actual harm or immediate jeopardy to residents.
Prevalence
Studies have reported a range of prevalence based on different sampling methods, survey designs, and definitions.
There is a gap in estimates of the frequency of elder abuse
and neglect. In the National Elder Mistreatment Study,
1 in 10 community-dwelling adults age 60 years or older
reported some type of abuse (excluding financial abuse) in
the past year. One-year prevalence by abuse type was 4.6%
for emotional abuse, 1.6% for physical abuse, 0.6% for sexual abuse, and 5.1% for potential neglect.
In a second national study, 3005 community-dwelling individuals aged 57 to 85 were asked about their
experience with verbal, physical, and financial abuse

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Sexual
Elderly people are not immune to sexual abuse in the
domestic or institutional setting. Sexual abuse is usually defined as sexual contact of any kind without the
individuals consent. This includes situations in which
older adults are unable to consent for reasons such
as cognitive or communication impairment. Sexual
abuse is likely underreported to authorities. This type
of abuse, sometimes categorized with physical abuse,
constitutes less than 1% of all cases reported to and substantiated by APS. Obvious examples of sexual abuse
include unwanted touching, coerced nudity, and sexual
assault such as incest, rape, or sodomy. The perpetrators
may also inappropriately engage the abused in nonviolent acts such as indecent exposure or lewd talk. Most
victims of sexual assault are women. Studies conflict
regarding the most common relationship of the perpetrator (marital, familial, or stranger) to the victim.
Genital or anal trauma is an obvious sign of sexual
abuse and may include abrasions, redness, bleeding,
swelling, and tears. Patterns of bruises on the breasts
or inner thighs may also be a physical indicator of sexual abuse. A victim may have difficulty walking or sitting, recurrent genital infections, or unexplained sexually transmitted diseases. On medical examination, stained, torn, or bloody undergarments may be
exposed. The abused elder may directly report or hint
of sexual assault. Clinicians may detect changes in the
victims behavior such as withdrawing to a fetal position
or repeatedly refusing personal care. The indirect statement of Dont let that man near me may be heard. The
victim should be given the opportunity to state the sex
preference of the interviewer before being interviewed.

the time as the most common type of physical abuse.

Some 81% of respondents had witnessed at least one
incident of psychological abuse against a resident, and
40% had committed such an act during the same period.
Yelling at a resident in anger and insulting or swearing at
a resident were the most common behaviors identified.

Types of Abuse
Abuse against the elderly takes place in many ways.
This section presents the definitions and indicators of
the basic forms of elder abuse (i.e., physical, psychological, sexual, and financial) and neglect. There is also
an explanation of self-neglect, although its inclusion
in definitions, literature, and state laws is inconsistent.
Most cases of elder abuse involve a one-to-one victim/
offender relationship.
Physical
Physical abuse is an act of violence and can encompass
a broad range of conduct. Physical force includes behaviors such as pushing, kicking, striking, pinching, biting,
and force feeding. The bodily harm or pain that ensues
may be by the abusers own hand or by use of an object.
The inappropriate use of drugs (under- or overuse) and
the improper use of restraints (physical or chemical) also
constitute physical abuse by some definitions.
Because its impact may be visible to others, physical
abuse is the most obvious form of harm. During pharmacists counseling on self-treatment, victims may expose
their injuries, or the injuries may be clearly visible. Abrasions, lacerations, and bruises are potential markers
of physical abuse. Bruising may be multicolored, of an
unusual shape or pattern (from knuckles or fingers), and
in various stages of healing. The age of a bruise cannot
be reliably predicted by its color. If bilateral and on the
arms, the bruise may suggest the elder has been grabbed
or shaken. Other potential indicators of physical abuse
include sprains, dislocations, and fractures. Single or multiple patches of alopecia may be the result of hair pulling.
A single sign or combination of signs may, in some
situations, be explained by reasons other than physical
abuse. The context in which an injury or event took place
must be considered. Accidental falls are a leading cause
of injury in the elderly, with common sequelae including bruises and fractures. It is reasonable to investigate
how the elder sustained the injury if suspicion exists.
Clinicians should be alert to the possibility of abuse if
caregivers offer implausible explanations or family members provide inconsistent stories. A delay between the
onset of an injury and the seeking of medical care may
also alert clinicians to potential abuse. Abuse of a nursing home resident may be marked by chemical restraint
with overuse of psychotropic drugs, a problem potentially identified by the consultant pharmacist during the
drug regimen review.

Elder Abuse

Psychological
Psychological abuse, also referred to as emotional
abuse, involves the infliction of pain, anguish, or distress. Verbal acts including insults, intimidation, humiliation, or harassment are examples. In addition, there
may be threats of punishment, abandonment, or deprivation of basic needs. As a result, older adults may be
unable to exercise their rights and be otherwise forced
to engage in or abstain from certain conduct. This type
of abuse also includes subjecting older adults to isolation, treating them like infants, or withholding emotional support.
The effects of psychological abuse present differently
among victims. Older adults may have diverse expectations and perceive treatment by family or caregivers
differently. Avoiding eye contact with the perpetrator,
flinching on approach, and displaying passivity may be
behavioral indicators of this type of abuse. The emotional health of the victim may be adversely affected
and manifest as agitation, fear, confusion, or social withdrawal. A change in eating pattern or sleep disturbance
may become evident. Recognition of psychological
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because of contractual agreement (paid person), special relationship (spouse, children), voluntary assumption, or order of the court. Of note, accountability for
the conduct may exist regardless of whether a caregiver
and elder live in the same residence.
Neglect may be referred to as active if the needs of the
elder are deliberately unmet; factors such a financial gain
may motivate active neglect. In the absence of intent,
neglect is termed passive. For example, the caregiver may
be unable to provide the care for reasons such as a lack
of physical strength, knowledge, maturity, or resources.
Abandonment, the desertion of a vulnerable elder, is
sometimes considered a type of neglect or placed in its
own category. Abandonment endangers the welfare of
the older adult if he or she is without adequate provisions.
Indicators of neglect are usually characteristic of the
goods or service not provided (e.g., the development of
malnutrition or pressure sores in nursing home residents
who do not receive needed help with eating or turning, respectively). Soiled clothing, multiple insect bites,
lice infestation, or a urine or fecal smell may signal poor
hygiene. An older adult with inadequate or inappropriate clothing for the weather may draw attention. Another
sign of neglect may be absent or faulty assistive equipment (e.g., eyeglasses, hearing aids, canes, wheelchairs) if
required. Finally, untreated medical conditions or unexpected deterioration in health may raise the suspicion of
neglect. In the pharmacy, inconsistent refills or outdated
prescriptions may suggest mismanagement of a dependent elders drug therapy. Such behavior leaves the older
adult vulnerable to adverse effects from sudden withdrawal or restarting a drug at the full dose.

abuse may be difficult, and the interviewer may have to

rely on observation because of a victims reluctance to
talk openly.
Financial
Financial abuse is also a significant problem; it has
been described as the inappropriate use of an elderly
persons funds or resources for personal gain. This type
of mistreatment, also referred to as material abuse or
exploitation, is unacceptable at any age. Unfortunately,
the elderly may be attractive targets because of not recognizing the value of their assets, being uncomfortable
with financial matters, or lacking a network of people
for support. A typical example is forging or forcing the
elders signature through coercion or any undue influence. The unwanted agreement may be a check, will,
power of attorney, or contract. Other cases involve the
theft of money or property without knowledge or authorization, misuse of conservatorship, or misappropriation of funds. Financial abuse is often accompanied by
physical or psychological abuse.
People who interact with older adults may be able to
identify activity that suggests financial abuse. One indicator of exploitation may be older adults living without the amenities or services they can clearly afford. In
this respect, the elder may have unmet needs pertaining to medical care or drug therapy. Pharmacists taking
drug histories may discover that a patients nonadherence is because of a caregivers preference to appropriate
funds for personal use rather than purchase the elders
drug therapy. Victims may be unaware that they are
not following instructions appropriately because their
drug therapy is the caregivers responsibility. Suspicious
bank account activity such as large withdrawals or frequent transactions may signal concerns. A heightened
awareness of financial abuse may be present if elders
new friends or relatives claim rights to financial affairs
or express excessive interest in expenditures. Missing
property or belongings may also be apparent during a
visit to the elders home.

Self-neglect
Self-neglect may be more common than any other
form of abuse or neglect by others. No formal or informal caregivers are involved in cases of self-neglect. The
term refers to refusal or failure to provide oneself with
the goods or services to meet basic needs. Every case is
different, with some cases minor and others seriously
threatening personal health or safety. Self-neglect may
even be an independent risk factor for death. According to the National Center on Elder Abuse, the definition excludes a situation in which a mentally competent
older adult understands the consequences of decisions
and exercises personal choice. Elders with dementia or
other cognitive impairment are especially vulnerable to
this abuse type. Signs in the victim, including general
decline, overlap with those of neglect by others. Social
isolation is common. At-risk elders may be living in conditions of squalor, hoarding belongings, or neglecting
household maintenance. As a result, neighbors or home
care providers may be first to recognize the problem.
One concern that surfaces in the decision to report
a suspicion of neglect is whether the situation is selfinflicted versus the fault of others. Clinicians may have

Neglect
Neglect means refusal or failure to fulfill any part of
an individuals obligations or duties to an elder. These
obligations and duties typically involve basic necessities such as food, water, shelter, hygiene, drug therapy,
and protection. Certified nursing assistants who participated in a focus group mentioned that neglect in nursing
homes was represented by failure to perform services
including the following: turn and reposition, range of
motion exercises, oral dental care, scheduled toileting,
and regular bathing. Other common areas of neglect
identified by certified nursing assistants included not
helping residents meet hydration needs and providing
them with too little help with eating. One challenge is to
identify who, if anyone, has responsibility for caregiving

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insufficient information to completely assess the situation, and state statutes do not always mandate the
reporting of self-neglect. A second challenge that clinicians face is ambiguity about an older adults capacity to make decisions. The APS will assess the conditions, including risk of harm and capacity to make decisions. Elders who show signs of self-neglect and who are
deemed competent have the right to refuse services. In
contrast, APS programs have a duty to act if there is lack
of capacity and harm or the risk of harm to the person.
In general, the least restrictive but effective interventions are used by APS. Options include engaging family in the process and making referrals to community
organizations. In emergency situations, it may be necessary to seek legal proceedings to protect the older adult.
Guardianship and involuntary placement fall under this
measure of action. The ethical issues that arise include
allowing the patient to choose freely (autonomy) versus
protecting the patient from harm (beneficence).

confidential setting. A process should be in place to provide appropriate and adequate follow-up.
Screening for elder abuse presents certain challenges. In
busy clinical settings, brief screens are preferred because
of time constraints. There is no absolute representation
of abuse or typical case of neglect. The possible indicators must be distinguished from age-related changes in
the body and medical conditions. Abuse may occur as
a single act or take time to escalate to a detectable level.
As such, screening only once may be inadequate. Cognitive impairment interferes with the ability to use standard
screening tools. Asking caregivers directly about the difficult behaviors shown by a care recipient may be useful.
In one study, people with dementia who directed certain
behavior at the caregiver predicted whether the caregiver
mistreated the individual.

Victim Considerations
Risk Factors in the Domestic Setting
Research has identified factors that place the elderly
at risk of abuse. A poor social network and isolation may
increase vulnerability for all forms of abuse including
self-neglect. Lack of access to trusted people in whom
to confide may reduce the opportunity for intervention.
Social isolation also reduces the likelihood that health
care professionals will recognize the issue and offer
help. Some studies suggest that a shared living arrangement increases the risk of abuse and neglect, with older
adults residing alone at lowest risk. If the abuser is on
the scene, a greater possibility exists for contact including conflict or tension. However, living alone increases
the likelihood of self-neglect.
Cognitive impairment may be another predictor
of elder mistreatment. If an elderly person has a limited ability to understand financial issues, the dependency on others may create a vulnerable situation. A
higher rate of physical and psychological abuse has been
reported among people with dementia. The challenging
behaviors associated with dementia, together with certain caregiver characteristics, may be causative. Physically and verbally aggressive acts that may incite abuse
by caregivers include throwing something that could
hurt, pushing or shoving, grabbing, insulting or swearing, and shouting or yelling. Depression and alcohol
dependence may increase the risk of self-neglect among
older adults. In these cases, difficulty maintaining their
self-care tasks is at the heart of the problem.
The relationship between physical impairment and
vulnerability differs across abuse types. Although
frailty diminishes the ability to defend oneself or escape
abusive circumstances, research has produced contradictory findings. However, abnormal physical performance and disability have been found to be correlates of
self-neglect. Higher self-neglect severity has been positively associated with lower levels of physical function.

Screening
Health care professionals are in a position to observe
and interact with elder abuse victims. Moreover, they
may be the only individuals in a victims life who have the
opportunity to intervene when a suspicion arises. Screening instruments have been developed, in part, because selfreporting is unlikely. The 1992 American Medical Association guidelines suggested that all community-dwelling
older adults be screened for family violence; the guidelines included a list of closed-ended questions for use by
physicians. Although a starting place for investigation, the
instrument is lengthy, and no formal study has validated
it. Interviewing the elder and caregiver about experiences
and risk factors may be an alternative approach, but interpretation of the findings remains uncertain. Other instruments have not gained widespread use. The Brief Abuse
Screen for the Elderly contains five standard questions
suitable in emergency or outpatient settings; however, it
requires training to administer.
The U.S. Preventive Services Task Forces 2004 statement found insufficient evidence to recommend for or
against routine screening of older adults or their caregivers for elder abuse. In making this determination,
the Task Force could not establish the balance between
the benefit and harm of screening. Case investigation of
false-positive tests may lead to psychological distress,
family tension, legal jeopardy, or loss of autonomy for
the victim. False-negative tests may impede the identification of at-risk elders. In addition, data on the effect
of interventions are insufficient. Regardless, health care
professionals should exercise clinical judgment and
concern for the safety of older adults and be aware of
the signs of elder abuse. If engaged in screening, they
should ask questions in a nonjudgmental manner and
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effects among postmenopausal women who reported

abuse included greater depressive symptomatology,
greater social strain, and lower optimism. Of note, the
association was found for women who reported verbal
abuse even in the absence of physical abuse. Exposure
to abuse may be associated with reactions including
anger, disappointment, or guilt. Often, the older adult
becomes socially isolated because of fear or shame. The
abused may experience a loss of confidence in their own
abilities and see themselves as powerless. Finally, abuse
and self-neglect have been associated with shorter survival in studies of community-dwelling adults 65 years
or older. The mechanism remains in doubt because the
immediate cause of shortened survival does not seem to
be the injury itself.
The extent to which the abused use the health care
system is not entirely known. Some victims seek treatment, but others are unwilling or unable to come forward. In the emergency department, the presentation
has not been linked to any specific injury type or chief
complaint. Subtle signs may be missed or mistaken for
another problem, with the actual abuse left to be discovered. In one study, more than 30% of emergency department visits by elders who had been physically abused
resulted in hospital admission. A longer length of hospital stay and higher cost of care may be outcomes for
those who sustain harm necessitating admission. In
a small percentage of cases, permanent placement in a
nursing home may be necessary to separate the victim
and abuser.

The effect of victims age, sex, or race on abuse is complex. In the NEAIS, the risk of mistreatment increased
with advancing age. Individuals older than 80 years
accounted for more than one-half of the reports of
neglect. Those in the 6064 and 6569 age groups had
the lowest reports in all categories of abuse. By contrast, more recent research found young-old elderly (<
70 years) at greater risk of mistreatment than the old-old
group. Rather than age alone, poor health and dependency may be reasons for vulnerability.
Women may be more likely to be victimized,
although some studies have revealed no difference in
rates on the basis of sex. In the NEAIS, all abuse types
were more common in women except for abandonment.
Potential explanations are that women outnumber men
and women may suffer more serious injury. Of note, a
greater proportion of older men reside with someone of
advancing age, which increases their own risk.
Racial differences in elder mistreatment remain to be
established in reliable national studies. In a populationbased survey of adults age 60 years and older in Allegheny County, Pennsylvania, African Americans were at
heightened risk of financial exploitation and psychological abuse compared with individuals of other races. Differences in the perceptions of abuse and in help-seeking
behaviors among nonwhite older adults may influence
the number of investigations. In a study of 90 elderly
women, Korean subjects were less likely to perceive a
situation as abusive compared with other ethnic groups.
Fears about exposing family shame or inciting conflict
were reasons for lack of reporting.

Perpetrator Considerations

Risk Factors in the Institutional Setting

Characteristics that place nursing home residents
at greater risk of abuse are less well known. Functional
impairments in activities of daily living and dependence
on care providers may be important risk factors for abuse
by staff. Victims of sexual abuse are usually women, and
any person with a diagnosis of confusion or dementia
may be especially vulnerable to this form of abuse.
The findings from one study suggest that behavioral
symptoms such as cursing, kicking, or pushing others
gave rise to the physical and psychological abuse of the
resident. In the framework of resident-to-resident violent incidents, a case-control study revealed that residents who were injured were more physically independent and therefore more likely to place themselves in
harms way. Other behaviors associated with provoking
an attack by another resident included verbal aggression
and wandering.

Risk Factors in the Domestic Setting

Certain characteristics of the perpetrators may be risk
factors for elder mistreatment, although the role may differ by abuse type. The NEAIS report found that the abuser
was a family member in almost 90% of the reported cases
in which the abuser was known. In two-thirds of the
cases, adult children or spouses perpetrated the abuse.
Other offenders include siblings, grandchildren, service
providers, and old or new friends. Abusers are both men
and women of any age, but men are more likely to commit physical abuse. Those who carry out abuse are not
defined by a single cultural or economic background.
A dependent state of affairs tends to exist between
abuser and abused. Adult children who abuse their
elderly parents are likely dependent on the victims for
emotional support or financial assistance. In some circumstances, abusers deprive elderly of needed care if
they stand to gain shelter, food, or transportation or if
they otherwise stand to benefit.
Mental health problems on the part of caregivers
may predict abusive conduct, but the link to a specific
abuse type must be addressed in future research. Psychiatric illness and an underlying personality disorder

Consequences
The health care professionals detection of abuse may,
in truth, be recognition of consequences of such treatment. Physical health of the abused may suffer because
of bodily injury. In one study, adverse mental health

PSAP-VII Geriatrics

123

Elder Abuse

may be causative in some cases. Retrospective studies have found that abusive family caregivers are more
likely than non-abusive ones to suffer from depression.
Depression has been specifically implicated in cases of
physical abuse. Alcohol use and abuse has been identified to be more common among offenders than nonoffenders. As a mechanism of neglect, caregivers who
drink excessively may not meet their obligations to
those who depend on them. In addition, the impaired
judgment associated with heavy alcohol consumption
may translate to violence directed at elders. According
to one study, daily consumption was more than twice
as likely among family caregivers who committed abuse
than in those who did not. The diversion of a dependent
persons prescription narcotic analgesics may be caused,
in part, by a caregivers own substance abuse problem.
Theories to explain abusive behavior toward elderly
people are evolving. The burden of caring for a dependent elder, together with external stressors, may gradually overwhelm an individual. The situational model
recognizes caregiver stress as a reason for elder mistreatment; however, confirmatory evidence is lacking,
and many individuals manage without inciting violence. Abuse may arise from caregivers out of resentment for what is deemed a duty rather than a privilege.
The transgenerational theory describes family violence
as a learned behavior that is passed from one generation
to the next (i.e., victims of child abuse may show the
same pattern of behavior when they grow older). Feminist and political economic theories address the imbalance of power in relationships and the marginalization
of elders in society, respectively. According to the ecologic model, violence results from the interplay of individual and interpersonal factors in the social context.

fraud, or rape. Depending on state statutes that define

the protected population and the prohibited conduct,
a claim for elder abuse or neglect may also be placed.
Fines, imprisonment, and restitution are common penalties for breaking the law. The exact punishment often
depends on the type and extent of the harm done. The
loss or suspension of an individuals professional license
is a possibility. Civil restitution may also be sought to
compensate the victim for his or her loss. Older adults
may be reluctant to take legal action or be unaware that
the judicial system can help. Challenges faced by victims in making the decision to go to court include a lack
of financial resources, difficulty of proof, and slow pace
of the legal process.
Most long-term care facilities participate in Medicare
and/or Medicaid programs. As such, they are subject to
annual surveys and federal deficiency citations for poor
facility practices or quality of care. Federal tags may be
issued for not following specific regulations governing
matters such as pressure sores, restraints, unnecessary
drug therapy, and use of psychotropic agents.
Improper chemical restraint of elderly nursing home
residents may be dangerous and even deadly. A critical
part of the monthly drug regimen review process done
by consultant pharmacists is monitoring. The assessment must ensure residents who take psychotropic
drugs (antipsychotics and sedative-hypnotics) have a
medically valid indication and undergo gradual dosage
reductions, unless clinically contraindicated. The overuse of psychotropic drugs may cause excessive lethargy,
and its documentation triggers an intervention. For any
drug, a physicians order must exist.

Risk Factors in the Institutional Setting

Elder abuse and neglect in institutional settings is
typically viewed as involving direct care workers; however, residents may also be mistreated by visitors, volunteers, family, and other residents. For employees of
nursing homes who engage in physical or psychological
abuse, burnout and resident aggression are contributing
factors. Younger staff members and those with negative
attitudes about residents may be more likely to perpetrate psychological abuse. Inadequate staff, high turnover, or heavy workload may lead to a stressful work
environment and inappropriate behavioral management. Other suggested risk factors include inadequate
training on how to respond appropriately to difficult situations and a lack of administrative or supervisor oversight. Good hiring and staff screening practices by a
facility may reduce the likelihood of elder mistreatment.

Requirements
Anyone can make a voluntary report of suspected
elder abuse or neglect. Although a federal standard does
not exist, most states have mandatory reporting requirements. The people required to report are governed by
the laws of the individual state. Some states specify any
person, whereas others provide a listing of responsible
individuals including law enforcement officials, social
service providers, and health care professionals. Pharmacists are explicitly identified in the inventory for a
select number of states.
Penalties exist for failure to report. Mandated reporters who knowingly and willfully fail to report may be
charged with a misdemeanor punishable by a fine,
imprisonment, or both. In addition, licensure ramifications for some professionals may be found. Pharmacists
should be familiar with their states laws, definitions,
and reporting obligations. Mandatory reporting may
not encompass the mentally competent elderly capable
of reporting or those who self-neglect without involvement of a third party.

Reporting

Consequences
Offenders may face criminal charges that correspond
to the form of abuse including assault, battery, theft,

Elder Abuse

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PSAP-VII Geriatrics

 To whom the report is made differs from state to

state. Often, the local APS office or area agency on
aging receives the report for abuse that occurs in private
homes. Some states require that mandated reporters
make the claim immediately or within a specific time.
As part of the EJA, individuals associated with a longterm care facility are required to report to law enforcement the suspicion of crime immediately. The time
frame lengthens to 24 hours if the event does not result
in bodily injury.
A hotline for reporting abuse is usually available. Oral
reports made by telephone or direct communication
may have to be followed by a written report. The content
of the report should generally include the following:
name, age, and address of the adult who is the subject
of the report; name and address of the alleged offender;
and information related to the nature and extent of the
alleged abuse or neglect. The contact information for
the reporting person may also be included; the option of
anonymity usually exists. Regardless, reports are generally subject to confidentiality provisions except by the
reporters written consent or order of the court.
Pharmacists can help individuals understand why
they should care about elder abuse and how widespread
the problem is. Pharmacists can also help individuals who want to make a report understand the process
better.

a violation of the Health Insurance Portability and

Accountability Act, health care professionals should
only provide relevant data within the scope of the
reporting statute. There may be unwillingness to be
involved in legal proceedings or concern about malpractice claims by the suspected abuser cleared of any
wrongdoing. In reality, reporters who act in good faith
are generally immune from criminal or civil liability as
well as professional disciplinary action.
Among those who report a suspicion of abuse, there
may be fear of risk to the victim when the offender
learns about the investigation. In fact, reports may trigger withdrawal of services rendered by the accused
caregiver. Violence may escalate to ensure that the victim does not provide any damaging information to an
authority. To ensure patient safety, intervention options
once APS becomes involved include monitoring the living arrangement, removing perpetrators from victims
homes, and moving victims to a safe setting if necessary.
Receiving Agencies
The standard for reporting is based on a reasonable
suspicion that a vulnerable older adult has been or is
likely to be mistreated. If the clinician believes that
someone is in a life-threatening situation or immediate danger, he or she should contact 911 or local law
enforcement. Otherwise, APS agencies are largely
responsible for investigation, risk assessment, and case
substantiation.
After intake of the information, caseworkers generally investigate emergency situations within 24 hours
and all other reports within the states regulated time
frame. An emergency report is one in which an immediate risk of further harm to the individual or others
exists. Risk assessment involves direct contact with
the alleged victim in the home or other place of residence. The person believed responsible for the mistreatment also may be interviewed. Unfortunately, there is a
need to rule out false accusations of elder mistreatment.

Obstacles
Health care professionals may not report suspected
elder abuse or neglect for various reasons. One important reason for underreporting may be a lack of understanding the reporting mechanisms. Others may not
report if the patient asks them not to and because of concern about a loss of trust in the patient-provider relationship. Although the victim may feel anger or betrayal, clinicians should help them understand the process.
Reluctance may come from concerns about breaching patient confidentiality. Although disclosure is not

Table 3-1. Resources for the Elderly and Their Caregivers

Resource
Eldercare Locator
www.eldercare.gov/
Alzheimers Association
www.alz.org
National Consumers Leagues Fraud Center
www.fraud.org
National Center on Caregiving (NCC)
www.caregiver.org
American Association of Retired Persons (AARP)
ww.aarp.org

PSAP-VII Geriatrics

Description
Identifies state and local area agencies on aging and communitybased organizations that serve older adults and their caregivers
Offers education and awareness on Alzheimer disease; provides
locator to find office in the community
Provides tips to avoid Internet and telemarketing fraud, scams, and
counterfeit drugs; online complaint form available
Provides caregiving information and advice; helps caregivers locate
support services in their communities
Provides information on topics including health, money, and
relationships; includes articles on scams and frauds

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Table 3-2. Elder Abuse Resources for the Health Care Professional
Resource
National Center on Elder Abuse (NCEA)
www.ncea.aoa.gov

Description
Offers information on statistics of abuse and neglect and
description of abuse types; provides state directory of help lines,
hotlines, and elder abuse prevention resources
National Long-Term Care Ombudsman Resource Describes the role of ombudsmen and lists nursing home residents
Center
rights; provides contact information for local and regional
www.ltcombudsman.org/ombudsman
ombudsmen in the state
Administration on Aging (AoA)
Provides information on aging statistics and action to take if abuse
www.aoa.gov
or neglect is suspected; offers links to resources for health care
professionals
Clearinghouse on Abuse and Neglect of the Elderly Provides computerized catalog of elder abuse literature, including
(CANE)
peer-reviewed journal articles, books, agency reports, hearing
www.cane.udel.edu
transcripts, and videos
International Network for the Prevention of Elder Provides information on the global problem of elder abuse through
Abuse (INPEA)
research, education, and advocacy; identifies upcoming
www.inpea.net
conferences

complaints. The ombudsman maintains the complaints

as confidential unless the residents consent is given;
thus, the reports are not always forwarded to APS, state
survey agencies, or law enforcement.

Collateral interviews may be conducted, and records

may be sought from other sources including the pharmacy. Thereafter, a determination on the case is made.
Cases deemed unsubstantiated or indeterminate
because of lack of or insufficient evidence are closed.
Cases with supporting evidence are categorized as
substantiated and open for a service plan. Depending on state statutes, a variety of supportive services
may be arranged such as meals, transportation, cleaning, home repair and modification, or pest and animal
control. Referrals might be made for home health care,
legal representation, fiscal management, or medical and
mental health services. Table 3-1 and Table 3-2 contain
examples of resources for older adults and health care
professionals.
In general, competent victims have the right to accept
or reject any or all services APS offers. Their lifestyle is
a matter of personal choice. For victims who lack the
capacity to understand their circumstances, the courts
may respond with some oversight. For example, the
courts may assign temporary guardians or grant orders
for protection. Workers from APS will continue to monitor the situation and reexamine the need for different
interventions until the case is closed. These individuals work with the victim to gain cooperation for outside
help by explaining the benefits.
The local ombudsmans office may be able to assist
with grievances made by, or on behalf of, individual residents of long-term care facilities. These facilities include
nursing homes, residential care facilities, and assisted
living facilities. As an advocate for patients, the state
ombudsman is concerned about violations of residents
rights and poor quality care. Although the programs
role is viewed differently across the country, a key
responsibility is to investigate and endeavor to resolve
Elder Abuse

Conclusion
Violence against the vulnerable elderly exists. Estimates of the prevalence of elder abuse and neglect are
complicated by differing definitions, underreporting,
and multiple reporting agencies. Instruments have been
developed for screening, but the effectiveness of these
methods for use in health care settings and the outcomes of interventions are not yet established. Theoretical explanations of why elder abuse occurs have
been suggested; however, no single model is universally
accepted. As the risk factors for both victims and offenders emerge from ongoing research, elder abuse prevention strategies may be further developed. Although not
consistently considered a form of abuse, self-neglect
represents a unique phenomenon and common reason
for APS referrals.
Pharmacists are uniquely positioned to encounter
abuse or neglect in the community with the increasing number of older adults who use more drug therapy. In addition, pharmacists may be a source of contact and support for victims in the institutional setting.
Pharmacists may not be designated mandatory reporters in every state, but the oath of a pharmacist includes
the promise to consider relief of suffering a primary
concern. As such, pharmacists must be knowledgeable
about mistreatment and accept the obligation to protect
vulnerable older adults. Pharmacists must listen carefully to patients, intervene when the suspicion of abuse
arises, and educate others about this hidden problem.
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PSAP-VII Geriatrics

Annotated Bibliography
1.

family should be routinely asked about abuse. A lack of

consensus on what constitutes an adequate standard for
validity of abuse measures limited the inclusion of studies in this research.

Dong XQ, Simon M, Mendes de Leon C, Fulmer T, Beck

T, Herbert L, et al. Elder self-neglect and abuse and mortality risk in a community-dwelling population. JAMA
2009;302:51726.

3.

In this prospective, population-based cohort study, participants of the Chicago Health and Aging Project were
divided into three groups: elder self-neglect, elder abuse,
or neither. Through linkage with social services agencies,
1544 cases of self-neglect and 113 cases of abuse were
reported from 1993 to 2005. All participants were age 65
or older and resided in an urban community on the south
side of Chicago, Illinois. There were 4306 deaths during a median follow-up of 6.9 years; 927 deaths occurred
among those with reported self-neglect during a median
follow-up of 0.8 year. Multivariable analysis revealed that
reported self-neglect was associated with a significantly
increased risk of 1-year mortality. After this period, mortality risk was lower, but it remained increased. Multivariable analysis also found a significantly increased risk of
overall mortality for reported abuse. Increased mortality
risk with either self-neglect or abuse was found regardless
of cognitive and physical function. Mortality risk associated with reported and confirmed self-neglect was not
limited to any single cause of death. This study, although
thorough in its analysis, has limitations. Reports of selfneglect and abuse are based on the records of social services agencies, and not all suspected cases come to their
attention. In Illinois, self-neglect is not mandated for
reporting. The specific behaviors of self-neglect and subtypes of abuse associated with mortality risk could not
be identified. Details about the type and extent of social
services agencies or health care professionals interventions because of the reported self-neglect and abuse were
unknown. These interventions themselves, in fact, might
have modified mortality risk. The authors point out that
early identification and prompt intervention of selfneglect is important because of the substantially higher
mortality risk in the first year of follow-up.
2.

In this study, a randomly selected national sample of

community-dwelling adults age 60 and older was surveyed to estimate prevalence and assess correlates of mistreatment. All participants were interviewed by telephone
and asked questions about demographic characteristics
and potential variables that might contribute to mistreatment. Data were collected from 5777 adults 60 years or
older, with a mean age of 71.5 years. One in 10 participants indicated they had experienced some type of abuse
(emotional, physical, or sexual abuse) or potential neglect
in the past year. The prevalence was 5.1% for neglect,
4.6% for psychosocial abuse, 1.6% for sexual abuse, and
0.6% for physical abuse. Low social support was the most
consistent correlate of mistreatment across abuse types.
Previous experience of traumatic events, including interpersonal and domestic violence ,was associated with
an increased likelihood of emotional and sexual abuse.
Older adults who needed assistance with activities of
daily living were more likely to be victims of verbal abuse
and financial exploitation. That the study excluded both
older adults without the cognitive impairment to consent
and those without a landline telephone limits generalization of the results. Although self-reporting introduces the
potential for bias, the authors took steps to increase the
likelihood of disclosure. The prevalence estimates of elder
abuse subtypes contrast with those of other studies, possibly because of differences in definitions.
4. Garre-Olmo J, Planas-Pujol X, Lpez-Pousa S, Juvinya
D, Vil A, Vilalta-Franch J; Frailty and Dependence in
Girona Study Group. Prevalence and risk factors of suspected elder abuse subtypes in people aged 75 and older.
J Am Geriatr Soc 2009;57:81522.

Cooper C, Selwood A, Livingston G. The prevalence of

elder abuse and neglect: a systematic review. Age Ageing
2008;37:15160.

This cross-sectional study described the prevalence and

risk factors of suspected elder abuse subtypes in a representative sample of inhabitants of Girona, Spain. Participants were 75 years and older with a mean age of 81.7
years. Individuals suspected of suffering from cognitive
impairment and dementia were excluded. All participants
were interviewed in their homes and asked about demographic characteristics and potential risk factors for mistreatment. The final part of the study protocol included
administering the American Medical Association Screen
for Various Types of Abuse or Neglect. The prevalence of
any type of suspected abuse was 29.3%. The prevalence
by suspected subtype was 16% for neglect, 15.2% for psychosocial abuse, 4.7% for financial abuse, and 0.1% for
physical abuse. Twenty-four cases presented with two
types of suspected abuse. Living with other family members, receiving help from social services, and not having
a trusted person increased risk of neglect. Psychological

These authors performed a systematic review of studies

measuring the prevalence of elder abuse or neglect. Fortynine studies met the inclusion criteria, but only seven
met the authors criteria for a valid and reliable measure
of abuse. The prevalence of overall abuse ranged from
3.2% to 27.5% on the basis of general population studies. Six percent of older adults reported significant abuse
in the past month. Almost one-fourth of dependent older
adults reported significant levels of psychological abuse.
One-third of family caregivers reported involvement in
significant abuse. Only a small proportion of abuse (less
than 1%) was reported to APS. Sixteen percent of longterm care staff reported committing considerable psychological abuse. The authors suggest that whistle-blowing would help improve reporting in this setting because
more than 80% have observed the occurrence of abuse.
The authors conclude that the vulnerable elderly and

PSAP-VII Geriatrics

Acierno R, Hernandez MA, Amstadter AB, Resnick HS,

Steve K, Muzzy W, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential
neglect in the United States: the National Elder Mistreatment Study. Am J Public Health 2010;100:2927.

127

Elder Abuse

cases reported to law enforcement and data in the 2000

2005 National Incident-Based Reporting System. Selection criteria limited cases to aggravated assault, simple
assault, and intimidation perpetrated against a victim
age 60 or older. Further restricting cases to those with
a one-to-one victim/offender relationship resulted in a
sample of 87,422 incidents. Most victims of elder abuse
were in the 6069 age group. Women were more often
victims of elder abuse than men. Most offenders of elder
abuse were men (72%). A child relationship constituted the largest proportion of family offenders (24%).
Male victims were more likely to be abused by both
acquaintances and strangers than female victims. The
most common form of abuse was simple assault (53%).
Male victims were more likely to experience aggravated
assault, and female victims were more likely to experience intimidation. Most incidents occurred in the victims residence (74%) and resulted in no injury to the
victim. One study limitation was the reliance on voluntary reporting of events; another was that not every
state participates in the incident-based reporting system. The criminal justice definition used in the study
does not account for all forms of elder abuse.

abuse was positively associated with living alone and

depressive symptoms. A higher percentage of financial
abuse was seen in adults 85 years and older, single people, and those with a low Mini-Mental State Examination
score. One study limitation is that self-reported abuse
was subject to recall bias and unsubstantiated. Because
the sample represented a rural area, and older adults
with moderate to severe cognitive deterioration were
excluded, generalizability of the results is limited.
5.

Lachs MS, Williams CS, OBrien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. JAMA
1998;280:42832.
This longitudinal study examined mortality in community-dwelling older adults who were participating in
the New Haven, Connecticut, cohort of the Established
Population for Epidemiologic Studies of the Elderly. A
subset of the sample had been seen by APS for suspicion
of mistreatment; the cohort members not seen by APS
served as the reference group. At the end of a 13-year
follow-up, subjects with sustained verified abuse and/
or neglect had poorer survival (9%) than those with
no contact with APS (40%). However, no investigation
revealed injury as the immediate cause of death, possibly because the study did not control for all confounders. A second limitation of the study was that physicians
might have been unaware that mistreatment existed or
contributed to death.

6.

8.

This was a cross-sectional chart review of 538 patients

with a diagnosis of self-neglect who had been referred
to a geriatric medicine team by APS. The average age of
the patients was 75.6 years, and 70% were women. As
part of the teams evaluation, a battery of assessment
measures was performed on the 460 patients age 65
and older. Abnormal scores on the Mini-Mental State
Examination (less than 24) and clock drawing test (2
or less) were found in 50% and 58.9% of the patients
who took the tests, respectively. Seventy-seven percent
of the patients who participated had some impairment
in activities of daily living based on the physical performance test. Study limitations included missing data
and referral bias. Not all data may have been entered
by clinicians, many patients were too impaired to complete tests, and some patients refused to participate. The
APS workers may not have referred patients because of
the requirement that they subsequently participate in
interdisciplinary team meetings. Some workers might
also have referred only their most difficult clients. The
authors theorize that self-neglect stems from executive
dysfunction, resulting in an inability to perform activities of daily living.

Rovi S, Chen PH, Vega M, Johnson MS, Mouton CP.

Mapping the elder mistreatment iceberg: U.S. hospitalizations with elder abuse and neglect diagnoses. J Elder
Abuse Negl 2009;21:34659.
This study compared hospitalizations coded with
diagnoses of elder abuse or neglect with all other hospitalizations of adults age 60 and older. The data from
994 hospitals in 37 states were weighted to produce
national estimates. There were 268 hospitalizations
coded with elder mistreatment in 2003. The most common type of mistreatment coded was neglect (45.9%),
followed by physical abuse (17.7%). As a primary diagnosis, abuse or neglect was identified 13.6% of the time.
Between the two groups, patients with elder mistreatment codes were 2 times as likely to be women and more
than 3 times as likely to be admitted through the emergency department. They also had longer lengths of hospital stays (7.0 days vs. 5.6 days). Transfer to a facility
rather than home was 34 times more likely among
elderly patients who had a code for mistreatment. Race
and socioeconomic status did not differ significantly
between the two groups. The small number of cases
coded for elder mistreatment limited analyses.

7.

9.

Krienert JL, Walsh JA, Turner M. Elderly in America:

a descriptive study of elder abuse examining National
Incident-Based Reporting System (NIBRS) data, 20002005. J Elder Abuse Negl 2009;21:32545.

Kennedy RD. Elder abuse and neglect: the experience,

knowledge, and attitudes of primary care physicians.
Fam Med 2005;37:4815.
In this study, a self-report questionnaire was mailed
to 250 family physicians and 250 general internists in
Ohio. The sample was randomly drawn from the membership lists of the American Academy of Family Physicians and the American College of Physicians. The
eight-page survey requested demographic, training,

This publication provides a brief review of victim and

abuser demographics based on previous literature on
elder abuse. The study examined data from elder abuse

Elder Abuse

Dyer CB, Goodwin JS, Pickens-Pace S, Burnett J, Kelly

PA. Self-neglect among the elderly: a model based on
more than 500 patients seen by a geriatric medicine
team. Am J Public Health 2007;97:16716.

128

PSAP-VII Geriatrics

board certification, and practice information. It also

asked questions to assess the experience, knowledge,
and attitudes of primary care physicians toward elder
mistreatment. The response rate was 78%, with 216
family physicians and 176 internists providing complete, useable data. Sixty-nine percent of those responding reported no exposure to elder mistreatment in the
preceding 12 months. For those who encountered a case
but did not make a report, the most common reasons
were that the abuse involved subtle signs (44%); the victim denied mistreatment (23%); and the physician was
unsure of reporting procedures (21%). Although only
23% of respondents perceived elder mistreatment to be
a significant problem in their patient populations, 98%
agreed that more should be done to educate physicians.
The authors call attention to the need for continuing
medical education on elder mistreatment for primary
care physicians.
10. Cooper C, Selwood A, Blanchard M, Walker Z, Blizard R, Livingston G. Abuse of people with dementia
by family carers: representative cross sectional survey.
BMJ 2009;338:b155.
This cross-sectional survey evaluated the prevalence of abusive behaviors by family caregivers toward
patients with dementia. In all, 220 caregivers with a
mean age of 61.7 years (range 2492 years) participated. Fifty-six percent were caring for a parent, 33%
for a spouse, and 13% for another relative. The family
caregivers were interviewed about how often in the past
3 months they had acted in psychologically and physically abusive ways toward the care recipient. More than
one-half of the caregivers (52%) reported some type of
abusive behavior. Verbal abuse was most often reported
and included screaming, yelling, insulting, swearing,
and using harsh tones with the care recipient. Only
three caregivers reported that physical abuse sometimes occurred. This study may have underestimated
the number and severity of abusive actions toward people with dementia because of the dependence on caregivers who were willing to report. The authors conclude
the article with the importance of asking about abuse to
safeguard the vulnerable elderly.

PSAP-VII Geriatrics

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Elder Abuse

130

PSAP-VII Geriatrics

Self-Assessment Questions
43. Which one of the following characteristics best
predicts self-neglect in A.F.?

Questions 41 and 42 pertain to the following case.

D.X. is a 76-year-old white man who is homebound
because of right-sided paralysis. A nearby church asked
for a well-being check, and he was found sitting incoherent in a recliner. The house was cold and dirty. He was
transported to a local hospital. The admitting diagnoses
included sepsis secondary to infected decubitus ulcers,
malnutrition, and dementia. He weighed only 50 kg
(110 lb) and had untreated injuries in various stages of
healing. D.X.s daughter receives $2500 a month in government assistance to care for him in their home. She is
married with children and has an alcohol abuse problem. The funds support her immediate family because
they have no other income. D.X. has had no contact
with his congregation, friends, or relatives other than
his daughter since suffering a stroke 2 years ago.

A.
B.
C.
D.

44. The social worker reports suspected self-neglect

to the county Adult Protective Services (APS)
agency. A.F. showed the capacity to make relevant
decisions, and the case was deemed unsubstantiated. The APS program still offered interventions
because a risk of harm to the person existed. A.F.
initially accepted home-delivered meals and then
declined the offer 1 month later. The APS program
respected her wish. Which of the following ethical principles is best represented in the APS program decision about A.F.?

41. Which of the following risk factors puts D.X.

most at risk of elder mistreatment?
A.
B.
C.
D.

A. Justice.
B. Nonmaleficence.
C. Privacy.
D. Autonomy.

Social isolation and dementia.

Poststroke paralysis and sex.
Race and dementia.
Sex and alcohol abuse problem.

45. One year later, the APS program again visits

A.F.s home. A concerned neighbor made the call
after A.F.s husband died. At this visit, the case of
self-neglect is deemed substantiated. A.F. seems
unaware that the telephone has been disconnected
and that the rent is overdue. She has family who are
willing to provide her care. Which one of the following is the most appropriate intervention by
APS on behalf of A.F.?

42. Local law enforcement charged D.X.s daughter

with elder neglect with serious injury. Which of the
following risk factors puts D.X.s daughter most
at risk of abusing her father?
A.
B.
C.
D.

Age and dependency.

Dependency and alcohol abuse problem.
Alcohol abuse problem and sex.
Marital status and age.

A. Family guardianship for surrogate

decision-making.
B. Involuntary, permanent placement in a
nursing home.
C. Confinement in her home with supportive
services.
D. Involuntary, temporary placement in a mental
health facility.

Questions 4345 pertain to the following case.

A.F. is a 66-year-old woman who is has lived with her
husband in an assisted living facility since suffering a
myocardial infarction 6 months ago. The on-site social
worker visited the couple after receiving an anonymous
report of an offensive smell and rodents coming from the
apartment. The social workers report indicated Social
Security is the couples only source of income. The residence was stacked from floor to ceiling with accumulated trash, photo albums, and collectibles. There was
little food in the refrigerator. A.F. was dressed in layers
of dirty clothing stained with urine. She complained of
lacking energy to get going, being less involved in usual
activities, and having difficulty falling asleep. She is
responsible for the care of her husband, who is wheelchair bound. He stated that A.F. was tearful almost
every day.
PSAP-VII Geriatrics

Caregiver status.
Presence of depression.
Fixed income.
Living arrangement.

46. A 90-year-old man with mental illness is transported to the hospital after a well-being check
reveals that he has suffered symptoms of heat
exhaustion including confusion, nausea, and dizziness. His home does not have air conditioning.
He cannot recall the last time he saw the grandson
he lives with. An emergency department physician
asks the patient, Are you alone a lot? This question is most likely to screen for which one of the
following types of elder mistreatment?
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A. Exploitation.
B. Physical abuse.
C. Neglect.
D. Financial abuse.

even though she is able to care for herself. She feels her
living situation was more comfortable before he moved
in. She can no longer afford to make home repairs or pay
the utility bills. She complains that her son uses her car
without permission.

Questions 47 and 48 pertain to the following case.

J.P. is a 90-year-old woman with a history of diabetes,
hypertension, osteoarthritis, and osteoporosis. She
resides in a nursing home and requires full assistance
with self-care tasks. Her drug therapy includes glipizide,
amlodipine, and oxycodone. In completing the monthly
drug regimen review, the consultant pharmacist reads
that J.P. experienced a skin tear during a position change
by one of the nurses. The nurses have noted difficulty in
rousing her after a recent increase in her narcotic analgesic. The facility physician also assessed her twice, first
when she was out with her family and slipped on the ice
and later in the month for agitation, which was found to
be caused by an unexplained dislocated shoulder.

49. Which one of the following is the best assessment

of the type of mistreatment V.F. is experiencing?
A.
B.
C.
D.

50. The pharmacist decides to report her suspicion

of elder abuse in V.F. and contacts the state Elder
Abuse Hotline. Which one of the following best
describes the most appropriate action for the
pharmacist to take when reporting?
A. Give only the name and phone number of
V.F.s son.
B. Speculate on the ways V.F.s son is spending
her pension checks.
C. Keep information V.F. shared in her own
words and in the same context.
D. Contact the abuse hotline only after V.F. has
provided a written consent.

47. Which one of the following most raises the suspicion of elder abuse in J.P.?
A. Skin tear on her elbow with a position change.
B. Slipping on ice while out with her family.
C. Difficulty awakening after the increased
narcotic dosage.
D. Agitation and an unexplained dislocated
shoulder.

Questions 51 and 52 pertain to the following case.

J.H. is an 80-year-old man with moderate- to late-stage
Alzheimer disease. He is cared for by his wife in their
home. An APS worker visits the home and finds J.H.
wearing dirty underclothes, rocking in a chair, and eating baby food. There are restraint marks on his arms.
His wife confides that he resists bathing and wanders.
He has not been taken to a physician in the past year.
The worker almost passes out from the smells and heat.
There is no working air conditioner in the home.

48. Relatives of J.P. worry about her well-being in the

nursing home and wish to report their concerns
about poor quality care. Because they are uncertain
how to proceed, they approach the consultant pharmacist for direction. Which one of the following
best describes the reporting process the pharmacist should recommend?
A. Relatives should contact a trusted nursing
assistant or other staff member.
B. The regional ombudsman should be contacted
to advocate on the patients behalf.
C. Relatives should call 911 after the patient has
been transferred to the hospital.
D. Relatives should have proof of abuse;
otherwise, they should not make a report.

51. Which one of the following is the most likely

type of mistreatment experienced by J.H.?
A.
B.
C.
D.

Questions 49 and 50 pertain to the following case.

V.F. is a 72-year-old woman who has used your community pharmacy for many years. She confides in you that
she signs over her pension check to her son because he
lost his job. She has no other income and must then ask
him for pocket money. She has been unable to afford her
prescriptions since he moved into her home 3 months
ago. She asks whether there are any programs in which
to enroll for free drugs. V.F. is afraid to confront her son
because he threatens to place her in a nursing home,
Elder Abuse

Neglect and psychological abuse.

Psychological and physical abuse.
Physical and financial abuse.
Financial and psychological abuse.

Physical abuse and neglect.

Physical and financial abuse.
Neglect and sexual abuse.
Physical and psychological abuse.

52. J.H. and his wife visit a physician the same week.
Which one of the following represents the most
effective screening method for abuse in J.H.?
A. Administer the American Medical Association
screening instrument to his wife.
B. Ask the caregiver questions about the patients
behavior.
C. Administer the American Medical Association
screening instrument to the patient.
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D. Ask the visiting nurse questions about the

patients behavior.

convenience, to quiet the resident down by writing

an order for haloperidol and then forcibly injecting
it. The nurse did not have the consent of the resident or health care proxy. The next day, the physician refused to sign the order, citing that it was not
necessary to treat the residents medical symptoms.
The state surveyor pays an unannounced visit.
Which one of the following best represents the
deficiency issued by the state surveyor?

Questions 53 and 54 pertain to the following case.

T.T. is a female nursing home resident who claims she
was injured after a caretaker gave her an unnecessary
laxative. T.T. talks with the nursing home administrator, who then makes a report on suspicion of a crime.
A nurse on the first shift admits to administering a rectal suppository as a prank on the second shift nurse that
would have to handle T.T. A nursing assistant observed
the event but did not report it. The second shift nurse
did not have knowledge of the prank. T.T. suffers from
various physical and mental conditions and is completely dependent on staff for care.

A.
B.
C.
D.

57. You accompany a nurse practitioner and dietitian

on an interdisciplinary clinic visit with a female
patient. The patient is 80 years old and recently widowed. She has not been getting her prescriptions
refilled as often as she should. Her blood pressure,
glucose, and lipids are no longer under control. The
patients daughter, who is present at the visit, states
that she took control of her mothers life when she
moved in 6 months ago. The nurse practitioner
comments that the patient seems more unkempt
than usual and withdrawn. Her daughter interrupts the dietitian about food choices, stating that
her mother is overweight and that they do not have
money for all the fancy foods the dietitian has suggested. The daughter says she needs to save money
for her kids meals. In discussing the visit later, you
and your colleagues decide that the patient may be
the victim of abuse or neglect, but you feel helpless
to do anything. Which one of the following is the
best rationale for reporting your suspicions?

53. Which one of the following best describes the

crime that occurred against T.T.?
A. Battery.
B. Fraud.
C. Assault.
D. Rape.
54. Which one of the following best represents the
parties that could face civil penalties if the crime
is substantiated?
A.
B.
C.
D.

Nurse on the first shift.

Nurses on both shifts.
Nurse on the first shift and nursing assistant.
Nurse on the first shift and nursing home
administrator.

55. A 67-year-old man is assaulted several times by

his adult son. He lives alone and is able to care for
himself. His son, who was abused as a child by the
father, strikes out at him when they argue. Neighbors reported a recent incident to the police, but
the father and son denied everything. Which one
of the following theories of elder abuse best
describes this situation?

A. Reduce the patients overall risk of injury and

dying.
B. Improve the patients blood pressure, glucose,
and lipid values.
C. Remove the patient and her finances from her
familys control.
D. Prevent the patients chance of abuse by her
grandchildren.

A. Feminist.
B. Transgenerational.
C. Situational.
D. Web of dependency.

58. An elderly man has a black right eye and large bruise
on his chest. He admits to an interviewer that his
son handled him roughly after he soiled himself and
needed cleaning. The son claimed it was an accident. Both deny the injury is serious. Which one
of the following is the most important question
you have about the interview process?

56. A 68-year-old nursing home resident has experienced a 5% weight loss since admission last month.
The dietitian assesses the residents condition and
makes modifications to the diet on the basis of the
residents food preferences. Albumin and hemoglobin are checked and found to be acceptable. Skin
is intact and is being checked daily. After the resident annoyed the head nurse by throwing a shoe
in her direction, the nurse decided, as a matter of
PSAP-VII Geriatrics

Nutrition status.
Physical restraint.
Pressure sores.
Chemical restraint.

A. Was the sex of the interviewer the same as that

of the father?
B. Was the father interviewed alone?
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Elder Abuse

C. Was the father given a narcotic analgesic

before the interview?
D. Was the father interviewed in his own home?
59. A staff pharmacist at a nursing facility conducted
a count of drugs in a nurses cart at the beginning
and end of a shift. The pharmacist found more
than 50 doses of drugs that were unaccounted for
or provided to residents. An internal investigation
revealed that the nurse falsified records to make it
seem as though the residents received the drugs.
The nurses only defense was that she had too many
drugs to pass. The facility recently downsized its
staff and dismissed some of them. Which one of
the following is the best action for the facility to
take to reduce the likelihood of neglect?
A. Hire more nursing assistants to administer the
drugs.
B. Reduce the number of drugs each resident
receives.
C. Ensure sufficient nursing staff to perform
medication pass.
D. Staff the floor daily with different agency
nurses.

Elder Abuse

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PSAP-VII Geriatrics