Elder abuse and mistreatment, like all other types of domestic violence, has been an unfortunate part of human existence since ancient times. Greek mythology and literature relate stories of the slaying of parents, called parricide, to gain power (2). Some primitive societal customs have involved killing, abandoning, or encouraging the ritual suicide of the less productive tribal elderly to promote the common welfare of the group in times of scarcity (2). In early American history, witch-hunt victims who were tortured or burned at the stake were often postmenopausal women (3). Elder mistreatment, like all forms of family violence, was traditionally regarded as a private matter and was historically excused from outside scrutiny (2, 4). Despite the incidence of elder abuse throughout history, it was not until 1975 that this subject, called granny battering, was introduced in two British journals published one month apart (5, 6). Sporadic reports appeared in the United States soon after, and before the end of the decade, the U.S. Senate Special Committee on Aging reported on mistreatments in nursing homes (7) and on domestic parental battering (8). Since then, there has been more extensive research worldwide (9, 10, 11, 12, 13, 14, 15, 16, 17). Research has led to provider awareness, dedication of resources, and appropriation of funds.

In the United States, congressional hearings on this issue first took place in the late 1970s and early 1980s. As a result, in 1987 the amendments to the Older Americans Act (OAA) sought to define terms for purposes of problem recognition. Following these, the Department of Health and Human Services established an Elder Abuse Task Force in 1990 to expand the scope of federal involvement in elder mistreatment. In so doing, the federal government identified elders in the community as well as residents of institutions as victims in need of aid. A year later, the Elder Care Campaign undertaken by the U.S. Administration on Aging created a National Aging Resource Center on Elder Abuse (NARCEA), currently called the National Center on Elder Abuse (NCEA). At about the same time, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) included elder abuse among other forms of domestic violence in its mandate for improvements in the recognition and management of these maladies (7, 8, 18). Since then, more states have jumped on the bandwagon to pass legislation regarding elder abuse and mistreatment. The relative explosion of interest and preliminary research that arose where virtually none had existed before prompted some experts to designate the 1980s the decade devoted to eradicating elder abuse (19). Slowly, health care providers, politicians, and other advocates are becoming more aware of this health issue as it is revealed from behind the closed doors that, until relatively recently, obscured our awareness of child abuse, sexual assault, and domestic-partner battering.

As a tangible approach to this goal, President William J. Clinton’s first legislative action was to sign the Family Medical Leave Act in 1993, which, in part, provided families with an easier means to care for their elder relatives. His administration also expanded Medicare benefits to help older Americans and cracked down on fraud. More recently, in 1998, the NCEA received a $1 million grant designed to expand the agency and its services. In 2003, this agency commissioned the National Research Council Panel to Review Risk and Prevalence of Elder Abuse and Neglect, indicating that other leaders will be as supportive of elder care. Indeed, astute elected officials will take this position not only for humanitarian reasons but for electoral reasons as well: as the country ages and today’s adult baby boomers become tomorrow’s senior citizens, candidates will need elders’ support for election.

Despite improvements in elder care during the past 20 years, health care providers can expect to see more cases of elder abuse and mistreatment in the coming decades simply because the American population is aging. Better and more accessible health care, advanced technology, less invasive procedures, and pharmacologic advances are keeping older Americans alive and in many cases healthier than ever before. The introduction of Medicare in the mid-1960s was a major step toward this goal. The emphasis on primary care introduced in the 1980s and its role in disease prevention, risk reduction, cancer screening, and promotion of healthier lifestyles for both young and old has undoubtedly contributed to the “graying of America” (2, 18).

Population statistics and projections are indeed staggering. Life expectancy has increased dramatically in this century alone. The U.S. Census Bureau projects the life expectancy of an American child born in 1990 to be more than 75 years, compared with an average life span of 47 years for a child born in 1900 (20). A person who reached age 65 in 1990 could expect to live for an additional 17.2 years (20). These data represent a marked increase
over the 12 additional years expected in 1900 and even a significant increase over the 15.2 additional years anticipated by a 65-year-old in 1970 (2, 20). The fastest growing segment of the elderly population is the “old old,” that is, over age 75. Often this age-group is further divided into the “very old,” between ages 75 and 84, and the “oldest old,” age 85 and over. This growth is demonstrated by recent population statistics, which reported a 38% increase in the number of Americans aged 85 or older from 1980 to 1990. Similarly, the number of centenarians doubled in these 10 years (2, 20).

Elderly persons represent an ever-increasing percentage of all Americans. In 1980, there were 25.5 million people older than 65 in the United States, representing 11.3% of the population (21). In comparison, the 2000 census documented 35 million people in this age-group, constituting 12.4% of the total US population (22). Over 12 million of these senior citizens were in the very old age-group, and an additional 4.2 million were aged 85 or older when they welcomed the new millennium (22). These oldest demonstrated the most rapid relative population growth. By the year 2020, more than 52 million Americans will be 65 or older (23).

This “elder boom” will bring even more interactions between the elderly and the health care system. It should come as no surprise that elderly people utilize health care resources more often and with disproportionate frequency than the population at large. This applies for both routine care and emergency services. Recent statistics from a 1994 report generated by the American Association of Retired Persons (AARP) showed that patients aged 65 and older accounted for 35% of all hospital stays and 46% of all inpatient care days (24). The seniors’ outpatient visits also outnumber those of the general population by nearly 2:1 (2). There will be particular stress placed on emergency physicians and emergency service providers (25). Several studies have demonstrated, as one might expect, that elderly people use emergency services more frequently than the general population (21, 26, 27, 28, 29). This amounted to an estimated 13.6 million visits to emergency departments (EDs) nationally in 1990 (21). The elderly also are more likely to require a comprehensive level of emergency care. They are more frequently admitted, and they need an intensive care unit more often than younger patients (21). These trends imply what another group of authors conclude on the basis of actual data: elder use of emergency services is in fact more efficient than that of young people (29). Perhaps cases of elder abuse and mistreatment will increase in proportion to the projected population growth. Perhaps its incidence and prevalence will drop as elders, their caregivers, and their health care providers become better educated and more cognizant of available resources. Those involved in the care of elders hope for the latter.

Definitions of what constitutes elder abuse and mistreatment vary substantially. This variance has been a major barrier to understanding the true prevalence of abused or mistreated elders. Indeed, the terms “abuse” and “mistreatment” may be used synonymously or synchronously with one another depending on which authors are read. The different types of maltreatment are also subject to different definitions. Extensive literature reviews performed for this book and by other authors (17, 30) have found no generally accepted meanings for these expressions. Furthermore, what constitutes abuse, mistreatment, or any other act in the opinion of one clinician, social worker, or layperson may not for another. Many authorities, including the American Medical Association (AMA) (31), prefer the term mistreatment to include both abuse and neglect (13, 18, 32). Inadequate care has also been proposed as a more universal phrase (33). In addition, clinical or common sense criteria for abuse may not be consistent with specific legal definitions. There is discrepancy even with regard to who is considered an elder. Most writers use the age of 65 as the accepted cutoff, but a few studies have included patients as young as 60 (1, 11, 34, 35). One can become very confused. It is best to keep in perspective that the ultimate goal is the safety and welfare of the elderly. Rather than add a new author’s interpretation into the mix, the reader should consider the relevant terminology and some of their existing definitions. The following practical definitions have already been published.

A broad definition of elder abuse or mistreatment is any adverse act of omission or commission against an elderly person (36). There is no consideration for intent in this most basic meaning. Other researchers restrict abuse to acts of commission with the intent to cause harm or injury (2). A Connecticut-based group that has compiled significant data since 1982 includes intent in its working definition of abuse: the willful infliction of physical pain, injury, or mental anguish, or the willful deprivation by a caretaker of services necessary to maintain physical and mental health (37). The US Congress in 1985 introduced the Elder Abuse Prevention, Identification and Treatment Act, which sought in part to clarify terminology (Table 10-1) (38). Its definition of abuse is similar to that of the aforementioned group. In 1992, the AMA published a comprehensive and sensible set of terms and classifications (31) This listing (Table 10-2) was an improvement and foreshadowed what will likely become the gold
standard for all those involved in the care of the elderly: the National Elder Abuse Incidence Study (NEAIS) of 1996 (39). This project, undertaken by the NCEA through the U.S. Department of Health and Human Services Administration on Aging, empowered a panel of experts to define terms prior to the study of domestic elder abuse. After a pilot testing period of definitions, the final versions were selected and utilized (Table 10-3).

Neglect is a term that is even more nebulous than abuse. Some authors consider neglect less serious than abuse with regard to intent (40). Others pointedly remark that neglect, although conceptually different, should not be deemed a lesser form of abuse and can be just as harmful (41). The Connecticut researchers define neglect as the failure of a designated or responsible caregiver to meet a dependent elder’s needs, or the inability of an elderly person without a caregiver to provide himself or herself with the means to maintain physical and mental health (37, 42). Some experts specifically designate this latter situation as self-neglect (41). Interestingly, neither the congressional nor the AMA framework addresses the concept of self-neglect. Abandonment is defined as the desertion of an elderly person by an individual or group responsible for providing care or by an individual with the physical custody of an elderly person (39).

This jargon can confuse even an experienced provider. The clinician should learn these terms and become familiar with the working definitions so as to recognize examples of elder mistreatment and to communicate effectively with the appropriate authorities. Although various medical organizations, legislative bodies, and government agencies may all adopt seemingly crisp definitions, an individual form of elder mistreatment or abuse does not occur in a vacuum; a victim of one type of mistreatment too often suffers multiple abuses (18). The bottom line for the emergency provider is still to recognize when
an elderly patient has suffered adverse physical or emotional health consequences as a result of abuse or neglect.

Initial studies in different countries classified elder abuse into three or four categories: abuse, split often into physical and emotional/psychological; financial exploitation; and neglect (11, 37, 42, 43). Tatara’s report for NARCEA in 1990 further expanded the scope of abuse and mistreatment to include three additional types: self-neglect, sexual abuse, and miscellaneous (44). The miscellaneous category was designated for “all other types” of abuse, such as abandonment (perhaps the extreme form of neglect) and violations of a citizen’s rights. Furthermore, certain abuses and most incidences of neglect could be either active (committed willfully) or passive (committed without intent) (41).

Physical abuse involves willful infliction of force that results in bodily harm, injury, impairment, or pain. Examples include hitting, slapping, striking with an object, pinching, kicking, pushing, shaking, burning, and rough handling (45, 46). The most common instrument used by an abuser to inflict damage, pain, force, or punishment is his or her own hand. A less commonly recognized type of physical abuse is force-feeding. Other abusive behaviors include improper and perhaps unindicated use of physical restraints, intentional withholding of medication, or overmedicating, such as with an anxiolytic or other mood-altering drug.

Physical neglect involves physical harm brought to an elder as a result of a caregiver’s failure to provide the means for well-being. Examples may include inadequate feeding or hydration, not enough physical exercise or therapy, unsanitary living conditions, and poor personal hygiene care. Other neglectful behaviors include failing to provide or maintain basic assistive devices, such as eyeglasses, hearing aids, dentures, commodes, canes, walkers, and wheelchairs. The absence or inadequacy of safety precautions, such as bathroom handrails or bed side rails, also qualifies as physical neglect. Some authors specify that neglect is unintentional by definition (45), whereas others subdivide neglect into active and passive forms with regard to intent (41). An example of passive neglect would be an overburdened caregiver simply not having the time or resources to provide the level of care needed by an elder. If that same caregiver intentionally withheld basic items for that elder’s quality of life, the neglect would be active.

Intent to cause harm is difficult to evaluate and even more difficult to prove. It is probably beyond the scope of the clinician to delve deeply into the issue of intent. The health care provider should be most concerned with damage control and safe disposition. An even more complex dilemma may arise in the area of self-neglect. Although the term is self-explanatory, self-neglect raises ethical issues and requires value judgments. An elderly person with moderate dementia, for example, who lives alone and cannot provide self-care, and who has signs of physical neglect, represents a case of passive self-neglect. A patient like this is probably incompetent and needs to be cared for, if necessary, against his or her will. Conversely, active self-neglect might involve a homeless adult who chooses not to utilize available community resources for the indigent and chooses a standard of living and personal hygiene below the socially expected norms (41). Other authors dismiss the notion of active self-neglect
and specifically exclude this type of conscious and voluntary situation from elder abuse (39).

Psychological abuse is the infliction of mental or emotional anguish by threat, humiliation, or other nonverbal abusive conduct. It may be willful (45). Examples include verbal harassment, yelling, intimidation, and berating. Threatening an elder with punishment, physical abuse, or deprivation of basic needs also constitutes psychological abuse. Infantilization of a competent senior citizen is perhaps the most brazen of emotional abuses. A frustrated caregiver may be unaware of hurtful words hurled at a needy elder in moments of stress. Such negative remarks contribute to feelings of low self-esteem in any age-group, particularly in the elderly who may already harbor feelings of uselessness (47). Clinical depression is already highly prevalent among senior citizens (48); one’s interactions at home should not fuel the fire.

Psychological neglect involves unintentional conduct that deprives an elder of good mental health. Examples include inadequate social stimulation caused by ignoring the victim, lack of companionship, or leaving the elder alone for inappropriately long periods of time (18). For instance, a caregiver might provide a dependent elder with adequate food, medical care, and housing but may not interact with that elder much at all. Such a caregiver may be supervising several seniors or may have other responsibilities that preclude him or her from providing even minimal social activity for an individual elder (47). Even facilitating a brief visit from a friend or giving assistance with a phone call to a relative might seem like undue effort for a harried provider.

Financial or material mistreatment may be abusive or neglectful. Directly exploitative behaviors include theft of an elder’s money or property, or coercing an elder to change a will, make purchases, or sign any agreement against his or her will. Many elderly people have their checks cashed by others without proper authority. Likewise, elders can fall victim to slick confidence scams perpetrated by professional con men. Many instances of financial abuse involve senior citizens who possess substantial assets. However, even small incomes from government checks can become an incentive for an abusive caregiver to exploit an elder, especially when that money may be a household’s only regular source of income (47). An exploiter with some official control over an elder’s decisions, such as a chosen or appointed guardian, conservator, or someone with power of attorney, may abuse this authority. Financial or material neglect occurs when the elder or the caregiver fails to utilize available funds or resources immediately to meet the elder’s needs.

Sexual abuse of an elder involves any nonconsensual sexual conduct or contact between an elder and an abuser. Examples include unwanted touching, fondling, and rape. Other kinds of sexual abuse may be less direct but just as unseemly: coerced nudity, explicit photography, indecent exposure, and lewd talk. Some people mistakenly believe that any sexual activity involving the elderly, even between consenting adults, is somehow inappropriate. This notion is clearly outdated and wrong. There is no reason for an elderly person to stop exploring sexuality on the sole basis of his or her age. Discouraging, restricting, or prohibiting consensual sexual relations between competent persons may be considered abusive. However, some elders may be incapable of consenting to sexual activity. One must be particularly cognizant not to dismiss the possibility that a senior citizen could be sexually assaulted or harassed. This subject is rarely addressed in studies of elder maltreatment, and there is not much data on the sexual abuse of elders. On a positive note, perhaps a contributing factor for the absence of data is infrequency of sexual abuse of elderly persons. One study reports that sexual abuse accounts for less than 1% of all elder mistreatment (49). This study notes that sexual abuse is particularly uncommon in a domestic environment; its usual setting is institutional.

The deprivation of an elder’s rights represents a miscellaneous form of mistreatment. These rights may include an elder’s right to privacy and his or her right to make decisions. These decisions for a competent elderly person may include medical, financial, or personal choices. Forcing an elder from a private residence without due process or placement of a competent elder in a nursing home against his or her will also fits this category. Medical professionals may unknowingly participate in elder rights violations with regard to reimbursements for certain hospitalizations. It has been suggested that the funding of hospital care based on diagnosis-related groups (DRGs) discriminates against the elderly by potentially denying them the longer hospital course that is often necessary to achieve recovery than for younger patients with similar diagnoses (50). DRG coding, with its emphasis on standardization of naturally varied and heterogeneous disease processes, does not account for age and its contribution to morbidity. There is no appreciation of the unique needs and characteristics of the elderly, such as slower recovery, comorbid illness, and possible inferior baseline function. That is not to suggest that all elders require longer hospital stays. Rather, assessment of any patient’s level of functioning and the provision for reimbursement, at least in part, on the basis of function-related groups might eliminate this under-recognized iatrogenic mistreatment.

Besides grouping mistreatments by specific types of actions or inactions, elder abuse may also be classified by its setting. Abuse or neglect may occur at the elder’s home or at the home of a caregiver. The caregiver would have some special relationship with the elder, such as spouse, sibling, child, other relative, or friend. This is referred to as domestic mistreatment (34, 39). Institutional mistreatment takes place outside a private dwelling, as in a nursing home, assisted-living facility, group home, or in elder foster care. The perpetrators of this type of maltreatment have some professional or contractual obligation to care for the elder. Abusers and neglecters can include nurses, aides, and licensed private elder care providers. In addition, administrators of facilities can exploit elders with regard to financial or material abuses without ever meeting that elder face to face.

The true incidence or true prevalence of elder abuse can only be estimated, but these approximations are frighteningly high for an enlightened and productive modern society. One must remember that the only cases of elder abuse that can be studied directly are those that have been reported. Thousands of cases go unreported each year, so data are skewed at best. Many studies that have attempted to enumerate these statistics have design flaws. There have been considerable discrepancies with regard to term definition, research methodology, data acquisition, sample size, and study goals. This situation makes any meta-analysis at this time impossible. Some studies attempt to extrapolate information using general population statistics to estimate national rates, whereas others confine the conclusions they draw to their data only. In addition, certain research groups have reported only on domestic elder mistreatment. Some other papers fail to include neglect as maltreatment. Sources of information also vary widely. Some focus on a small geographic area, whereas other studies compile data from nationally representative sites. Some studies directly sample cohorts of elderly patients in a community; some rely on previously collected information by protective service agencies; others retrospectively review hospital charts of elders, looking for evidence for or documented suspicion of mistreatment. The following text will review some of the more pertinent epidemiologic studies to date.

One of the earliest surveys, by Block and Sinnott in 1979, utilized both primary sources (actual community elders) and secondary sources (medical and elder care professionals) to acquire prevalence data. They found that 4.1% of elders who replied as primary respondents reported at least one incident of abuse (1). The U.S. House of Representatives Select Committee on Aging in 1981 reported a similar prevalence of 4% on the basis of secondary data obtained from state agencies. This prevalence translates into an estimated 1 million abused seniors yearly (39). Other studies estimate the prevalence to be as high as 2.5 million (51).

The first somewhat large-scale survey was conducted in Boston in the mid-1980s by Pillemer and Finkelhor, who interviewed more than 2,000 elders and reported a prevalence of 3.2% (17). This study was one of the first to use clearly defined parameters for the mistreatments sought: physical abuse, psychological abuse, and neglect. These authors modified a previously validated scale popular in the family violence literature called the Conflict Tactics Scale to the specifics of elder abuse. This instrument consists of a brief series of questions designed to elicit evidence and frequency of actions or verbal assaults that might have occurred during a conflict with a relative, friend, or caretaker. Just one reported case of physical violence was sufficient for a positive response to physical abuse. The guidelines for psychological abuse were different. This maltreatment was limited to verbal forms of abuses, and at least ten instances in a person’s life after age 65 were required for a positive case of psychological elder abuse. The damaging effects of verbal emotional abuse appear to lie in the chronic nature of repeated infliction, not just once or twice, which explains why fewer instances of verbal assaults were not considered abusive. The assessment of neglect used a different sociological instrument called the Older Americans Resources and Services test, which evaluated ten activities of daily living to ascertain whether or not any aid was withheld. Once again, ten aspects of neglect were needed for a positive result. At these rates, the national estimate of abused elder Americans ranged from just over 700,000 to nearly 1.1 million. Because of the narrowly defined terms, this study may have actually underestimated this problem’s prevalence (51). In addition, an elder who reported fewer than ten separate incidents of verbal attacks or neglectful occurrences would have been excluded from the victim groups. European surveys of similar sample sizes reported comparable rates of abuse in the early 1990s, demonstrating that elder abuse is a global problem (11). These studies inquired additionally about financial or material exploitation as a type of mistreatment. Prevalence data are summarized in Table 10-4 (11, 17, 35, 52).

In 1996, the NCEA conducted the most comprehensive study on elder abuse to date, the NEAIS. The U.S. Department of Health and Human Services published its results in 1998 (39). The study’s fundamental goal was to determine the incidence of domestic elder abuse and neglect in the United States. Its design was quite elegant and its
conclusions well supported. The NEAIS estimated approximately 450,000 (range 211,000–689,000) cases of domestic elder abuse and/or neglect during the study year. This figure does not include incidents of self-neglect and rises to approximately 551,000 (range 315,000–787,000) when all cases are totaled. Alarmingly, adult protective services (APS) could have expected notification on a mere 20% of these cases. The NEAIS concluded that nearly 450,000 elders suffered domestic abuse or neglect in 1996. Of this, only 16% of cases were reported to APS offices. That leaves 84% of victims below the tip of the iceberg and unidentified by APS. In other words, more than five times as many new instances of elder abuse and neglect occur in domestic settings as those about which APS already knows. The figures improve slightly when self-neglect cases are included in the calculations, but they are still dismal. Seventy-nine percent of elder sufferers of all mistreatments, including self-neglect, remain unknown to an APS agency. It is worthwhile to examine this study in depth. For a thorough review of the NEAIS, refer to the appendix at the end of this chapter.

The NEAIS and other data collectors have compiled demographic information about the victims of abuse and the perpetrators to better characterize both groups of people. Drawing definite conclusions is difficult because of the many differences in study design, but some patterns emerge upon examination of the literature. The available data suggest that victims of domestic elder abuse and neglect are more typically older than 75 or 80 years, depressed, and to some degree unable to provide self-care. Perpetrators in general are more likely male and closely related to the victim. Abusers also have a high rate of alcoholism and substance abuse.

Age has been shown as a risk factor for mistreatment. NEAIS results show that seniors in the over-80 group are abused or neglected two to three times beyond their proportion in the general population (39). APS agencies reported that this group held wide majorities in all categories of maltreatment except abandonment. Earlier studies have also suggested this on the basis that the most elderly may have the most overall heath problems and be the most dependent and susceptible to maltreatment (2, 12, 17, 36). Although some recent studies have not found a direct link between frailty or dependence and the likelihood of abuse (13, 43, 53), it seems reasonable that an elder’s overall physical infirmity and dependence may increase susceptibility to mistreatment (42). With regard to gender, the NEAIS data strongly demonstrated a female majority among victims in proportional excess to population differences (39). Figure 10.1 demonstrates a 2:1 female predominance in published data for the successive years 1990 through 1996. Whether gender is truly a risk factor is still in question. Some studies demonstrate statistical significance of a female majority (53), whereas others simply reflect a trend (13, 43) toward this predominance. Others reveal the opposite: more men suffer reported mistreatments than women (17).