Mistreatment

Elder mistreatment refers to harm or the threat of harm to an older person that is brought about by another person.

Older people can be mistreated by having harmful things done to them (abuse) or by having necessary things withheld from them (neglect). Elder mistreatment is a growing problem as the number of older people increases.

Each year in the United States, thousands of older people are mistreated. The perpetrator of mistreatment is often a family member, usually an adult child or spouse who is serving as the older person's caregiver. Caregivers may experience extreme stress and frustration, particularly if they are lacking in skills and resources, which may lead them to mistreat those in their care. Sometimes, professional caregivers, such as home health care workers or employees of nursing homes and other institutions, are perpetrators. Many perpetrators are financially dependent on the person they mistreat.

People who are mistreated are often frail, and many have several disabling chronic diseases. But any older person, regardless of health, can become a victim of mistreatment.

Because of their frailty and dependence, abused older people often do not seek help. They may be physically unable to seek help or may be afraid to do so. They may be afraid of further harm or of being abandoned. For all these reasons, elder mistreatment often goes unrecognized by doctors, nurses, social workers, friends, and family members.

Types of Mistreatment

Abuse: Abuse can be physical, sexual, psychologic, or financial. An older person may be subjected to one of these types of abuse or to a combination of two or more types.

Physical abuse is the use of force to harm or threaten harm. Examples of physical abuse are striking, shoving, shaking, beating, restraining, and improperly feeding. Possible indications of physical abuse include unexplained injuries or injuries that go without adequate treatment, rope burns and other rope marks, and scratches, cuts, and bruises. A caregiver's refusal to allow the older person to have time alone with visitors or health care practitioners can raise concerns about physical abuse.

Sexual abuse is sexual contact without consent or by force or threat of force. Examples are intimate touching and rape. Bruises around the breasts and genital area or unexplained bleeding from the vagina or anus may indicate sexual abuse. However, sexual abuse does not always result in physical injuries.

Psychologic abuse is the use of words or actions to cause emotional stress or anguish. Examples of psychologic abuse are issuing threats, insults, and harsh commands; remaining silent for prolonged periods; and ignoring the person. Another form of psychologic abuse is treating the older person like a child (infantilization), sometimes with the goal of encouraging the person to become dependent on the abuser. People who are psychologically abused may become passive and withdrawn, anxious, or depressed.

Financial abuse is the exploitation of a person's possessions or funds. It includes swindling, pressuring an older person to distribute assets, and managing an older person's money irresponsibly. A caregiver may spend most of an older person's income on himself, providing only minimum resources to the person for whom they were intended.

Many experts believe that restricting an older person's freedom to make important life decisions, such as whom to socialize with and how to spend money, constitutes another, more subtle, form of abuse.

Neglect: Neglect is the failure to provide food, drugs, personal care, or other necessities. In some instances, necessities are withheld intentionally; in others, they are simply forgotten or overlooked by irresponsible or inattentive caregivers. Some caregivers are unaware that their treatment of an older person has crossed the line from being less than ideal to mistreatment. These caregivers lack a sense of what constitutes adequate and appropriate care, or they may have very different notions of what is and what is not acceptable conduct. Sometimes neglect arises out of desperate circumstances despite the caregiver's best intentions.

A person who is neglected may lose weight from malnutrition and develop dry skin and a dry mouth because of dehydration. An unpleasant odor may emanate from a person who is poorly cleaned. Pressure sores may develop on the buttocks or heels from sitting or lying in one position for prolonged periods.

Prevention of Mistreatment

An older person who fears being vulnerable to mistreatment can take steps to decrease its likelihood. Living with someone who has a history of violent behavior or substance abuse should be avoided. Keeping in touch with friends and former neighbors is helpful if an older person has to relocate to a caregiver's house. Likewise, family members and friends can help prevent mistreatment by maintaining close ties with the person. Staying connected with social and community organizations reduces the chances that mistreatment will go unnoticed.

Older people can also avoid mistreatment by insisting on legal advice before signing any documents related to where they will live or who controls their finances. The local Area Agency on Aging can refer people for legal help.

Responding to Mistreatment

An older person should never think that mistreatment is part of being old or being dependent. At the very least, being mistreated threatens a person's dignity and sense of well-being. At the very worst, it can cost him his life.

Detecting mistreatment of an older person can be difficult. The person may isolate himself, hiding mistreatment because of shame, fear of retaliation, or a desire to protect the perpetrator. The person may fear being abandoned or forced into a nursing home if he tells others about the mistreatment. Further, the perpetrator often increases this sense of isolation by limiting phone calls or access to visitors and health care practitioners.

If an older person who is being mistreated believes he is in danger, he can call an elder abuse hotline for immediate help. Such hotlines are listed in the local phone book, usually in the Blue Pages, or can be provided by a phone operator. The local Area Agency on Aging is another good source of information and referral. If the person does not feel endangered but is still seeking help, he can try to convey word of his situation to his doctor or other health care practitioner. However, many health care practitioners are unfamiliar with addressing problems of elder mistreatment because the topic has not been a traditional part of medical training and education.

In general, because mistreatment and its effects can vary greatly, interventions need to be tailored to each person's situation. Interventions may include medical assistance, education (such as information about mistreatment and available options as well as help with devising safety plans), and psychologic support (such as psychotherapy and support groups). Law enforcement and legal intervention (such as arrest of the perpetrator, orders of protection, and legal advocacy) may be called in. Alternative housing options (such as housing that provides safe shelter, with protection from the perpetrator) may be needed.

Relatives, friends, and acquaintances have a responsibility to help if they know of or strongly suspect mistreatment. Health care practitioners who become aware of or suspect mistreatment have the same responsibility. The reporting of suspected or confirmed abuse or neglect is mandatory in all states if the mistreatment occurs in an institution and in most states if it occurs in a home. Indeed, every state has laws protecting and providing services for vulnerable, incapacitated, or disabled adults. In most states, the agency designated to receive abuse reports is the state social service department (Adult Protective Services). In a few states, the designated agency is the state unit on aging. For abuse within an institution, the local long-term care ombudsman's office or the state department of health should be contacted. Telephone numbers for these agencies and offices in any part of the United States can be found by calling the Eldercare Locator (800-677-1116) or the National Center on Elder Abuse (202-682-2470) and giving the person's county and city of residence or zip code.

See the sidebar Self-Neglect.