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 3–5 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;364:1263–72.

PSAP-VII • Geriatrics

117

Elder Abuse

the End Abuse Later in Life Act of 2011 has also been referred to a congressional committee for consideration. Other reports deemed substantiated in NEAIS were received Definitions Consensus is lacking with respect to what constitutes elder abuse. about five more were unreported to APS. spouse. family member. 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. and health care disciplines have identified the Elder Abuse 118 PSAP-VII • Geriatrics . friend. 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. but with some variation. intentionality. and policy-makers. neglect. Elder mistreatment takes many forms.g. as are acts by individuals considered incapable of intent. the EJA has authorized $777 million over 4 years for various activities and programs. “elder abuse is a single. financial. legislative bodies. training. only 16% were in APS files. the older adult may depend on someone for care or have a diminished capacity for self-protection. Of the almost 450. 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 elder’s basic needs or to protect the elder from harm. 62. One key provision establishes an Elder Justice Coordinating Council of government officials. or repeated act. or lack of appropriate action. thereby suggesting the victim is a weaker person mistreated by a stronger one. sexual. however. and self-neglect. 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. signed into law on March 23. Although no appropriation has yet been provided. In 1978. The definition adopted by the World Health Organization (WHO) stipulates that a trusting relationship exists between the abused and abuser. psychological.. the Elder Abuse Victims Act of 2011. but not to the extent of the states. In general. Vulnerability as a defining feature is introduced. elder abuse is distinct from criminal violence by strangers. The inclusion of victim vulnerability often appears in state statutes covering elder abuse.000 substantiated reports in 1996. for every case of abuse or neglect reported to authorities. occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person. 2010. Congress required each state to establish and operate an ombudsman program for longterm care facilities. 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. The term does not have a universally accepted definition. and resolving complaints made by and on behalf of facility residents. federal resources to combat elder abuse. Age 60 is the beginning of old age by federal designation. According to the definition of WHO. Other issues in the field include whether a single act counts or whether the abuse must be repetitive. distinguishing strangers from non-strangers is not always simple. represents the first legislation to specifically provide. the abusive conduct must be deliberate. A companion bill. This finding revealed that. investigating. Controversies about defining elder abuse have stirred debate among clinicians. has not yet been passed by the U. among other things. but vulnerability is not easily defined.problem. Reckless behavior is excluded. the six major types of elder abuse are categorized as physical.” By this definition. The EJA also authorizes grants to state and local APS agencies to support their activities. most APS agencies continue to be supported primarily by state and local funding sources. The Elder Justice Act (EJA). Senate. or vulnerability. researchers. the EJA authorizes grants to strengthen ombudsman activities and provide incentives for the training of direct care workers.S. or 65 years. Likewise. and whether the conduct has to result in harm or whether it is the conduct that matters.” If such a relationship (e. service provider) is required. and coordination activities. Among other things. A 1992 amendment to the original legislation authorized funding for elder abuse awareness. Some variations in how abuse is defined include the requirement for special relationship. The Council’s purpose is to make recommendations to the Secretary of Health and Human Services on how to coordinate the elder justice–related work of different agencies. For example. this piece of legislation would create an Office of Elder Justice within the Department of Justice. Most definitions include the infliction of some type of harm or deprivation and the responsibility of a specific person for the situation. Of course. 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. but state laws covering elder abuse refer to ages 60. For long-term care facilities. The functions of the ombudsman include identifying. Many organizations.

One percent of the sample population reported physical or sexual assault in the 5 years before the survey. and not all individuals would admit to being mistreated. nursing facilities is the On-line Survey. surveying by telephone has weaknesses including a lack of visual support. This study used a more liberal definition of abuse (theft was included) and required the event to come to the attention of the respondents. physical. There is a gap in estimates of the frequency of elder abuse and neglect.1% for potential neglect. care. Ombudsmen handle many different types of complaints in areas including. Respondents having suffered at least one act of violence since turning 65 years of age were at greatest risk of physical abuse. caregiver. or spouse in the past 5 years. Medicaid Fraud Control Units respond to allegations of abuse among nursing home residents in many states. and 5. 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 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.6% for sexual abuse. Verbal abuse emerged as the most widespread form of mistreatment. Of the cases then reported to state authorities. The incident rate of abusive events was 20.243 cases of alleged elder abuse were investigated by APS (29 states). The highest percentage of deficiencies in this category was for improper physical restraint (10. In a second national study. 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. A total of 192. 16.5%) suffered psychological abuse. 9% reported being insulted or put down by a family member.916 complaints of abuse. survey designs.0% experienced more than one mistreatment type.78% of facilities were cited for poor facility practices for reasons of chemical and physical restraints. The most common form of physical abuse was being pushed. 1.2% of substantiated reports occurred in long-term care facilities. Prevalence has also been calculated based on surveys of professional caregivers. In one study of people with dementia who lived at home. as well as neglect. Financial and physical abuse was reported by 3. however. In a 1999 telephone survey of family violence in Canada. 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. 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 note. the next most common type was having contact with family or friends limited. 3005 community-dwelling individuals aged 57 to 85 were asked about their experience with verbal. the actual incidence might be higher because not all APS agencies investigate abuse in this setting. followed by caregiver neglect. Victims may be afraid to answer openly or at all because the abuser is in the household.5% and 0. 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. respectively. or shoved. A database of more than 200. 0. residents’ rights. and financial abuse PSAP-VII • Geriatrics 119 Elder Abuse . Almost 25% of facilities received one or more deficiencies that caused actual harm or immediate jeopardy to residents. the results relied on victims’ disclosure of events. In 2009. 31. and definitions. State survey agencies enter facilitylevel information in the On-line Survey. The majority of victims (88.7 per 1000 nursing home residents. the average substantiation rate was 46% (24 states). the most common grievance was physical abuse. 7% of older adults reported experiencing emotional abuse by a child.6% for physical abuse. gross neglect. 1 in 10 community-dwelling adults age 60 years or older reported some type of abuse (excluding financial abuse) in the past year.in the past year. In the National Elder Mistreatment Study. The study collected data in the domains of physical and psychological abuse.S.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. About 6. abuse.6% for emotional abuse. Of the 12. hospitals. The home setting served as the location for 89. The types of emotional abuse varied but the most common was being put down or called names. 355 of the respondents provided data on both abuse numbers and outcomes.3% of substantiated reports (13 states). Self-neglect was the most common category of investigated reports. In 2003.78%). grabbed. Another source of data on the quality of care in U. and staff treatment of residents. Certification and Reporting System database after an on-site evaluation. the mistreatment rate by admission of their caregivers was 47%. Of interest. or exploitation. 29% were substantiated. but not limited to. For states that made available both investigated and substantiated reports.2% of respondents. or banks. In both the Boston and Canadian surveys. and financial exploitation (19 states). Certification and Reporting System. not all states were able to provide data for victims age 60 years and older. and quality of life. Prevalence Studies have reported a range of prevalence based on different sampling methods. 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. One-year prevalence by abuse type was 4.

Abrasions. and in various stages of healing. of an unusual shape or pattern (from knuckles or fingers). Clinicians may detect changes in the victim’s behavior such as withdrawing to a fetal position or repeatedly refusing personal care. and bruises are potential markers of physical abuse. The emotional health of the victim may be adversely affected and manifest as agitation. Bruising may be multicolored. involves the infliction of pain. If bilateral and on the arms. The context in which an injury or event took place must be considered. there may be threats of punishment. a problem potentially identified by the consultant pharmacist during the drug regimen review. or stranger) to the victim. or distress. and fractures. Clinicians should be alert to the possibility of abuse if caregivers offer implausible explanations or family members provide inconsistent stories. Avoiding eye contact with the perpetrator. Verbal acts including insults. On medical examination. Yelling at a resident in anger and insulting or swearing at a resident were the most common behaviors identified. and force feeding. treating them like infants. or bloody undergarments may be exposed. This section presents the definitions and indicators of the basic forms of elder abuse (i. Some 81% of respondents had witnessed at least one incident of psychological abuse against a resident. constitutes less than 1% of all cases reported to and substantiated by APS. Genital or anal trauma is an obvious sign of sexual abuse and may include abrasions.e. kicking. and displaying passivity may be behavioral indicators of this type of abuse. Because its impact may be visible to others. intimidation. familial. sexual. torn. The effects of psychological abuse present differently among victims. the time as the most common type of physical abuse.or overuse) and the improper use of restraints (physical or chemical) also constitute physical abuse by some definitions. also referred to as emotional abuse. older adults may be unable to exercise their rights and be otherwise forced to engage in or abstain from certain conduct. physical. although its inclusion in definitions. Other potential indicators of physical abuse include sprains. dislocations. victims may expose their injuries. and state laws is inconsistent. humiliation. Obvious examples of sexual abuse include unwanted touching. The perpetrators may also inappropriately engage the abused in nonviolent acts such as indecent exposure or lewd talk. A delay between the onset of an injury and the seeking of medical care may also alert clinicians to potential abuse. lacerations. Studies conflict regarding the most common relationship of the perpetrator (marital. The age of a bruise cannot be reliably predicted by its color. biting. Physical force includes behaviors such as pushing. Accidental falls are a leading cause of injury in the elderly. The indirect statement of “Don’t 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. bleeding. During pharmacists’ counseling on self-treatment. redness. anguish. fear. Single or multiple patches of alopecia may be the result of hair pulling. Patterns of bruises on the breasts or inner thighs may also be a physical indicator of sexual abuse. confusion. coerced nudity. or social withdrawal. recurrent genital infections. and financial) and neglect. As a result. A victim may have difficulty walking or sitting. be explained by reasons other than physical abuse. and sexual assault such as incest. physical abuse is the most obvious form of harm. or unexplained sexually transmitted diseases. Recognition of psychological 120 PSAP-VII • Geriatrics . rape. Sexual abuse is usually defined as sexual contact of any kind without the individual’s consent. flinching on approach.Sexual Elderly people are not immune to sexual abuse in the domestic or institutional setting. or harassment are examples. abandonment. A change in eating pattern or sleep disturbance may become evident. Types of Abuse Abuse against the elderly takes place in many ways. sometimes categorized with physical abuse. literature. psychological. or withholding emotional support. A single sign or combination of signs may. Elder Abuse Psychological Psychological abuse. and tears. This type of abuse also includes subjecting older adults to isolation. or sodomy. Sexual abuse is likely underreported to authorities. It is reasonable to investigate how the elder sustained the injury if suspicion exists. with common sequelae including bruises and fractures. pinching. The bodily harm or pain that ensues may be by the abuser’s own hand or by use of an object. Most cases of elder abuse involve a one-to-one victim/ offender relationship. Abuse of a nursing home resident may be marked by chemical restraint with overuse of psychotropic drugs.. In addition. The inappropriate use of drugs (under. and 40% had committed such an act during the same period. This type of abuse. or the injuries may be clearly visible. This includes situations in which older adults are unable to consent for reasons such as cognitive or communication impairment. There is also an explanation of self-neglect. stained. Physical Physical abuse is an act of violence and can encompass a broad range of conduct. or deprivation of basic needs. striking. Most victims of sexual assault are women. The abused elder may directly report or hint of sexual assault. Older adults may have diverse expectations and perceive treatment by family or caregivers differently. in some situations. the bruise may suggest the elder has been grabbed or shaken. swelling.

including general decline. According to the National Center on Elder Abuse. the elderly may be attractive targets because of not recognizing the value of their assets. These obligations and duties typically involve basic necessities such as food. the development of malnutrition or pressure sores in nursing home residents who do not receive needed help with eating or turning. oral dental care.g.g. Neglect may be referred to as active if the needs of the elder are deliberately unmet. Soiled clothing. or neglecting household maintenance. the definition excludes a situation in which a mentally competent older adult understands the consequences of decisions and exercises personal choice. Victims may be unaware that they are not following instructions appropriately because their drug therapy is the caregiver’s responsibility. with some cases minor and others seriously threatening personal health or safety. Self-neglect may even be an independent risk factor for death. hearing aids. range of motion exercises. 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. overlap with those of neglect by others. Abandonment endangers the welfare of the older adult if he or she is without adequate provisions. and regular bathing. The term refers to refusal or failure to provide oneself with the goods or services to meet basic needs. and the interviewer may have to rely on observation because of a victim’s reluctance to talk openly. drug therapy. and protection. Social isolation is common. For example. respectively). In the absence of intent. or a urine or fecal smell may signal poor hygiene. Signs in the victim. is unacceptable at any age.. Clinicians may have Neglect Neglect means refusal or failure to fulfill any part of an individual’s obligations or duties to an elder. also referred to as material abuse or exploitation. At-risk elders may be living in conditions of squalor. One indicator of exploitation may be older adults living without the amenities or services they can clearly afford. abuse may be difficult. Pharmacists taking drug histories may discover that a patient’s nonadherence is because of a caregiver’s preference to appropriate funds for personal use rather than purchase the elder’s drug therapy. One challenge is to identify who. Unfortunately. Self-neglect Self-neglect may be more common than any other form of abuse or neglect by others. it has been described as the inappropriate use of an elderly person’s funds or resources for personal gain. the elder may have unmet needs pertaining to medical care or drug therapy. accountability for the conduct may exist regardless of whether a caregiver and elder live in the same residence. the caregiver may be unable to provide the care for reasons such as a lack of physical strength. lice infestation. neighbors or home care providers may be first to recognize the problem. has responsibility for caregiving PSAP-VII • Geriatrics 121 Elder Abuse . or contract. In this respect. water. An older adult with inadequate or inappropriate clothing for the weather may draw attention. knowledge. Every case is different. or order of the court. or misappropriation of funds. Elders with dementia or other cognitive impairment are especially vulnerable to this abuse type. shelter. is sometimes considered a type of neglect or placed in its own category. misuse of conservatorship. eyeglasses. Indicators of neglect are usually characteristic of the goods or service not provided (e. scheduled toileting. Financial Financial abuse is also a significant problem. The unwanted agreement may be a check. A typical example is forging or forcing the elder’s signature through coercion or any undue influence. maturity. if anyone. canes. Another sign of neglect may be absent or faulty assistive equipment (e. inconsistent refills or outdated prescriptions may suggest mismanagement of a dependent elder’s drug therapy. wheelchairs) if required. This type of mistreatment. neglect is termed passive. children). In the pharmacy. special relationship (spouse.. multiple insect bites. or lacking a network of people for support. One concern that surfaces in the decision to report a suspicion of neglect is whether the situation is selfinflicted versus the fault of others. Missing property or belongings may also be apparent during a visit to the elder’s home. factors such a financial gain may motivate active neglect. Of note. Such behavior leaves the older adult vulnerable to adverse effects from sudden withdrawal or restarting a drug at the full dose. Finally. voluntary assumption. No formal or informal caregivers are involved in cases of self-neglect. will. 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. being uncomfortable with financial matters. Financial abuse is often accompanied by physical or psychological abuse. Suspicious bank account activity such as large withdrawals or frequent transactions may signal concerns. power of attorney. the desertion of a vulnerable elder.because of contractual agreement (paid person). hoarding belongings. 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. People who interact with older adults may be able to identify activity that suggests financial abuse. As a result. Abandonment. hygiene. untreated medical conditions or unexpected deterioration in health may raise the suspicion of neglect. or resources. Other cases involve the theft of money or property without knowledge or authorization.

In general. A second challenge that clinicians face is ambiguity about an older adult’s capacity to make decisions. abnormal physical performance and disability have been found to be correlates of self-neglect. If an elderly person has a limited ability to understand financial issues. In addition. Screening for elder abuse presents certain challenges. Although frailty diminishes the ability to defend oneself or escape abusive circumstances. Guardianship and involuntary placement fall under this measure of action. In busy clinical settings. and state statutes do not always mandate the reporting of self-neglect. In one study. A poor social network and isolation may increase vulnerability for all forms of abuse including self-neglect. The APS will assess the conditions. together with certain caregiver characteristics. APS programs have a duty to act if there is lack of capacity and harm or the risk of harm to the person. the dependency on others may create a vulnerable situation. including risk of harm and capacity to make decisions. Depression and alcohol dependence may increase the risk of self-neglect among older adults. Victim Considerations Risk Factors in the Domestic Setting Research has identified factors that place the elderly at risk of abuse. Elders who show signs of self-neglect and who are deemed competent have the right to refuse services. If the abuser is on the scene. however. the least restrictive but effective interventions are used by APS. it requires training to administer. The ethical issues that arise include allowing the patient to choose freely (autonomy) versus protecting the patient from harm (beneficence). because selfreporting is unlikely.insufficient information to completely assess the situation. Lack of access to trusted people in whom to confide may reduce the opportunity for intervention. Cognitive impairment may be another predictor of elder mistreatment. Screening Health care professionals are in a position to observe and interact with elder abuse victims. Other instruments have not gained widespread use. Cognitive impairment interferes with the ability to use standard screening tools. and no formal study has validated it. Social isolation also reduces the likelihood that health care professionals will recognize the issue and offer help. Screening instruments have been developed. A process should be in place to provide appropriate and adequate follow-up. The relationship between physical impairment and vulnerability differs across abuse types. Although a starting place for investigation.S. screening only once may be inadequate. research has produced contradictory findings. but interpretation of the findings remains uncertain. If engaged in screening. the instrument is lengthy. legal jeopardy. the guidelines included a list of closed-ended questions for use by physicians. The Brief Abuse Screen for the Elderly contains five standard questions suitable in emergency or outpatient settings. Case investigation of false-positive tests may lead to psychological distress. grabbing. In emergency situations. living alone increases the likelihood of self-neglect. Interviewing the elder and caregiver about experiences and risk factors may be an alternative approach. The possible indicators must be distinguished from age-related changes in the body and medical conditions. The U. The 1992 American Medical Association guidelines suggested that all community-dwelling older adults be screened for family violence. they should ask questions in a nonjudgmental manner and Elder Abuse 122 PSAP-VII • Geriatrics . False-negative tests may impede the identification of at-risk elders. family tension. confidential setting. Preventive Services Task Force’s 2004 statement found insufficient evidence to recommend for or against routine screening of older adults or their caregivers for elder abuse. The challenging behaviors associated with dementia. data on the effect of interventions are insufficient. However. in part. A higher rate of physical and psychological abuse has been reported among people with dementia. health care professionals should exercise clinical judgment and concern for the safety of older adults and be aware of the signs of elder abuse. Some studies suggest that a shared living arrangement increases the risk of abuse and neglect. Moreover. Higher self-neglect severity has been positively associated with lower levels of physical function. In contrast. a greater possibility exists for contact including conflict or tension. with older adults residing alone at lowest risk. difficulty maintaining their self-care tasks is at the heart of the problem. pushing or shoving. Options include engaging family in the process and making referrals to community organizations. they may be the only individuals in a victim’s life who have the opportunity to intervene when a suspicion arises. the Task Force could not establish the balance between the benefit and harm of screening. Regardless. As such. In making this determination. and shouting or yelling. However. Physically and verbally aggressive acts that may incite abuse by caregivers include throwing something that could hurt. may be causative. it may be necessary to seek legal proceedings to protect the older adult. insulting or swearing. brief screens are preferred because of time constraints. Abuse may occur as a single act or take time to escalate to a detectable level. In these cases. or loss of autonomy for the victim. There is no absolute representation of abuse or typical case of neglect. people with dementia who directed certain behavior at the caregiver predicted whether the caregiver mistreated the individual. Asking caregivers directly about the difficult behaviors shown by a care recipient may be useful.

In some circumstances. but others are unwilling or unable to come forward. poor health and dependency may be reasons for vulnerability. or pushing others gave rise to the physical and psychological abuse of the resident. the association was found for women who reported verbal abuse even in the absence of physical abuse. Some victims seek treatment. all abuse types were more common in women except for abandonment. Racial differences in elder mistreatment remain to be established in reliable national studies. abusers deprive elderly of needed care if they stand to gain shelter. with the actual abuse left to be discovered. the older adult becomes socially isolated because of fear or shame. The mechanism remains in doubt because the immediate cause of shortened survival does not seem to be the injury itself. food. Fears about exposing family shame or inciting conflict were reasons for lack of reporting. Other offenders include siblings. but the link to a specific abuse type must be addressed in future research. Pennsylvania. permanent placement in a nursing home may be necessary to separate the victim and abuser. Those in the 60–64 and 65–69 age groups had the lowest reports in all categories of abuse. Abusers are both men and women of any age. Women may be more likely to be victimized. Differences in the perceptions of abuse and in help-seeking behaviors among nonwhite older adults may influence the number of investigations. kicking. and lower optimism. In the NEAIS. Exposure to abuse may be associated with reactions including anger. The effect of victims’ age. more than 30% of emergency department visits by elders who had been physically abused resulted in hospital admission. African Americans were at heightened risk of financial exploitation and psychological abuse compared with individuals of other races. Potential explanations are that women outnumber men and women may suffer more serious injury. In one study. service providers. a greater proportion of older men reside with someone of advancing age. or transportation or if they otherwise stand to benefit. Often. In the NEAIS. Victims of sexual abuse are usually women. be recognition of consequences of such treatment. The extent to which the abused use the health care system is not entirely known. In the framework of resident-to-resident violent incidents. Subtle signs may be missed or mistaken for another problem. Of note. In the emergency department. Mental health problems on the part of caregivers may predict abusive conduct. Of note. greater social strain. Other behaviors associated with provoking an attack by another resident included verbal aggression and wandering. in truth. the presentation has not been linked to any specific injury type or chief complaint. The NEAIS report found that the abuser was a family member in almost 90% of the reported cases in which the abuser was known. 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. The abused may experience a loss of confidence in their own abilities and see themselves as powerless. which increases their own risk. although the role may differ by abuse type. the risk of mistreatment increased with advancing age. sex. By contrast. grandchildren. adult children or spouses perpetrated the abuse. Individuals older than 80 years accounted for more than one-half of the reports of neglect. Adult children who abuse their elderly parents are likely dependent on the victims for emotional support or financial assistance. disappointment. In a populationbased survey of adults age 60 years and older in Allegheny County. abuse and self-neglect have been associated with shorter survival in studies of community-dwelling adults 65 years or older. Perpetrator Considerations Risk Factors in the Institutional Setting Characteristics that place nursing home residents at greater risk of abuse are less well known.effects among postmenopausal women who reported abuse included greater depressive symptomatology. more recent research found young-old elderly (< 70 years) at greater risk of mistreatment than the old-old group. In two-thirds of the cases. Physical health of the abused may suffer because of bodily injury. In a small percentage of cases. although some studies have revealed no difference in rates on the basis of sex. A dependent state of affairs tends to exist between abuser and abused. or race on abuse is complex. Rather than age alone. In one study. A longer length of hospital stay and higher cost of care may be outcomes for those who sustain harm necessitating admission. and old or new friends. or guilt. adverse mental health PSAP-VII • Geriatrics 123 Elder Abuse . but men are more likely to commit physical abuse. Functional impairments in activities of daily living and dependence on care providers may be important risk factors for abuse by staff. Finally. Risk Factors in the Domestic Setting Certain characteristics of the perpetrators may be risk factors for elder mistreatment. a case-control study revealed that residents who were injured were more physically independent and therefore more likely to place themselves in harm’s way. Those who carry out abuse are not defined by a single cultural or economic background. In a study of 90 elderly women. Korean subjects were less likely to perceive a situation as abusive compared with other ethnic groups. Psychiatric illness and an underlying personality disorder Consequences The health care professional’s detection of abuse may.

together with external stressors. Good hiring and staff screening practices by a facility may reduce the likelihood of elder mistreatment. Older adults may be reluctant to take legal action or be unaware that the judicial system can help. Mandatory reporting may not encompass the mentally competent elderly capable of reporting or those who self-neglect without involvement of a third party. Although a federal standard does not exist. Pharmacists are explicitly identified in the inventory for a select number of states. or both. and many individuals manage without inciting violence. or heavy workload may lead to a stressful work environment and inappropriate behavioral management. respectively. may gradually overwhelm an individual. The people required to report are governed by the laws of the individual state. volunteers. a claim for elder abuse or neglect may also be placed. As a mechanism of neglect.” whereas others provide a listing of responsible individuals including law enforcement officials. by a caregiver’s own substance abuse problem. theft. Civil restitution may also be sought to compensate the victim for his or her loss. and reporting obligations. The exact punishment often depends on the type and extent of the harm done. Younger staff members and those with negative attitudes about residents may be more likely to perpetrate psychological abuse. According to the ecologic model. the impaired judgment associated with heavy alcohol consumption may translate to violence directed at elders. The overuse of psychotropic drugs may cause excessive lethargy. The diversion of a dependent person’s prescription narcotic analgesics may be caused. Depression has been specifically implicated in cases of physical abuse.may be causative in some cases. and its documentation triggers an intervention. A critical part of the monthly drug regimen review process done by consultant pharmacists is monitoring. imprisonment. Requirements Anyone can make a voluntary report of suspected elder abuse or neglect. fraud. imprisonment. The burden of caring for a dependent elder. daily consumption was more than twice as likely among family caregivers who committed abuse than in those who did not. restraints. battery. In addition. high turnover. residents may also be mistreated by visitors. they are subject to annual surveys and federal deficiency citations for poor facility practices or quality of care. however. Feminist and political economic theories address the imbalance of power in relationships and the marginalization of elders in society. For any drug. family. a physician’s order must exist. burnout and resident aggression are contributing factors. Most long-term care facilities participate in Medicare and/or Medicaid programs. victims of child abuse may show the same pattern of behavior when they grow older). in part. and slow pace of the legal process. As such. The transgenerational theory describes family violence as a learned behavior that is passed from one generation to the next (i. Penalties exist for failure to report. and restitution are common penalties for breaking the law. The loss or suspension of an individual’s professional license is a possibility. confirmatory evidence is lacking. unless clinically contraindicated. or rape. Abuse may arise from caregivers out of resentment for what is deemed a duty rather than a privilege. The situational model recognizes caregiver stress as a reason for elder mistreatment. caregivers who drink excessively may not meet their obligations to those who depend on them. According to one study. Retrospective studies have found that abusive family caregivers are more likely than non-abusive ones to suffer from depression. The assessment must ensure residents who take psychotropic drugs (antipsychotics and sedative-hypnotics) have a medically valid indication and undergo gradual dosage reductions. violence results from the interplay of individual and interpersonal factors in the social context. Risk Factors in the Institutional Setting Elder abuse and neglect in institutional settings is typically viewed as involving direct care workers. Federal tags may be issued for not following specific regulations governing matters such as pressure sores. For employees of nursing homes who engage in physical or psychological abuse. In addition. Improper chemical restraint of elderly nursing home residents may be dangerous and even deadly. licensure ramifications for some professionals may be found. Alcohol use and abuse has been identified to be more common among offenders than nonoffenders. Elder Abuse 124 PSAP-VII • Geriatrics . Pharmacists should be familiar with their state’s laws. difficulty of proof. Fines. Depending on state statutes that define the protected population and the prohibited conduct. most states have mandatory reporting requirements. unnecessary drug therapy.. and use of psychotropic agents. Some states specify “any person. Mandated reporters who knowingly and willfully fail to report may be charged with a misdemeanor punishable by a fine. and other residents. Challenges faced by victims in making the decision to go to court include a lack of financial resources. Theories to explain abusive behavior toward elderly people are evolving. and health care professionals. social service providers. Other suggested risk factors include inadequate training on how to respond appropriately to difficult situations and a lack of administrative or supervisor oversight. definitions.e. however. Inadequate staff. Reporting Consequences Offenders may face criminal charges that correspond to the form of abuse including assault.

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.fraud. and case substantiation. Regardless. As part of the EJA. Oral reports made by telephone or direct communication may have to be followed by a written report. Although disclosure is not Table 3-1. Unfortunately. and information related to the nature and extent of the alleged abuse or neglect. APS agencies are largely responsible for investigation. health care professionals should only provide relevant data within the scope of the reporting statute. provides locator to find office in the community Provides tips to avoid Internet and telemarketing fraud. Some states require that mandated reporters make the claim immediately or within a specific time. 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.aarp. online complaint form available Provides caregiving information and advice. Resources for the Elderly and Their Caregivers Resource Eldercare Locator www.org National Center on Caregiving (NCC) www. To ensure patient safety. Violence may escalate to ensure that the victim does not provide any damaging information to an authority. A hotline for reporting abuse is usually available. 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. The time frame lengthens to 24 hours if the event does not result in bodily injury. In reality. there is a need to rule out false accusations of elder mistreatment. Pharmacists can also help individuals who want to make a report understand the process better. intervention options once APS becomes involved include monitoring the living arrangement.gov/ Alzheimer’s Association www. a violation of the Health Insurance Portability and Accountability Act. The content of the report should generally include the following: name. and moving victims to a safe setting if necessary.caregiver. scams. 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. Otherwise. Although the victim may feel anger or betrayal. An emergency report is one in which an immediate risk of further harm to the individual or others exists.org American Association of Retired Persons (AARP) ww. clinicians should help them understand the process.alz. Among those who report a suspicion of abuse. name and address of the alleged offender. reporters who act in good faith are generally immune from criminal or civil liability as well as professional disciplinary action. After intake of the information. caseworkers generally investigate emergency situations within 24 hours and all other reports within the state’s regulated time frame. he or she should contact 911 or local law enforcement. To whom the report is made differs from state to state. reports are generally subject to confidentiality provisions except by the reporter’s written consent or order of the court. The contact information for the reporting person may also be included. risk assessment. money. Pharmacists can help individuals understand why they should care about elder abuse and how widespread the problem is.org National Consumers League’s Fraud Center www. and counterfeit drugs. In fact. reports may trigger withdrawal of services rendered by the accused caregiver. If the clinician believes that someone is in a life-threatening situation or immediate danger. and relationships. helps caregivers locate support services in their communities Provides information on topics including health. Reluctance may come from concerns about breaching patient confidentiality. the local APS office or area agency on aging receives the report for abuse that occurs in private homes. The person believed responsible for the mistreatment also may be interviewed. age. individuals associated with a longterm care facility are required to report to law enforcement the suspicion of crime immediately. removing perpetrators from victims’ homes. Often. includes articles on scams and frauds 125 Elder Abuse . Risk assessment involves direct contact with the alleged victim in the home or other place of residence. there may be fear of risk to the victim when the offender learns about the investigation. There may be unwillingness to be involved in legal proceedings or concern about malpractice claims by the suspected abuser cleared of any wrongdoing. the option of anonymity usually exists.eldercare. and address of the adult who is the subject of the report.

Although the program’s role is viewed differently across the country. thus. These individuals work with the victim to gain cooperation for outside help by explaining the benefits. For victims who lack the capacity to understand their circumstances. provides state directory of help lines. Pharmacists are uniquely positioned to encounter abuse or neglect in the community with the increasing number of older adults who use more drug therapy. Elder Abuse Resources for the Health Care Professional Resource National Center on Elder Abuse (NCEA) www. but the oath of a pharmacist includes the promise to consider relief of suffering a primary concern. Depending on state statutes. As such. residential care facilities. home repair and modification. books.aoa. The local ombudsman’s office may be able to assist with grievances made by. and multiple reporting agencies. Although not consistently considered a form of abuse. hotlines. the courts may assign temporary guardians or grant orders for protection. and records may be sought from other sources including the pharmacy. and assisted living facilities. the courts may respond with some oversight. intervene when the suspicion of abuse arises.gov Description Offers information on statistics of abuse and neglect and description of abuse types. In addition. The ombudsman maintains the complaints as confidential unless the resident’s consent is given. a determination on the case is made. the reports are not always forwarded to APS. For example. a variety of supportive services may be arranged such as meals. underreporting. Cases with supporting evidence are categorized as substantiated and open for a service plan. 126 PSAP-VII • Geriatrics .ncea. Thereafter.Table 3-2.inpea. Instruments have been developed for screening.aoa. Estimates of the prevalence of elder abuse and neglect are complicated by differing definitions. and advocacy. and educate others about this hidden problem. however. As the risk factors for both victims and offenders emerge from ongoing research. Pharmacists must listen carefully to patients. provides contact information for local and regional www. identifies upcoming www. Workers from APS will continue to monitor the situation and reexamine the need for different interventions until the case is closed. self-neglect represents a unique phenomenon and common reason for APS referrals. or on behalf of. Pharmacists may not be designated mandatory reporters in every state. offers links to resources for health care professionals Clearinghouse on Abuse and Neglect of the Elderly Provides computerized catalog of elder abuse literature. Cases deemed unsubstantiated or indeterminate because of lack of or insufficient evidence are closed. or medical and mental health services. These facilities include nursing homes. As an advocate for patients. Table 3-1 and Table 3-2 contain examples of resources for older adults and health care professionals. no single model is universally accepted.org/ombudsman ombudsmen in the state Administration on Aging (AoA) Provides information on aging statistics and action to take if abuse www. Their lifestyle is a matter of personal choice.cane. individual residents of long-term care facilities.gov or neglect is suspected. pharmacists may be a source of contact and support for victims in the institutional setting. or pest and animal control. cleaning. the state ombudsman is concerned about violations of residents’ rights and poor quality care.edu transcripts.ltcombudsman.net conferences complaints. In general. Theoretical explanations of why elder abuse occurs have been suggested.udel. but the effectiveness of these methods for use in health care settings and the outcomes of interventions are not yet established. elder abuse prevention strategies may be further developed. and videos International Network for the Prevention of Elder Provides information on the global problem of elder abuse through Abuse (INPEA) research. Referrals might be made for home health care. fiscal management. Collateral interviews may be conducted. transportation. state survey agencies. agency reports. education. or law enforcement. legal representation. and elder abuse prevention resources National Long-Term Care Ombudsman Resource Describes the role of ombudsmen and lists nursing home residents’ Center rights. including (CANE) peer-reviewed journal articles. pharmacists must be knowledgeable about mistreatment and accept the obligation to protect vulnerable older adults. competent victims have the right to accept or reject any or all services APS offers. a key responsibility is to investigate and endeavor to resolve Elder Abuse Conclusion Violence against the vulnerable elderly exists. hearing www.

Sixteen percent of longterm care staff reported committing considerable psychological abuse.6% for psychosocial abuse. All participants were interviewed in their homes and asked about demographic characteristics and potential risk factors for mistreatment. Multivariable analysis also found a significantly increased risk of overall mortality for reported abuse.302:517–26. Participants were 75 years and older with a mean age of 81. Amstadter AB. in fact. mortality risk was lower. Reports of selfneglect and abuse are based on the records of social services agencies.9 years. Selwood A. 1544 cases of self-neglect and 113 cases of abuse were reported from 1993 to 2005. Herbert L. 4.37:151–60. 4. Dong XQ. Frailty and Dependence in Girona Study Group. One in 10 participants indicated they had experienced some type of abuse (emotional. Mortality risk associated with reported and confirmed self-neglect was not limited to any single cause of death. Low social support was the most consistent correlate of mistreatment across abuse types. 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.7% for financial abuse. Increased mortality risk with either self-neglect or abuse was found regardless of cognitive and physical function. Planas-Pujol X. Vilà A. Beck T. Multivariable analysis revealed that reported self-neglect was associated with a significantly increased risk of 1-year mortality.1% for neglect. 1. One-third of family caregivers reported involvement in significant abuse. physical. 4. 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. The final part of the study protocol included administering the American Medical Association Screen for Various Types of Abuse or Neglect.2% to 27. The prevalence of overall abuse ranged from 3. Living with other family members. Fortynine studies met the inclusion criteria. population-based cohort study. the authors took steps to increase the likelihood of disclosure. There were 4306 deaths during a median follow-up of 6. 927 deaths occurred among those with reported self-neglect during a median follow-up of 0. López-Pousa S. The prevalence of any type of suspected abuse was 29. The authors suggest that whistle-blowing would help improve reporting in this setting because more than 80% have observed the occurrence of abuse. Simon M. Twenty-four cases presented with two types of suspected abuse.7 years. although thorough in its analysis. sexual. and not all suspected cases come to their attention. Prevalence and risk factors of suspected elder abuse subtypes in people aged 75 and older. The specific behaviors of self-neglect and subtypes of abuse associated with mortality risk could not be identified. Am J Public Health 2010. might have modified mortality risk. A lack of consensus on what constitutes an adequate standard for validity of abuse measures limited the inclusion of studies in this research. including interpersonal and domestic violence . In this study. That the study excluded both older adults without the cognitive impairment to consent and those without a landline telephone limits generalization of the results. This study. self-neglect is not mandated for reporting. 127 Elder Abuse . In Illinois. Spain. Previous experience of traumatic events. and 0. Although self-reporting introduces the potential for bias. Juvinya D. and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Vilalta-Franch J. receiving help from social services.5 years. possibly because of differences in definitions. The prevalence estimates of elder abuse subtypes contrast with those of other studies. Almost one-fourth of dependent older adults reported significant levels of psychological abuse.8 year. The prevalence of elder abuse and neglect: a systematic review. Fulmer T. a randomly selected national sample of community-dwelling adults age 60 and older was surveyed to estimate prevalence and assess correlates of mistreatment.6% for physical abuse. All participants were interviewed by telephone and asked questions about demographic characteristics and potential variables that might contribute to mistreatment. Through linkage with social services agencies. Illinois. has limitations. 2. family should be routinely asked about abuse. Resnick HS. but only seven met the authors’ criteria for a valid and reliable measure of abuse. Steve K. and not having a trusted person increased risk of neglect. The prevalence was 5.3%. or sexual abuse) or potential neglect in the past year. Only a small proportion of abuse (less than 1%) was reported to APS. 15. Elder self-neglect and abuse and mortality risk in a community-dwelling population. et al. et al. participants of the Chicago Health and Aging Project were divided into three groups: elder self-neglect. The authors conclude that the vulnerable elderly and PSAP-VII • Geriatrics Acierno R.100:292–7. Older adults who needed assistance with activities of daily living were more likely to be victims of verbal abuse and financial exploitation. These interventions themselves.Annotated Bibliography 1. Mendes de Leon C. After this period. Prevalence and correlates of emotional. Livingston G.2% for psychosocial abuse. Muzzy W. Age Ageing 2008. The prevalence by suspected subtype was 16% for neglect. with a mean age of 71.1% for physical abuse.5% on the basis of general population studies. J Am Geriatr Soc 2009. Psychological These authors performed a systematic review of studies measuring the prevalence of elder abuse or neglect. 3. elder abuse. and 0. Garre-Olmo J. but it remained increased. Six percent of older adults reported significant abuse in the past month. JAMA 2009. or neither.57:815–22.6% for sexual abuse. This cross-sectional study described the prevalence and risk factors of suspected elder abuse subtypes in a representative sample of inhabitants of Girona. In this prospective. physical. Individuals suspected of suffering from cognitive impairment and dementia were excluded. Hernandez MA.was associated with an increased likelihood of emotional and sexual abuse. Data were collected from 5777 adults 60 years or older. Cooper C. All participants were age 65 or older and resided in an urban community on the south side of Chicago.

The APS workers may not have referred patients because of the requirement that they subsequently participate in interdisciplinary team meetings. They also had longer lengths of hospital stays (7. Fam Med 2005. Vega M. The most common type of mistreatment coded was neglect (45.9%). and intimidation perpetrated against a victim age 60 or older. Between the two groups. Am J Public Health 2007. Study limitations included missing data and referral bias. Johnson MS. Connecticut. single people. Kelly PA. This publication provides a brief review of victim and abuser demographics based on previous literature on elder abuse. 5. Kennedy RD. Pillemer KA. a self-report questionnaire was mailed to 250 family physicians and 250 general internists in Ohio. followed by physical abuse (17. the cohort members not seen by APS served as the reference group.6 days). Lachs MS. A subset of the sample had been seen by APS for suspicion of mistreatment. Further restricting cases to those with a one-to-one victim/offender relationship resulted in a sample of 87. Elderly in America: a descriptive study of elder abuse examining National Incident-Based Reporting System (NIBRS) data. This longitudinal study examined mortality in community-dwelling older adults who were participating in the New Haven. respectively. This study compared hospitalizations coded with diagnoses of elder abuse or neglect with all other hospitalizations of adults age 60 and older. Walsh JA. Some workers might also have referred only their most difficult clients. The small number of cases coded for elder mistreatment limited analyses. 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. Women were more often victims of elder abuse than men. and 70% were women. The most common form of abuse was simple assault (53%). Not all data may have been entered by clinicians. and older adults with moderate to severe cognitive deterioration were excluded. possibly because the study did not control for all confounders. knowledge. Turner M.S.97:1671–6. The criminal justice definition used in the study does not account for all forms of elder abuse. training. Charlson ME. Williams CS. Burnett J. Because the sample represented a rural area. no investigation revealed injury as the immediate cause of death. and attitudes of primary care physicians. Transfer to a facility rather than home was 3–4 times more likely among elderly patients who had a code for mistreatment. In this study. simple assault. 5. Most incidents occurred in the victim’s residence (74%) and resulted in no injury to the victim. 9.21:346–59. JAMA 1998. The authors theorize that self-neglect stems from executive dysfunction. The eight-page survey requested demographic. A second limitation of the study was that physicians might have been unaware that mistreatment existed or contributed to death. Pickens-Pace S. A higher percentage of financial abuse was seen in adults 85 years and older. J Elder Abuse Negl 2009.21:325–45.280:428–32. Rovi S. cohort of the Established Population for Epidemiologic Studies of the Elderly. Krienert JL. However. and those with a low Mini-Mental State Examination score. O’Brien S. The data from 994 hospitals in 37 states were weighted to produce national estimates. 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. As part of the team’s evaluation. 8. subjects with sustained verified abuse and/ or neglect had poorer survival (9%) than those with no contact with APS (40%). Goodwin JS. As a primary diagnosis. 6. and female victims were more likely to experience intimidation. many patients were too impaired to complete tests.cases reported to law enforcement and data in the 2000– 2005 National Incident-Based Reporting System. One study limitation was the reliance on voluntary reporting of events.6 years. and some patients refused to participate. Mouton CP. Most victims of elder abuse were in the 60–69 age group. Male victims were more likely to experience aggravated assault.6% of the time.0 days vs. At the end of a 13-year follow-up.37:481–5. hospitalizations with elder abuse and neglect diagnoses. Elder abuse and neglect: the experience. The mortality of elder mistreatment. Seventy-seven percent of the patients who participated had some impairment in activities of daily living based on the physical performance test. generalizability of the results is limited. Race and socioeconomic status did not differ significantly between the two groups. abuse was positively associated with living alone and depressive symptoms. Abnormal scores on the Mini-Mental State Examination (less than 24) and clock drawing test (2 or less) were found in 50% and 58. One study limitation is that self-reported abuse was subject to recall bias and unsubstantiated.7%). a battery of assessment measures was performed on the 460 patients age 65 and older. 20002005. resulting in an inability to perform activities of daily living. A child relationship constituted the largest proportion of family offenders (24%). Selection criteria limited cases to aggravated assault. Most offenders of elder abuse were men (72%). 7. 128 PSAP-VII • Geriatrics . abuse or neglect was identified 13. J Elder Abuse Negl 2009. The study examined data from elder abuse Elder Abuse Dyer CB.422 incidents. another was that not every state participates in the incident-based reporting system. There were 268 hospitalizations coded with elder mistreatment in 2003. Mapping the elder mistreatment iceberg: U.9% of the patients who took the tests. Self-neglect among the elderly: a model based on more than 500 patients seen by a geriatric medicine team. The sample was randomly drawn from the membership lists of the American Academy of Family Physicians and the American College of Physicians. The average age of the patients was 75. Male victims were more likely to be abused by both acquaintances and strangers than female victims. Chen PH.

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. Walker Z.7 years (range 24–92 years) participated. swearing. and practice information. Selwood A. For those who encountered a case but did not make a report. More than one-half of the caregivers (52%) reported some type of abusive behavior. Blanchard M. Cooper C. useable data. 220 caregivers with a mean age of 61. and 13% for another relative. the most common reasons were that the abuse involved subtle signs (44%). This cross-sectional survey evaluated the prevalence of abusive behaviors by family caregivers toward patients with dementia. Sixty-nine percent of those responding reported no exposure to elder mistreatment in the preceding 12 months.board certification. insulting. Livingston G. Although only 23% of respondents perceived elder mistreatment to be a significant problem in their patient populations. 33% for a spouse. BMJ 2009. with 216 family physicians and 176 internists providing complete. and the physician was unsure of reporting procedures (21%). Abuse of people with dementia by family carers: representative cross sectional survey. The authors call attention to the need for continuing medical education on elder mistreatment for primary care physicians. Fifty-six percent were caring for a parent. the victim denied mistreatment (23%). 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. Verbal abuse was most often reported and included screaming. It also asked questions to assess the experience. and using harsh tones with the care recipient. knowledge. Only three caregivers reported that physical abuse sometimes occurred. 98% agreed that more should be done to educate physicians. yelling. The response rate was 78%. PSAP-VII • Geriatrics 129 Elder Abuse . 10. In all. and attitudes of primary care physicians toward elder mistreatment.338:b155. Blizard R. The authors conclude the article with the importance of asking about abuse to safeguard the vulnerable elderly.

Elder Abuse 130 PSAP-VII • Geriatrics .

malnutrition. A. One year later. B. C. She is married with children and has an alcohol abuse problem. Nonmaleficence. most at risk of elder mistreatment? A.F. the case of self-neglect is deemed substantiated.X. Living arrangement. Which of the following risk factors puts D. He cannot recall the last time he saw the grandson he lives with. A.? 41.Self-Assessment Questions 43. friends. Age and dependency.’s daughter receives $2500 a month in government assistance to care for him in their home. and collectibles.F. is a 76-year-old white man who is homebound because of right-sided paralysis. Justice. Race and dementia. B. being less involved in usual activities. She has family who are willing to provide her care. Fixed income. Which of the following ethical principles is best represented in the APS program decision about A. was dressed in layers of dirty clothing stained with urine. 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. “Are you alone a lot?” This question is most likely to screen for which one of the following types of elder mistreatment? 131 Elder Abuse . The social worker’s report indicated Social Security is the couple’s only source of income. and dizziness.X. There was little food in the refrigerator. Autonomy. She is responsible for the care of her husband.F. nausea.X. 44. D. He stated that A. The house was cold and dirty. who is wheelchair bound. Questions 43–45 pertain to the following case. D.F. Sex and alcohol abuse problem.F. A. The on-site social worker visited the couple after receiving an anonymous report of an offensive smell and rodents coming from the apartment.F. Involuntary. An emergency department physician asks the patient.’s husband died. Alcohol abuse problem and sex.F.X.F. The APS program still offered interventions because a risk of harm to the person existed. A.F. or relatives other than his daughter since suffering a stroke 2 years ago. seems unaware that the telephone has been disconnected and that the rent is overdue. showed the capacity to make relevant decisions. photo albums. and dementia. A. 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. D. A. The social worker reports suspected self-neglect to the county Adult Protective Services (APS) agency. Which one of the following is the most appropriate intervention by APS on behalf of A. B. and having difficulty falling asleep.? Questions 41 and 42 pertain to the following case. the APS program again visits A. and he was found sitting incoherent in a recliner. Confinement in her home with supportive services. has had no contact with his congregation. Local law enforcement charged D. He weighed only 50 kg (110 lb) and had untreated injuries in various stages of healing. Which one of the following characteristics best predicts self-neglect in A. Privacy.’s daughter with elder neglect with serious injury. Family guardianship for surrogate decision-making.X. C. 46. A nearby church asked for a well-being check. and the case was deemed unsubstantiated. Which of the following risk factors puts D. 45.’s daughter most at risk of abusing her father? A. A. permanent placement in a nursing home. D. B. C. was tearful almost every day.F. D. temporary placement in a mental health facility. C. At this visit. The funds support her immediate family because they have no other income. A. Involuntary. initially accepted home-delivered meals and then declined the offer 1 month later. D.X.’s home. The APS program respected her wish. He was transported to a local hospital.F. His home does not have air conditioning. The residence was stacked from floor to ceiling with accumulated trash. D. A concerned neighbor made the call after A. Presence of depression. PSAP-VII • Geriatrics Caregiver status. The admitting diagnoses included sepsis secondary to infected decubitus ulcers. She complained of lacking energy to get going. Poststroke paralysis and sex. D.? 42. Marital status and age. Dependency and alcohol abuse problem. B. C. Social isolation and dementia.

B. Administer the American Medical Association screening instrument to his wife. is a 90-year-old woman with a history of diabetes. C. 49. Relatives of J.F. Relatives should call 911 after the patient has been transferred to the hospital. Speculate on the ways V. D. Psychological and physical abuse. Relatives should have proof of abuse. Questions 47 and 48 pertain to the following case. She has been unable to afford her prescriptions since he moved into her home 3 months ago. Which one of the following most raises the suspicion of elder abuse in J. 50.H. Physical and financial abuse.H.P. The facility physician also assessed her twice. She asks whether there are any programs in which to enroll for free drugs. Physical abuse and neglect. C. Because they are uncertain how to proceed.P. In completing the monthly drug regimen review. hypertension. D. J.H.F. Ask the caregiver questions about the patient’s behavior. Slipping on ice while out with her family. is afraid to confront her son because he threatens to place her in a nursing home. they approach the consultant pharmacist for direction. and contacts the state Elder Abuse Hotline. Neglect and sexual abuse. Exploitation.F. and eating baby food. He is cared for by his wife in their home.H. 48. Agitation and an unexplained dislocated shoulder. Physical and financial abuse.F. Difficulty awakening after the increased narcotic dosage.F. B. which was found to be caused by an unexplained dislocated shoulder. The regional ombudsman should be contacted to advocate on the patient’s behalf. Elder Abuse Neglect and psychological abuse. J. Which one of the following best describes the most appropriate action for the pharmacist to take when reporting? A. B.F. rocking in a chair. Physical abuse.F. B. An APS worker visits the home and finds J. Financial and psychological abuse. Contact the abuse hotline only after V. D. D. D. C. B. He has not been taken to a physician in the past year. She has no other income and must then ask him for pocket money. has provided a written consent. and osteoporosis. worry about her well-being in the nursing home and wish to report their concerns about poor quality care. Which one of the following is the best assessment of the type of mistreatment V. She feels her living situation was more comfortable before he moved in. even though she is able to care for herself.’s son. The nurses have noted difficulty in rousing her after a recent increase in her narcotic analgesic. V. first when she was out with her family and slipped on the ice and later in the month for agitation. C.H. His wife confides that he resists bathing and wanders. The worker almost passes out from the smells and heat. V. Which one of the following represents the most effective screening method for abuse in J. Neglect. Financial abuse. osteoarthritis. 132 PSAP-VII • Geriatrics . There are restraint marks on his arms. C. She confides in you that she signs over her pension check to her son because he lost his job. She complains that her son uses her car without permission. Which one of the following is the most likely type of mistreatment experienced by J. otherwise. shared in her own words and in the same context. Questions 49 and 50 pertain to the following case. Which one of the following best describes the reporting process the pharmacist should recommend? A. is a 72-year-old woman who has used your community pharmacy for many years. wearing dirty underclothes. Give only the name and phone number of V. 51. Questions 51 and 52 pertain to the following case. She can no longer afford to make home repairs or pay the utility bills.P. and oxycodone.F. Keep information V.’s son is spending her pension checks.? A.to late-stage Alzheimer disease.? A. is experiencing? A. There is no working air conditioner in the home. Relatives should contact a trusted nursing assistant or other staff member. 47.A. experienced a skin tear during a position change by one of the nurses. Physical and psychological abuse.? A. She resides in a nursing home and requires full assistance with self-care tasks. J. C. and his wife visit a physician the same week. 52. D. The pharmacist decides to report her suspicion of elder abuse in V. Administer the American Medical Association screening instrument to the patient. they should not make a report. C. Skin tear on her elbow with a position change. B.P. is an 80-year-old man with moderate. Her drug therapy includes glipizide. B. amlodipine. the consultant pharmacist reads that J.

who then makes a report on suspicion of a crime. Web of dependency. and lipids are no longer under control. The second shift nurse did not have knowledge of the prank. Rape. but the father and son denied everything. 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. C. talks with the nursing home administrator. D. who is present at the visit. Situational. A 68-year-old nursing home resident has experienced a 5% weight loss since admission last month. the physician refused to sign the order. The patient’s daughter. convenience. Nurse on the first shift and nursing home administrator. The next day. 58. Which one of the following best represents the parties that could face civil penalties if the crime is substantiated? A. Pressure sores. B. The nurse practitioner comments that the patient seems more unkempt than usual and withdrawn. the nurse decided.T. D. Neighbors reported a recent incident to the police. His son. Ask the visiting nurse questions about the patient’s behavior. The daughter says she needs to save money for her kids’ meals. strikes out at him when they argue. B. Physical restraint.T. but you feel helpless to do anything. you and your colleagues decide that the patient may be the victim of abuse or neglect. suffers from various physical and mental conditions and is completely dependent on staff for care. D.D. A nursing assistant observed the event but did not report it. T. C. Which one of the following best represents the deficiency issued by the state surveyor? Questions 53 and 54 pertain to the following case. Was the father interviewed alone? 133 Elder Abuse . He lives alone and is able to care for himself. He admits to an interviewer that his son handled him roughly after he soiled himself and needed cleaning. Improve the patient’s blood pressure. as a matter of PSAP-VII • Geriatrics Nutrition status. Albumin and hemoglobin are checked and found to be acceptable. The nurse did not have the consent of the resident or health care proxy. citing that it was not necessary to treat the resident’s medical symptoms. 57. B. The dietitian assesses the resident’s condition and makes modifications to the diet on the basis of the resident’s food preferences. A. The son claimed it was an accident. Feminist. In discussing the visit later.T. Battery. glucose. B. states that she took control of her mother’s life when she moved in 6 months ago. D.T. Prevent the patient’s chance of abuse by her grandchildren. Nurses on both shifts.? A. An elderly man has a black right eye and large bruise on his chest. Fraud. to quiet the resident down by writing an order for haloperidol and then forcibly injecting it. After the resident annoyed the head nurse by throwing a shoe in her direction. She has not been getting her prescriptions refilled as often as she should. Which one of the following is the best rationale for reporting your suspicions? 53. 55. who was abused as a child by the father. D. A. Which one of the following best describes the crime that occurred against T. and lipid values. Remove the patient and her finances from her family’s control. Nurse on the first shift. C. Was the sex of the interviewer the same as that of the father? B. C. 54. Chemical restraint. You accompany a nurse practitioner and dietitian on an interdisciplinary clinic visit with a female patient. Which one of the following is the most important question you have about the interview process? 56. Her blood pressure. Assault. Her daughter interrupts the dietitian about food choices. Nurse on the first shift and nursing assistant. T. Skin is intact and is being checked daily.T. C. T. Both deny the injury is serious. Which one of the following theories of elder abuse best describes this situation? A. The state surveyor pays an unannounced visit. glucose. Transgenerational. A 67-year-old man is assaulted several times by his adult son. A. B. is a female nursing home resident who claims she was injured after a caretaker gave her an unnecessary laxative. Reduce the patient’s overall risk of injury and dying. stating that her mother is overweight and that they do not have money for all the fancy foods the dietitian has suggested. The patient is 80 years old and recently widowed.

A staff pharmacist at a nursing facility conducted a count of drugs in a nurse’s cart at the beginning and end of a shift. The nurse’s only defense was that she had too many drugs to pass. Ensure sufficient nursing staff to perform medication pass. Reduce the number of drugs each resident receives.C. D. B. Staff the floor daily with different agency nurses. Was the father interviewed in his own home? 59. The facility recently downsized its staff and dismissed some of them. The pharmacist found more than 50 doses of drugs that were unaccounted for or provided to residents. Was the father given a narcotic analgesic before the interview? D. Elder Abuse 134 PSAP-VII • Geriatrics . An internal investigation revealed that the nurse falsified records to make it seem as though the residents received the drugs. C. 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.