Abuse and Neglect
Madelyn A. Iris, Ph.D.
Identification and assessment
of abuse and neglect of community-dwelling older persons is difficult
and presents many challenges. Often, abuse and neglect are perpetrated
by close family members, particularly spouses and/or adult children.
Because elder abuse is closely linked to family issues, victims
may deny or play down its seriousness to protect the abuser and
maintain the image of a caring and loving family. Victims may
be reluctant to identify family members as abusers for fear of
involving the criminal justice system. Sometimes victims are unable
to report abuse or neglect due to cognitive incapacity. Social
supports for victims of abuse and neglect may not be readily available,
and finally, health care professionals may minimize complaints
rates are difficult to determine, due to lack of consistency
in definitions. Generally, the types of abuse identified are
(in order of decreasing frequency or incidence):
- Physical abuse
- includes pushing and shoving,
hitting, slapping, burning, etc.
- Psychological or emotional
- includes threats, harassment,
insults, denial or refusal to meet the social needs of the elderly
person (e.g., by denying visitors or outings). Such abuse is
difficult to define and identify, especially within the family
- refers to misuse or misappropriation
of financial resources and assets and ranges from misuse of income
to converting assets for use by the abuser. Since many older
persons rely on spouses or children to help manage financial
affairs, exploitation is difficult to assess, as abusers often
have authorized access to bank accounts, credit cards, deeds,
- Sexual abuse
- is defined as sexual contact
against the will of the older person and includes fondling, exposure,
and rape. Reports of sexual abuse are difficult to obtain and
incidence rates are probably highly underestimated. Assessing
sexual abuse can be difficult, and may require a physical examination,
especially in cases of rape. However, it may be extremely difficult
to obtain consent for such an examination. If the victim does
consent, the same procedures should be used as in all other cases
of sexual assault.
- Medication abuse
- includes inappropriate use
of medications (e.g., overuse of sedatives) or withholding prescribed
- Signs that raise suspicion
but are NOT diagnostic:
- Unexplained trauma (lacerations,
punctures, welts, bruises, fractures, burns, and evidence of
the use of restraints)
- Sexually transmitted diseases
- Reluctance to speak around
- Demonstrations of fear of
- Unwillingness of the abuser
to leave the victim alone
- Sudden inability of victim
to pay his/her bills
- Patient's statements about
missing valuables (even in the presence of mild dementia)
- Poor response to therapy
Neglect of an older person covers a wide range of situations.
In all cases, signs of neglect include malnutrition or sudden
weight loss, poor hygiene, deplorable living conditions, inappropriate
clothing or lack of clothing, lack of compliance with a treatment
protocol in a previously compliant patient, and the presence of
sores, excrement, and dirt on the body. Misplaced or broken glasses,
false teeth, hearing aids, or other prostheses or equipment are
also indicators. Two types of neglect may occur: benign neglect
and willful neglect.
- Benign neglect occurs when
the caregiver is ignorant of or unable to provide appropriate
care. This may be remedied by the provision of educational and/or
supportive services to assist the caregiver in his or her caregiving
- Willful neglect is regarded
as deliberate and meant to harm. It includes denying the elderly
person access to resources, medical care, medications, food,
etc. Willful neglect should be treated in the same manner as
other types of abuse.
All elderly persons are potentially
vulnerable to abuse, especially those with physical or mental
impairments, regardless of racial background, social class, educational
level, etc. Eight risk factors have been identified:
- Poor health and functional
impairment in the elderly person
- Cognitive impairment in the
- Substance abuse by or mental
illness in the potential abuser
- Dependence of the potential
abuser on the victim (financial or psychological)
- Shared living arrangements
- External factors causing stress,
especially for the potential abuser
- Social isolation of the elderly
person and/or the potential abuser
- A history of violence in the
Health care professionals should
follow a standardized protocol for assessment, intervention and
treatment of elder abuse and neglect.
- Regard impaired caregiver
function (for whatever reason) as a significant health risk for
the patient and assess as thoroughly as you would any other health
- Continually assess caregiving
situations to identify the older person believed to be abused,
neglected, or at risk.
- Provide medical evaluation
and treatment for injuries or conditions resulting from abuse
DRG 454 can be used as admitting
diagnoses for inpatient assessment. This DRG corresponds to ICD
codes 995.85 Other Adult Abuse and Neglect. ICD code 995.8 Other
Specified Adverse Effects, Not Elsewhere Classified lists subcategories
that include various types of abuse and neglect situations.
- Pursue action to alleviate
the abuse or neglect, protect the safety and well-being of the
victim, and assist the victim and family in reestablishing a
nonabusive and caring environment.
- Be aware of protocols and
community services that can assist with assessment and management.
- Attempt to establish and maintain
a supportive relationship with the victim and with other family
members, to ensure that harmful situations do not reoccur.
- Report abuse or neglect in
accordance with state or local statutes.
- Remain objective and nonjudgemental.
- Advocate for the protection
and rights of those who cannot do so for themselves.
Legal and ethical issues
Three issues warrant special
- Most states, whether reporting
is mandatory or voluntary, offer immunity and anonymity for reporters.
Health care professionals should report even suspicions of abuse
or neglect to the appropriate adult protective services.
- Elder abuse raises ethical
issues of competency, privacy, and the right to refuse intervention.
All older persons are deemed competent unless adjudicated otherwise
through a formal competency hearing; thus, they reserve the right
to refuse intervention regardless of perceived dangers. If victims
refuse to participate in assessment or deny that abuse exists,
despite extensive evidence to the contrary, investigators may
have no legal right to intervene or overrule such decisions.
Effective January 1, 1999, the
Illinois Elder Abuse and Neglect Act requires health care professional
to report suspected abuse, exploitation or neglect, if the older
person is thought to be unable to do so on his or her own behalf.
This change implies that judgements about cognitive capacity can
be made without seeking a formal adjudication in a court of law.
- Many dilemmas arise because
elder abuse can be both a family systems issue as well as a criminal
matter. While abuse and neglect may be most effectively dealt
with through counseling or social services, some state or local
statutes may define them as criminal acts, bringing the victim
and abuser into the criminal justice system.
All who provide services to
abused and neglected elderly must remain aware of the complex
needs of this vulnerable population and access support services
on behalf of their patients and clients.
For assistance in helping patients
and families address issues of elder abuse and neglect, consult
geriatricians, social workers, or local Departments on Agents
Adult Protective Services.
Illinois maintains a 24 hour
Elder Abuse Reporting Hotline at 1-800-252-8966.