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Abuse Stories

This collection contains all stories of abuse that have been featured in the Victim, Family & Caregiver Resources:  Neglect & Abandonment , Sexual Abuse , Physical Abuse , Psychological Abuse, and Financial Exploitation .

NEGLECT & ABANDONMENT

Abandonment by adult daughter.

Juliette, 87, lived with her daughter, Nanette, for the past 3 years.  Nanette helped Juliette with daily activities, such as getting her meals, bathing, and cleaning the house.  Nanette decided to move in with her boyfriend in another state and left her mother alone in the home.  About a week later, Juliette’s niece happened to be in town and stopped by to visit her aunt. She saw that the inside of the house was in very bad condition and found Juliette in poor health.  Juliette’s niece contacted Adult Protective Services (APS) and the State Area Agency on Aging. 

Neglect by Daughter and Son-in-Law

Kofi, 84, was diagnosed with Alzheimer’s disease and moved in with his daughter's family. Sometimes Kofi had trouble sleeping, had physical and verbal outbursts, and began wandering. His daughter and son-in-law were afraid that Kofi might wander out of the house if they left him alone.  They locked the doors to the house so that Kofi could not get out and wander around when they left for work.  A neighbor noticed Kofi trying to get out of the house. She contacted the local police and Adult Protective Services (APS).   

Neglect by Son and Daughter-in-Law

Tamara, 76, lived alone but had trouble getting around.  Her son and his wife asked Tamara to move in with them. Tamara had her own bedroom on the second floor and stayed there most of the time.  She could not use the stairs easily.  Her son and daughter-in-law both traveled frequently for work and sometimes neglected to give her adequate food and water.  They also failed to groom her or to clean her room consistently.  One day Tamara became dizzy, weak and disoriented so her daughter took her to the hospital. The hospital staff discovered that she was dehydrated, disheveled and obviously unwashed.  They asked about her care but Tamara said she was well cared for.   Nevertheless, as required by law, the hospital staff reported suspected neglect to Adult Protective Services (APS).  

Neglect by Sons

Clarence, 79, invited his two adult sons to move in with him so he would not be alone after his wife died. The sons soon sent Clarence out to live in the shed and locked him out of the house. Sometimes his sons put food out for him. Occasionally they gave him a basin of cold water with a washcloth. When one of Clarence’s neighbors noticed that Clarence seemed to be living in the shed, she called Adult Protective Services (APS) anonymously and reported what she had seen. She then decided Clarence may need immediate help so she called the police to do a welfare check.  

Abandonment by Guardian/Conservator

Henrietta, 88, required a court appointed guardian due to combined physical and mental disabilities that left her partially incapacitated.  Her niece, Roberta, was appointed as Henrietta’s guardian.  Roberta visited Henrietta in her home a few times but then never came back and made no further arrangements for her care.  A neighbor noticed the lack of activity at Henrietta’s house.  The neighbor knocked but couldn’t get Henrietta to answer door so she called law enforcement for a welfare check and Adult Protective Services (APS).  

June, 73, suffered a severe brain injury.  At first she was able to care for herself but as she got worse, a court appointed Sam as her legal guardian to assist her.  He saw June two times in the first six months but did not return to see June and did not arrange for her care.  He falsified reports to the court stating that he saw June every three months.  As a result, no one knew that June was living on her own without Sam’s help.  June was unable to remember to clean her house and the trash had not been taken out in many months.  Due to the deterioration of her house, June received a visit from a county health officer who discovered that June was very frail.  The county health officer was a mandatory reporter and called Adult Protective Services (APS). APS petitioned the court for a new guardian.  

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SEXUAL ABUSE

Sexual abuse by nursing aide.

Margaret, 77, lived in a nursing home that was known for good residential care.  One day, a nursing aide noticed that Margaret appeared anxious but Margaret would not explain why. While preparing her for a bath, the nursing aide saw multiple bruises on Margaret's arms, neck and back and asked what happened. Initially, Margaret did not say anything. Subsequently, the director of nursing learned from another resident that a new aide had sexually assaulted Margaret. As required by law, the director of nursing reported the sexual assault to Adult Protective Services (APS), and APS initiated an investigation, involving the Ombudsman and local law enforcement.  

Sexual Assault by Caregiver

Eduardo, 80, had a stroke.  His family hired an in-home caregiver to assist with his daily needs such as bathing and going to the toilet. One day his daughter stopped by to help see her Dad. As she helped him get dressed, he winced and she noticed that his genital area was red and irritated. Her father started to cry and mumbled something about the caregiver hurting him there. The daughter immediately called Adult Protective Services (APS) to make a report. She also called the agency where the caregiver worked, made a complaint, and ended services. APS alerted the law enforcement.  

Sexual Assault by Family Member

Pearl, 70, took her nephew in when his mother could not handle his behavior problems. The nephew began viewing pornography on the TV that he shared with his aunt. Pearl was uncomfortable about this and told her nephew to stop. One day, the nephew came home and was high on drugs.  He forced himself sexually upon his aunt. Pearl called 911 for local law enforcement and went to the hospital where she met with a sexual assault victim specialist.  

Sexual Abuse by Guardian/Conservator

Angela, 71, required guardianship because of her continued alcohol and drug abuse.  The court appointed Richard as her guardian.  Soon after his appointment, he gave Angela more drugs, sexually assaulted her, and threatened her with prison for her drug use if she reported him.  Angela summoned the courage to go the local police and contacted a lawyer to obtain a new guardian.  

PHYSICAL ABUSE

Physical abuse by adult grandsons.

Katherine, 82, raised two grandsons, Joel and Kent.  They had physically abused her since they were teenagers.  After 12 years in prison, Joel returned to his grandmother's home because he had nowhere to go. One night Joel came home and was drunk.  He banged on the door but Katherine told Joel to go away. After he entered the house through a back window, Joel beat his grandmother. Katherine went to a neighbor’s house and called 911. Joel was arrested and Katherine was taken to the hospital. The police contacted Adult Protective Services (APS).  

Physical Abuse by Disabled Adult Son

When George, 79, lost his wife of 50 years to cancer, his son, Lawrence, came to live with him. Lawrence was on disability due to a traumatic brain injury.  The brain injury caused behavior changes, including difficulty with self-control and verbal and physical outbursts.  The injury also caused violent mood swings. Occasionally, Lawrence went to a neighbor's apartment and got drunk. One night when Lawrence returned home, George asked him if he was drunk. Lawrence yelled "NO" and punched his father in the face. Because George was afraid of further violence, he called 911 to get help from the police.     

Physical Abuse by Spouse

After 58 years of marriage, Virgil and Ella, both 83, knew each other's habits well. Sometimes, when they argued they became physically violent. Nevertheless, they said they loved each other and had never considered divorce.  Violence was unfortunately a part of their relationship.  As Ella aged, she developed osteoporosis.  She began to worry that if she fell down when they were fighting each other she might end up with a broken bone. She confided this to a friend, and her friend suggested calling the local domestic violence hotline to speak with a counselor.  

Physical Abuse by Guardian/Conservator

Blair, 65, had no close relatives.  Because of early-onset dementia, he was placed in a nursing home and required guardianship.  Chris, Blair’s guardian, came to Blair’s nursing home every few months to see how Blair was doing.  During the last visit, Chris began slapping Blair to wake him up.  Joan, a care attendant rushed to the room when Blair began crying out for Chris to stop.  Joan noticed marks on Blair’s face and asked what had happened.  Blair was unable to tell Joan what had happened but Chris quickly left the room.  Joan reported the incident to her supervisors who helped her make a report to Adult Protective Services (APS).  The report triggered involvement by the state ombudsman and local law enforcement.  

Physical Abuse by Long-Term Care Aide

Monica, 79, was placed in a long term care facility when her ALS became severe and her family could no longer care for her.  Her family became concerned when they saw bruising on her arms and back.  Monica was not able to speak and could not tell her family how she got the bruises.  Monica’s family asked the staff about the bruising but was not satisfied with the explanation. The family also noticed that when a certain aide helped bathe her, Monica became upset and agitated.  They suspected that the aide was hitting Monica and called local law enforcement.  

PSYCHOLOGICAL ABUSE

Psychological abuse by daughter.

Zoe, 79, was healthy, independent and lived with her unmarried daughter, Trish, to share expenses. Zoe believed they had a good relationship. Nevertheless, Trish sometimes yelled at Zoe, calling her horrible names and telling her she was worthless.  Trish began threatening to put Zoe in a nursing home. Zoe tried to ignore these rants because she was grateful to live with her daughter.  However, she thought she deserved to be safe from such comments. Zoe eventually told a close friend about Trish’s yelling and threats.  The friend suggested that Trish and Zoe seek counseling and that Trish get respite help from a local Agency on Aging.     

Psychological and Physical Abuse by Spouse

Sarah, 75, had been married for over 50 years to Saul who was abusive.   The abuse had a pattern. Her husband would start following her around watching her every move.  Then he would make comments under his breath. Finally, he would start pointing his finger in her face and pushing her around.  Since Saul’s retirement, this pattern seemed to be getting worse and happening more often.  Sarah picked up a pamphlet on Domestic Violence at her synagogue and decided to make her first call for help.  From her conversation with the domestic violence advocate, she learned about resources in her area and steps she could take to be safe.  

Jane had not seen her friend Harry, 87, at Mass for weeks.  This was not like her friend since Harry went to Mass almost every Sunday.  Jane stopped by Harry’s house.  Harry answered the door and Jane was shocked.  Her friend had lost weight, looked terrible, and had obviously been crying.  Harry told Jane in a hushed voice that since his daughter had moved in she would not let him go to church, the senior center, or even out of the house.  Harry said that his daughter was now controlling everything including his money.  Before Jane could say anything, Harry’s daughter started yelling and Harry quickly closed the door.  Jane decided to make an anonymous report to Adult Protective Services (APS).  

Psychological Abuse by Guardian/Conservator

Mark, 75, had Alzheimer’s disease and was beginning to have severe memory loss and trouble walking around the house.  Mark’s paid caregiver, Yolanda, asked the court to appoint a guardian.  Each time the guardian, Mrs. McKee, visited with Mark, she made fun of his memory problems and inability to remember where he was or even who Yolanda was.  Yolanda became worried about Mark and the fact that Mrs. McKee, the court appointed guardian, did not seem to take Mark’s condition seriously.  Yolanda called Adult Protective Services (APS) and the probate court to review Mark’s guardianship.  

Psychological Abuse (cyber bullying) by Stranger

Rosie, 75, lived alone in an independent senior housing community.  Her next door neighbor, a disabled retiree, repeatedly emailed her rude messages and sent vulgar and threatening messages to her cell phone. Fearing her neighbor might harm her if she told him to stop Rosie contacted local law enforcement, and filed criminal charges as well as a petition for a civil restraining order. She also notified housing management.  

FINANCIAL EXPLOITATION

Financial Exploitation by Family, Close Friends, or Neighbors

Financial Exploitation (fraud) by Spouse

John, 68, and Bernice, 65, had a “second marriage.”  John worked as an engineer and Bernice stayed home.  Jointly, they had purchased 22 acres with a second home for their retirement. Trying to mend poor relationships with her sons from her first marriage, Bernice asked John to add one son to the property deed. He agreed. While John was on a business trip, Bernice faxed John the last three pages of the deed for his signature. He signed and returned the form. Unknowingly, he had signed a form deeding the entire property to Bernice who then “gifted” the property to her son. John contacted a lawyer.  

Financial Exploitation (identity theft) by Adult Child

Joseph and Malvina, both 80 and retired, had taken in their daughter after her release from prison. Soon after she moved in, the couple received one credit card bill for $8,347, another for $12,694, and a third for $10,012.  The couple had no idea their daughter had used their credit cards or that she had opened additional credit card accounts in her mother’s name. Now, Joseph and Malvina were faced with significant debt.  The couple’s other adult child contacted Adult Protective Services (APS), the credit card company and the Federal Trade Commission (FTC).  

Financial Exploitation (theft) by Guardian/Conservator

Monte, 82, had moderate dementia and required guardianship due to his worsening disease.  Unfortunately, Monte had never given his only son, Samson, Power of Attorney.  Monte also no longer had sufficient mental capacity to execute a power of attorney for Samson, who now lived out of state. Monte’s personal assistant, John, handled all of Monte’s financial transactions for him.  Samson was concerned about John’s access to his father’s finances and reviewed Monte’s account statements while visiting his father over the summer. Samson discovered that several times John had taken over $3000 from one of Monte’s little used accounts.  Samson contacted the investment firm, local law enforcement and Adult Protective Services (APS) for help.  

Financial Exploitation (misuse of a power of attorney) by Relative

Russell, 88, needed help managing his day to day affairs. His nephew, Jack was out of work and offered to come and live with Russell and help him while Jack looked for a job. Jack took his uncle to the bank saying he wanted to protect Russell’s money.  Russell told the bank teller to add Jack to his bank accounts.  Jack then downloaded a power of attorney (POA) form from the Internet and had Russell sign it.  With the POA, Russell’s credit card company added Jack as a second user to his credit card. When Russell's sister visited him, she asked about the situation.  Russell told her that he thought their nephew was stealing his money. She and Russell went to the bank and learned that Jack had spent a considerable amount of his uncle’s money.  The sister alerted bank officials, Adult Protective Services (APS) and local law enforcement. Russell filed for an emergency civil protective order to have Jack removed from his home.  

Financial Exploitation (theft) by Friend

Ya, 84, became friends with Michelle, 72, in a computer class at the senior center. Using her own computer, Michelle established an online account to help Ya pay her bills. However, Michelle wrote checks for some of her own bills as well as for Ya’s bills.  Ya was unaware that Michelle was writing checks for herself until she saw a returned check made out to a cell phone company. Ya didn’t own a cell phone.  When she checked her account, Ya discovered that most of her money was gone.  Ya contacted  local law enforcement and asked her bank to investigate.  

Financial Exploitation (promises exchanged) by Acquaintance

Barbara, 76, a retired high-ranking federal government employee, was independent and lived alone.  She was recently diagnosed with Alzheimer’s disease and knew she would need more help in the future.  Barbara asked Margie, a former neighbor, who was recently divorced, to move in with her. Over time, they agreed that Margie would care for Barbara in her old age and that in return, Barbara would provide Margie’s with food and housing.  Barbara gave Margie her power of attorney for access to all her accounts and named her the sole beneficiary of her investment portfolio. After a several months, Barbara noticed her accounts were almost empty and called local law enforcement which also notified Adult Protective Services (APS).  

Financial Exploitation by Trusted Professionals

Financial Exploitation (inappropriate products) by Investment Broker

Jackie was a successful investment broker.  She had a reputation for making her clients wealthy.  Recently Julio, 80, asked Jackie for financial advice.  She recommended investments that had high growth potential but were risky for older adults.  When Julio’s daughter reviewed his investment portfolio, she found he had investments that wouldn’t provide a return for 30 years and would do Julio little good.  Julio contacted the Commodity Futures Trading Commission (CFTC) to check the background of financial professionals, the Securities and Exchange Commission ( SEC) and Adult Protective Services (APS).  

Financial Exploitation (investment fraud) by Financial Advisor

Millie, 63, was a public school cafeteria worker who saved for retirement and wanted to help her grandson go to college. A friend recommended Tom, a polite, outgoing financial adviser. Millie didn’t understand the stock market but, after attending a retirement seminar, trusted Tom to invest her money. When she wanted to give her grandson money for college, Millie learned most of the money she had invested was gone. Tom had created fake account statements that showed Millie was making money.  Millie contacted Tom’s company and reported him to the Attorney General and Adult Protective Services (APS) in her state.   

Financial Exploitation (investment fraud) by Tax Preparer

Alex, an accountant, gave discounts for tax preparation to clients who were over age 65. He built a clientele of wealthy older single adults, widows or widowers, and found ways to get them tax refunds.  Many of Alex’s clients gave him Power of Attorney; he also served as their financial adviser. Upon request, Alex gave his clients a statement of their account. Otherwise, he called clients with good news about their investments or about tax loopholes that he took advantage of for the client. When a client’s son learned the deed to his father’s house was in Alex’s name, he looked into his father’s finances and discovered Alex controlled all of his father’s assets.  The client’s son contacted the Attorney General, IRS and Adult Protective Services (APS) in his father’s state.  

Financial Exploitation (forgery) by Professional Caregiver

Amarjit, 91, paid his own bills. When he opened his bank statement he noticed four $150 checks had been made out to his home health aide.  He knew he had not written or signed the checks. Amarjit contacted his bank and local law enforcement.  

Financial Exploitation (improperly obtained power of attorney) by Professional Caregiver

Roman, 84, was bedridden.  He hired Bob to provide caregiving services.  Soon after, Bob forged Roman’s signature to create a fake Power of Attorney (POA) that gave Bob the power to act in Roman’s place.  Using this illegal Power of Attorney, the bank allowed Bob to put his name on Roman’s savings and checking accounts.  Bob explained to the bank that Roman agreed to the change but couldn’t be present because he was bedridden.  Bob later put his own home address name on Roman’s accounts.  Roman became concerned when he stopped receiving monthly statements from the bank.  Roman contacted the bank immediately and local law enforcement.

Financial Exploitation (fraud) by Representative Payee

Carollee appeared to take good care of the older adults, including veterans, who lived in the group home where she worked. Because most of the residents were disabled and had no family to represent them, Carollee became the representative payee for their Social Security and Veteran’s Benefits. The regular postal carrier became curious when he started delivering over 30 envelopes from Social Security and Veteran’s Benefits to Carollee’s home each month.  He thought she lived alone so he notified the local postal inspector through the US Postal Inspection Service hotline, Veterans Affairs, and Adult Protective Services (APS).

Financial Exploitation (inappropriate product) by Mortgage Broker

John, 68, wanted to provide for his wife, Vickie, 62, and leave money for his children when he died.  He and his wife thought their home would provide this economic security after they both retired. Less than a year after his retirement, John had a massive stroke and died.  Vickie contacted a mortgage broker whose ad she saw in a local magazine.  The mortgage broker persuaded Vickie, who had been diagnosed with dementia, to sign a reverse mortgage on her house.  Vickie’s daughter learned of the transaction and contacted local law enforcement and Vickie’s mortgage lender.  

Financial Exploitation by Strangers

Financial Exploitation (internet identity theft) by Stranger

Naira, 71, was single, disabled and retired.  When she got an email from her bank requesting verification of her account numbers, Naira complied. Later she opened an email that she thought was from a government official investigating Medicare fraud.  The email asked her to provide her Medicare number to verify that there was no fraud on her account. When her bank manager called to confirm that she wanted to close her accounts, Naira learned the money in her savings and checking accounts was gone. She told the bank manager about the bank email and he told her that it must have been a scam. When she explained how she’d given her Medicare number after the second email, the bank manager contacted the Centers for Medicaid and Medicare, the Federal Bureau of Investigation and Adult Protective Services (APS).  

Financial Exploitation (fraud) by New Sweetheart

Arturo was a popular hair stylist. He was charming and attentive to widows and older women and often asked clients who seemed well-off out to dinner. During these meals, Arturo discussed his financial woes. Some customers gave him their bank account information and put him on their accounts “just in case.”  Arturo helped three of these wealthy women manage their real estate investments.  Two of them even made him a joint owner of their homes.  When one customer died, the executor discovered her bank and investment accounts were depleted, her home now belonged to Arturo, and heirlooms were missing.  The executor contacted Adult Protective Services (APS), local law enforcement and the FBI.  

Financial Exploitation (grandparent scam) by Stranger

Charlie, 82, received a phone call from a “sheriff” in New Orleans.  He said Charlie’s grandson had been arrested for intoxication. To be released, the sheriff said that someone needed to pay the grandson’s fine and that his parents were not home. The sheriff told Charlie to wire money to an online address. After the money was delivered, Charlie got a call from someone he thought was his grandson saying that he needed money to get home from New Orleans.  Charlie became suspicious when he asked the person claiming to be his grandson a few personal questions that he couldn’t answer.  The call ended amicably.  Then Charlie called a nearby Federal Bureau of Investigation field office to report the incident and filed a complaint with the FBI’s Internet Crime Complaint Center online.  

Financial Exploitation (home repair scam) by Stranger

At 83, Shirley, who was a retired lawyer now lived alone after the death of her husband.  It had become difficult to keep up repairs on her house. One day a handyman she’d never seen before rang her doorbell and told her the gutters on her house needed to be cleaned and that she might need a new roof.  Because she didn’t have anyone else to help her with these tasks, Shirley paid him $500 to clean the gutters and an additional $10,000 as a down payment for a new roof.  She never saw the handyman again.  She told a neighbor what had happened and the neighbor contacted Adult Protective Services (APS), local law enforcement, and the state’s consumer protection agency within the Attorney General’s office.   

Financial Exploitation (lottery scam) by Stranger

Armando, 78, was thrilled when someone from the lottery called to confirm he had won $10,000.  The person on the phone said that they would send the money after Armando sent a winner's fee of $500.  Thinking only about what he would do with the winnings, he wired the $500 “winner’s fee” to the address the caller provided.  Because he did not receive the promised lottery winnings after a month, he contacted the Federal Trade Commission (FTC).

Protecting Our Seniors From Abuse & Neglect

Recent Elder Abuse in Nursing Homes: Case Studies

Elder abuse is far more common than many people would like to believe. What’s worse, recent reports confirm that nursing home abuse skyrocketed during the COVID-19 pandemic. Help keep your loved ones safe by reading these recent case studies on elder abuse in nursing homes. Accepting that elder abuse is a real problem is the first step in preventing it.

Examples of Elder Abuse in Nursing Homes: A Nationwide Problem

Nursing home abuse happens when trust is violated through an act — or a failure to act — that harms an older person. It can include emotional, financial, physical, or sexual abuse as well as nursing home neglect.

Tragically, a 2020 report from the World Health Organization (WHO) estimates that roughly 1 in 6 adults 60 years old and over were the victims of elder abuse in nursing homes and other community settings.

Even worse, the WHO warns that this already alarming figure is likely to be too low since only 1 in 24 cases of elder abuse is ever reported.

Recent case studies on elder abuse in nursing homes show that this is, unfortunately, a nationwide problem.

The most common forms of nursing home abuse are:

• Emotional abuse : when an older person is yelled at, threatened, or belittled
• Nursing home neglect : substandard care of a nursing home resident
• Physical abuse : any form of violence that leaves an older person significantly injured, including cases of wrongful death
• Sexual abuse : any sexual contact with an elder who cannot give their consent

Thankfully, help is available if you or a loved one suffered nursing home abuse or neglect. Get a free case review to see if you can access legal compensation right now.

Get a free legal case review if you or a loved one has suffered abuse or neglect.

Examples of Case Studies on Elder & Nursing Home Abuse

1. suspected nursing home abuse in massachusetts.

After hundreds of 911 calls were made about suspected nursing home abuse, a criminal investigation is underway against an assisted living facility in Watertown, Massachusetts.

Several of the heartbreaking reports include:

• After responding to a call about a faulty ventilator, firefighters found that none of the electrical outlets in a resident’s room were working
• An injured nursing home resident was on the floor asking for help, but when firefighters asked the staff member in charge about it, she just laughed
• Firefighters found staff performing CPR on a man who had already been dead for hours

Further, in a case of suspected physical abuse at the same nursing home, the daughter of a dementia patient found her mother’s face severely battered.

“It was horrific. She had a huge gash on her forehead and a lump the size of a golf ball, her whole face was bruised.” – Daughter of Massachusetts nursing home resident

These examples reveal a widespread pattern of abuse and neglect by staff, which will hopefully be corrected. No nursing home resident should ever have to endure these hardships.

2. Nursing Home Sexual Abuse in Minneapolis

A male caregiver at a Minneapolis care facility was sentenced to eight years in prison for the rape of a nursing home resident with Alzheimer’s disease.

“My final memories of my mother’s life now include watching her bang uncontrollably on her private parts for days after the rape, with tears rolling down her eyes, apparently trying to tell me what had been done to her, but unable to speak.” – Daughter of sexual abuse victim

A follow-up investigation by CNN revealed that the rapist had assaulted multiple other residents, including those who suffered from mental or physical handicaps, before he was finally caught.

3. Nursing Home Neglect in Iowa

A nursing home resident in Iowa died after extreme neglect related to dehydration . The emergency room doctor believes she died from a stroke after not receiving any type of fluid for at least four to five days. The nursing home was fined $77,463.

Examples of Elder Abuse in Nursing Homes During the Pandemic

While nursing home abuse and neglect were already a very serious issue, the ongoing coronavirus pandemic made things even worse.

According to Human Rights Watch, neglect and isolation may be responsible for causing severe damage to countless nursing homes residents during the COVID-19 crisis.

Recent nursing home abuse case studies revealed:

• A resident in her 80s who was healthy and pre-pandemic died shortly after visitation stopped due to suspected malnutrition
• In less than a year, a dementia patient living in a nursing home went from 106 pounds to 82 pounds before being discharged and dying several days later
• A dementia patient in her 70s lost 20 pounds during the pandemic and developed painful bedsores on her buttocks and toes

Why Does Elder Abuse Happen in Nursing Homes?

Elder abuse in nursing homes is believed to occur for several reasons.

Nursing home abuse may happen due to:

• Understaffing
• Inadequate staff training, especially in dementia care
• Lack of supervision
• Staff burnout

No matter what the explanations for elder abuse are, it is never acceptable. All nursing home residents deserve to be free from harm and properly cared for.

How Common Is Elder Abuse?

Although there is a lack of concrete data, recent reports suggest that elder abuse is common.

It is believed that elder abuse is more likely to occur with nursing home residents than with older adults living in community settings. In fact, 2 in 3 nursing home staff members admitted to abusing or neglecting residents in the 2020 WHO report.

Common Signs of Nursing Home Abuse

The most common signs of nursing home abuse are physical symptoms and any type of sudden change in behavior.

Depending on the form, some additional signs of nursing home abuse may include:

• Bruising, scars, or welts seen on the body
• Mumbling, sucking one’s thumb, or rocking
• Unexplained STDs or other genital infections
• Bedsores, malnutrition, or dehydration

Get Help For Elder Abuse in Nursing Homes

If you or a loved one was the victim of nursing home abuse, you may be entitled to compensation. Money awarded in a nursing home lawsuit can help pay for medical expenses and bring peace of mind.

The Nursing Home Abuse Center is dedicated to helping victims of nursing home neglect, abuse, and wrongful death. Contact us now to find out if we can help you and your family.

The Nursing Home Abuse Center (NHAC) was founded to bring justice to those affected by nursing home and elder abuse. Our mission is to educate and empower victims of abuse and their families to take a stand against this unlawful mistreatment. We work to return dignity back to those who have been broken down by nursing home abuse and neglect.

• BMC Health Services Research. (2020). Elder Abuse And Neglect: An Overlooked Patient Safety Issue. A Focus Group Study Of Nursing Home Leaders’ Perceptions Of Elder Abuse And Neglect. Retrieved August 14, 2021 from https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-020-5047-4
• Fiandaca, C. (2021). I-Team: Watertown Long-Term Care Facility Investigated For Possible Abuse, Neglect. CBS Boston. Retrieved from August 14, 2021 https://boston.cbslocal.com/2021/02/12/long-term-care-facility-nursing-home-elder-abuse-investigation/
• Human Rights Watch. (2021). Us: Concerns Of Neglect In Nursing Homes. Retrieved August 14, 2021 from https://www.hrw.org/news/2021/03/25/us-concerns-neglect-nursing-homes
• Merrilees, A. (2019). '83 Years Old, Unable To Speak, Unable To Fight Back.' Daughters Share Heartbreaking Stories Of Abuse In Nursing Homes. ABC News. Retrieved from August 14, 2021 https://abcnews.go.com/Politics/83-years-unable-speak-unable-fight-back-daughters/story?id=61504444
• World Health Organization. (2021). Elder Abuse. Retrieved August 14, 2021 from https://www.who.int/news-room/fact-sheets/detail/elder-abuse

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Elder Abuse: Cultural Contexts and Implications

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#97824: Elder Abuse: Cultural Contexts and Implications

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CASE STUDY 1

For several weeks, church members noticed that Mr. L, 82 years of age, had bruises, cuts, and scrapes on his face, hands, and arms. Mr. L always had some plausible explanation and, knowing that he was the sole caretaker for his very ill wife of 61 years, they did not press the issue. A hospital social worker finally contacted APS after Mr. L drove himself to the hospital emergency room, over 20 miles from his home, with multiple fractures to his left arm. The APS social worker eventually discovered that Mr. L was being attacked by his wife, who was suffering from undiagnosed Alzheimer disease and had become combative. Mr. L did not know that his wife's behavior was a part of her illness and was protecting her.

CASE STUDY 2

Mrs. J, a long time insulin-dependent diabetic, was admitted to the hospital after being brought to her physician's office by a neighbor who became concerned after not seeing Mrs. J for several days. Mrs. J finally told hospital staff members that she had run out of insulin several days ago and had given her grandson all the money she had to go and refill her prescription. He did not return, and Mrs. J did not call family members because she did not want to get him in trouble.

CASE STUDY 3

Mr. B, 74 years of age, complains with increasing frequency of pain. His physician is puzzled by the complaints because the methadone she has prescribed should be controlling the pain. She has already increased the dosage a couple of times and is reluctant to do so again. She finally asked a family member to bring in all of Mr. B's medications so that she could check for drug/drug interactions or perhaps prescribe another medication. Examination of the methadone tablets revealed that someone had switched most of the methadone with over-the-counter potassium tablets, which are nearly the same size and color. Mr. B's failing eyesight prevented him from being able to tell the difference between the very similar tablets. Questioning revealed that Mr. B's niece, a former drug addict, had been living with him in exchange for his care, and that she prepared his medications each day. The family suspected that she was using drugs again, but was reluctant to probe too deeply because there was no one else to care for Mr. B.

CASE STUDY 4

Mr. R, 54 years of age, and Mrs. R, 49 years of age, work full time in very demanding jobs. About one year ago, Mr. and Mrs. R built an apartment addition onto their home, depleting their savings, to accommodate Mrs. R's mother, Mrs. D. Mrs. R is the oldest of three siblings and care for her aging mother had become primarily her responsibility. The 90-minute drive to her mother's apartment in a nearby city each weekend had become increasingly taxing, and her mother's care had become more time consuming. When Mrs. D's long-time physician announced his intent to leave private practice, it became reasonable to make the move. Mrs. D, while not enthusiastic, was agreeable. Mrs. R's brother and sister, who rarely visited or helped with her mother's growing needs, became angry about the move and stated that they had no intention of making such a trip. Now, in addition to working 9 to 10 hours per day, Mrs. R goes home to find numerous messages from her mother with various requests and demands. Additionally, because her mother can see her car drive up, the phone is usually ringing by the time she gets into the house to begin dinner for the three of them. There is an in-home aide who comes three days per week to help with bathing and light cleaning, but lately Mrs. R has questioned whether this is worth the added burden of mediating disputes between the aide and her mother. Each morning before work, Mrs. R prepares her mother's medications for the day and makes sure she has something available for breakfast. She longs for a vacation, but the routine continues seven days per week. Besides, all her vacation and sick leave must be devoted to taking care of her mother's medical appointments and treatments. Lately, Mrs. R has been having difficulty sleeping with disturbing dreams of having forgotten some major task. She feels tired all of the time. She has also noticed that she snaps at her spouse and friends often and that her anxiety level is increasing. Her own household chores are piling up because she does not have the time or energy to do them. Last week she noticed a red rash on her thigh and wonders when she might find the time to see her own doctor.

CASE STUDY 5

Mr. J had returned to live with his mother, Mrs. J, a widow of ten years, after his wife insisted he leave their house. During this time, he became depressed and started to drink. Mrs. J's neighbors became concerned that Mrs. J had lost a tremendous amount of weight and looked sad and disheveled lately. One day, Mrs. J confided to one of her neighbors that ever since her son returned to live with her, he had been pilfering her Social Security checks. Initially, she noticed that small amounts of money were missing from her pocketbook, but now, Mr. J threatens her both verbally and physically. He would smash and throw china at her until Mrs. J handed her signed Social Security check to him.

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• Published: 23 September 2022

ELDER ABUSE

Silent suffering: the plague of elder abuse

• Kathleen Wilber   ORCID: orcid.org/0000-0001-6211-9726 1 &
• Kelly Marnfeldt 1  

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Elder abuse has been recognized as a serious problem for decades. Yet rigorous studies are rare. Burnes and colleagues move the field forward by identifying how pervasive the problem is, the factors that increase and decease vulnerability, and how these factors change over a three-year period.

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Acknowledgements

The work of K.W. and K.M. was supported in part by award 2020-75-CX-0001, awarded by the National Institute of Justice, Office of Justice Programs, US Department of Justice. The opinions, findings, and conclusions or recommendations expressed in this publication are those of the authors and do not necessarily reflect those of the Department of Justice.

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• Published: 12 March 2020

Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders’ perceptions of elder abuse and neglect

• Janne Myhre   ORCID: orcid.org/0000-0001-8983-7998 1 ,
• Susan Saga 1 ,
• Wenche Malmedal 1 ,
• Joan Ostaszkiewicz 2 &
• Sigrid Nakrem 1  

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The definition and understanding of elder abuse and neglect in nursing homes can vary in different jurisdictions as well as among health care staff, researchers, family members and residents themselves. Different understandings of what constitutes abuse and its severity make it difficult to compare findings in the literature on elder abuse in nursing homes and complicate identification, reporting, and managing the problem. Knowledge about nursing home leaders’ perceptions of elder abuse and neglect is of particular interest since their understanding of the phenomenon will affect what they signal to staff as important to report and how they investigate adverse events to ensure residents’ safety. The aim of the study was to explore nursing home leaders’ perceptions of elder abuse and neglect.

A qualitative exploratory study with six focus group interviews with 28 nursing home leaders in the role of care managers was conducted. Nursing home leaders’ perceptions of different types of abuse within different situations were explored. The constant comparative method was used to analyse the data.

The results of this study indicate that elder abuse and neglect are an overlooked patient safety issue. Three analytical categories emerged from the analyses: 1) Abuse from co-residents: ‘A normal part of nursing home life’; resident-to-resident aggression appeared to be so commonplace that care leaders perceived it as normal and had no strategy for handling it; 2) Abuse from relatives: ‘A private affair’; relatives with abusive behaviour visiting nursing homes residents was described as difficult and something that should be kept between the resident and the relatives; 3) Abuse from direct-care staff: ‘An unthinkable event’; staff-to-resident abuse was considered to be difficult to talk about and viewed as not being in accordance with the leaders’ trust in their employees.

Conclusions

Findings in the present study show that care managers lack awareness of elder abuse and neglect, and that elder abuse is an overlooked patient safety issue. The consequence is that nursing home residents are at risk of being harmed and distressed. Care managers lack knowledge and strategies to identify and adequately manage abuse and neglect in nursing homes.

Peer Review reports

Little is known about elder abuse in nursing homes, and compared to research on other forms of interpersonal abuse, research about elder abuse in nursing homes is still in its infancy [ 1 , 2 ]. Although no national prevalence data are available in any country internationally, high rates of elder abuse and neglect have been reported in nursing homes, including Norway [ 1 , 3 ]. According to the World Health Organisation (WHO), elder abuse has been identified in almost every country where these institutions exist [ 4 ]. In the Toronto Declaration, WHO defines elder abuse as ‘a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which cause harm or distress to an older person’ [ 5 ] p:3. Prevention of harm is a core principle in health care services and a leadership responsibility [ 6 , 7 , 8 ]. Nursing home leaders are legally and morally responsible for ensuring that required quality and safety standards are met [ 6 , 9 , 10 ]. The National Patient Safety Foundation (United States) defines patient safety as ‘freedom from accidental or preventable injuries or harm produced by medical care’ [ 10 ], p,2. This includes preventing elder abuse and examining the factors that foster an unsafe environment for both residents and staff [ 6 , 7 , 11 ]. Furthermore, elder abuse can be categorized according to type of abuse. The definition from ‘Protecting Our Future: Report from the Working Group on Elder Abuse’ (Ireland) includes physical, psychological, financial and sexual abuse, and neglect (Table 2 ) [ 12 ]. Abuse in nursing homes may also be categorized according to type of relation [ 1 ]; staff-to-resident abuse [ 3 , 13 ], family-to-resident abuse [ 14 , 15 ] and resident-to-resident abuse, also called resident-to-resident aggression [ 16 , 17 ].

A recent meta-analysis of the prevalence of elder abuse in long-term care settings estimated a pooled prevalence of 64.2% of abuse perpetrated by staff in the past year, where psychological abuse and neglect had the highest prevalence [ 1 ]. A survey of 16 nursing homes in the central part of Norway found that 91% of staff had observed a colleague engaging in some form of inadequate care,

and 87% of staff reported that they themselves had perpetrated some form of inadequate care in the past [ 3 ]. Comparably, in a study from Ireland, Drennan et al. found that 57.5% of staff had observed one or more abusive behaviours from a colleague in the previous year [ 13 ]. Neglect and psychological abuse were the most commonly observed or perpetrated acts [ 3 , 13 ]. Living in a nursing home may also mean sharing room and space with co-residents, and in recent literature, resident-to-resident aggression has been identified as a common form of abuse in nursing homes [ 16 , 17 , 18 ]. Lachs and colleagues revealed that 407 of 2011 residents from ten facilities had experienced at least one resident-to-resident event over one month observation, showing a prevalence of 20.2%, and the most common form was verbal abuse [ 16 ]. The literature about elder abuse in domestic settings shows that close family and friends can be perpetrators of abuse [ 15 ], but few studies have investigated the role of family members as perpetrators of abuse in nursing homes. A study from the Czech Republic found that nursing home staff had observed relatives participating in financial exploitation combined with psychological pressure on residents in nursing homes [ 14 ]. However, comparing findings in the literature on elder abuse in nursing homes is challenging because definitions and understandings of abuse can vary in different cultures, jurisdictions, and among health care staff, researchers, family members, and residents themselves [ 1 , 2 , 11 , 19 , 20 , 21 ]. Different understandings of what constitutes abuse and its severity complicate detecting, reporting and managing the problem.

Nursing homes are complex social systems that consist of different participants, including staff, leaders, residents and relatives in constantly shifting interactions [ 22 , 23 ]. The aetiology of abuse in nursing home settings is described as complex, comprising varying associations between personal, social and organisational factors [ 2 , 24 ]. Nursing home residents often have complex care needs, dementia or other forms of cognitive impairment [ 25 ], display challenging behaviour [ 26 ], and depend on assistance in daily activities and care, all factors associated with a high risk of abuse and neglect [ 3 , 13 , 24 , 27 ]. In Norway, 80% of nursing home residents have dementia, and 75% have significant neuropsychiatric symptoms such as agitation, aggression, anxiety, depression, apathy and psychosis [ 25 ]. Residents who display aggressive behaviour toward staff are at greater risk of experiencing abuse [ 13 , 27 , 28 ]. Findings in Drennan et al.’s Irish study revealed that 85% of the nursing home staff had experienced a physical assault from a resident in the previous year [ 13 ]. Aggressive behaviour has also been found to trigger resident-to-resident aggression in nursing homes [ 16 , 17 ]. Related to organisational factors, there is an association between inappropriate environmental conditions for residents, low levels of staffing, and abuse and neglect [ 13 , 14 , 29 ]. As a result of this complexity, elder abuse in nursing homes is difficult to define precisely [ 11 ]. Within the literature, elder abuse in nursing homes is conceptualised as a specific form of institutional abuse [ 30 ] and a setting in which abuse and neglect take place [ 14 ], since rules and regulations in institutions can be abusive themselves, e.g., deciding residents’ sleeping and meal times, the use of restraint, and shared living spaces with other residents.

Good leadership plays a key role in developing staff’s understanding of residents’ needs [ 31 , 32 ] and creating a strong safety culture of respect, dignity, and quality [ 6 , 7 , 9 , 33 ]. The importance of leadership in developing a patient safety culture is highlighted in a report from the National Patient Safety Foundation [ 10 ]. In Norway, governmental strategies to improve leadership and safety culture have been launched, such as the Patient Safety Programme and a system for monitoring health services using quality indicators [ 34 ]. Leadership is defined as a process whereby a person influences a group of individuals to reach a common goal [ 35 ], such as a strong safety culture. The safety culture of an organisation is defined as ‘the product of individual and group values, attitudes, perceptions, competencies, and patterns of behaviour that determine the commitment to, and the style and proficiency of, an organisation’s health and safety management’ [ 10 , 36 ] p:23. This includes detecting situations that can be harmful to residents. However, several studies have shown that underreporting of abuse and neglect is a significant problem [ 1 , 37 , 38 ]. Residents’ own inability to communicate about the abuse or their fear of repercussions and retaliation are important factors of underreporting [ 1 , 2 ]. Therefore, staff should be able to recognise and report situations that can be perceived as harmful or distressful from the perspective of residents. However, a systematic review of staff’s conceptualisation of elder abuse in residential care found that staff were often uncertain about how to identify abuse, especially psychological abuse and caregiver abuse and neglect [ 39 ]. Despite the vast knowledge that exists about the importance of leadership, nursing home research has not yet paid much attention to the role leaders play regarding identifying elder abuse. Consequently, there is a gap in knowledge about elder abuse from the perspective of nursing home leaders. Knowledge about nursing home leaders’ perceptions of elder abuse and neglect are essential because their understanding of the phenomenon will affect what they signal to staff as important to report and what they investigate to create a safe and healthy environment. To our knowledge, this is the first study that seeks to understand the nature of elder abuse from the perspective of nursing home leaders.

Aim of the study

The aim of the study was to explore nursing home leaders’ perceptions of elder abuse and neglect.

The present study is part of a larger study funded by the Research Council of Norway (NFR), project number 262697. A qualitative exploratory design with focus group interviews was conducted to gain greater insight into this important but poorly understood topic. Qualitative methods provide knowledge about people’s experience of their situation and how they interpret, understand and link meaning to events [ 40 , 41 ]. In focus group interviews, group dynamics allow the questions to be discussed from several points of view, and the group’s dynamics can create new perspectives and opinions during the discussion [ 42 ]. This study follows The Consolidated Criteria For Reporting Qualitative Research (COREQ) (Additional file 1 ).

In Norway, approximately 39,600 residents live in nursing homes (12.9% of the population > 80 years), and their mean age is 85 years [ 43 ]. These nursing homes are mainly run by the municipalities and financed by taxes and service user fees. Residents pay an annual fee equal to 75% of the resident’s national age pension. In addition, residents may pay an additional fee if they have income of their assets, but with an upper limit decided by the government. However, the payment cannot exceed the actual expenses of the institutional stay [ 44 ].. Management of care in Norwegian nursing homes is regulated by ‘the regulation of management and quality improvement in health care services’ [ 45 ]. The regulation focusses on the leader’s responsibility to ensure that residents’ basic needs are satisfied. This includes the leader’s responsibility to ensure there is a system in place to monitor residents’ overall quality and safety and to create a safety culture that detects situations and factors that can cause harm to residents and staff [ 45 ].

Each nursing home is required to have an administrative manager, called the nursing home director, and some nursing home directors lead more than one facility. In addition, each nursing home has ward leaders and quality leaders, and in some municipalities, a service leader. Together, individuals in these leader roles form the leadership team in each nursing home [ 46 ]. The ward leader is a registered nurse (RN) who supervises and manages staff. Ward leaders are also responsible for budgets in their own wards and the quality of care for residents. There are often several wards and ward leaders in each nursing home. The quality leader is an RN who monitors the overall quality of care in the nursing home in collaboration with the ward leaders. The service leader supervises and manage service staff members who are in contact with nursing home residents (e.g., activity coordinators, cleaning staff and kitchen staff) and is also responsible for the budget related to his or her staff. Individuals employed in one of these leader positions provide the closest level of leadership to staff and residents but are not part of the daily direct hands-on care of residents. There is no national requirement regarding formal leader education to be employed in these leader positions, but leader education is a high priority in many municipalities. These individuals often have lengthy experience as RNs or have previous leader experience.

The study sample was recruited from 12 nursing homes in six municipalities in Norway. Inclusion criteria were a person who: (a) was employed in a leader position as ward leader, quality leader, or service leader in a nursing home, and (b) was employed full time in the leader position. The inclusion criteria were chosen because these individuals directly affect quality and safety in the nursing home, as they are the closest level of leadership to the staff and residents. Purposive sampling was initially used to ensure that participants recruited could see the phenomenon from the perspective of a leader. During the data collection, each municipality and its nursing home leaders were recruited using a step-wise approach, as we were seeking to get a theoretical sampling until saturation of data was achieved [ 40 , 41 ]. A total of 28 individuals participated in the study, 23 participants were ward leaders, two participants were quality leaders, and three participants were service leaders. However, in this study, all 28 participants are named ‘care managers’. Characteristics of the participants are presented in Table 1 .

Recruitment and data collection

Participants were recruited over a period of six months, from August 2018 through the end of January 2019. A recruitment email was sent to health care managers in 11 municipalities in both urban and rural areas. Health care managers from five municipalities stated that they could not find time to participate in the study, while six health care managers accepted the invitation. Thereafter, a second recruitment email was sent to all nursing home directors in these six municipalities. The email included an invitation letter, which the nursing home director forwarded to all individuals employed in a leader position at their nursing homes. Six focus group interviews were conducted, with three to six participants in each group. The focus groups were composed as follows: one focus group with three participants; two focus groups with four participants; one focus group with five participants; two focus groups with six participants.

All six focus group interviews took place in a meeting room in a nursing home in the participating municipalities. Each focus group interview lasted approximately 90 min. All participants gave informed written consent before the interviews started. Two researchers carried out the interviews. JM was the moderator in all six interviews, SN was co-moderator for two group interviews, and SS was co-moderator in one group interview. In the other three interviews, two researchers from the larger research team were co-moderators. During the introductory information about the focus group interview, we presented a figure (Fig. 1 ), and asked participants about their experience and thoughts on the topic of elder abuse from health care staff, co-residents or relatives. Participants were encouraged to speak freely. However, during the first interview, we experienced that participants were not familiar with the topic. To explore the topic in the ensuing interviews, the moderator gave the participants keywords from the categorization of abuse (e.g., abuse can be described as physical, psychological, sexual, financial, or neglect) (Table 2 ) [ 12 ]. We found that this helped the participants reflect, and they subsequently came up with examples of abusive situations they had heard about or witnessed. During the process of data collection, we further compared our experiences in interview one with interview two, which is in line with the constant comparative method [ 40 ]. This led to including keywords in the interview guide to ensure that all topics were covered (Additional fil 2). To ensure the credibility of an open thematic understanding of participants’ experiences and diminish bias by presenting the keywords, we were conscious about letting the participants speak freely about their experiences and thoughts on this topic. Moreover, they were not given any definition of abuse or examples related to these keywords (Table 2 ) [ 12 ]. The participants freely decided in which order they wanted to talk about different forms and situations of elder abuse. All interviews were recorded and transcribed verbatim, retaining pauses and emotional expressions.

Model of interactions where abuse can occur as used in the interviews

Data analysis

A constant comparative method with a grounded theory approach was used. This allowed us to generate a thematic understanding of elder abuse through an open exploration of the experience described by nursing home leaders [ 40 , 41 ]. The constant comparative method facilitated possible identification of themes and differences between individuals and cases within the data [ 40 ]. Our analysis started right after each interview, where the first author listened to the recorded interview. Memo writing was then used through the whole process of data collection and analysis and served as a record of emerging ideas, questions and categories [ 41 ]. Next, in line with the constant comparative method, open line-by-line coding of the transcribed interviews was performed [ 40 , 41 ], since we wanted to capture the meaning from the participants’ perspectives as they emerged from the interviews. The codes were compared for frequencies and commonalities and then clustered to organise data and develop sub-categories. The sub-categories were examined to construct the final categories and main theme. To add credibility and diminish researcher bias, two researchers (JM and SN) coded the transcribed interviews independently. During the analysis process, the authors held several meetings where codes and their connections were discussed until consensus was reached. To ensure that the emerging categories and themes fit the situations explored, the researchers went back and forth between contextualization, data analysis and memo writing [ 40 ]. An example of the analysis process is shown in Table 3 .

Ethical consideration

Ethical approval for this study was given by the Norwegian Centre for Research Data (NSD), Registration No: 60322. Each participant signed a written consent form after receiving oral and written information about the study. All identifiable characteristics are excluded from the presentation of data to ensure the anonymity of all individuals.

The main theme, ‘Elder abuse in nursing homes, an overlooked patient safety issue’, found in this study indicates an overall lack of awareness of elder abuse and its harm among care managers. Three analytical categories emerged from the analyses: 1) Abuse from co-residents – ‘A normal part of nursing-home life’ , 2) Abuse from relatives – ‘A private affair’ , and 3) Abuse from direct-care staff – ‘An unthinkable event’. Since there were no remarkable differences in care managers’ experiences, we present results without differentiating the participants. Below, we describe each category, together with examples of forms of abuse and neglect. These examples are used to describe the care managers’ perceptions of elder abuse and neglect (Table 4 ).

Abuse from co-residents – ‘A normal part of nursing-home life’

Resident-to-resident aggression was described as the biggest issue related to abuse in nursing homes and a daily challenge for the participants: ‘ That is what I also see, that co-residents are the biggest challenge regarding this topic’ (Group 2). The main cause of resident-to-resident aggression reported by care managers was symptoms of dementia, especially in the initiator, but also in the victim. The care managers expressed that they did not know how to address this problem. As one said, ‘ It happens because of the cognitive failure, so yes. But, at the same time, it is also difficult to do something about it’ (Group 2). Some care managers also stated that the risk of harm caused by resident-to-resident aggression was something residents must accept when living in a nursing home: ‘ There is a predictable risk, when living in nursing homes, [of] such incidents; there is a foreseeable risk that this will happen’ (Group 5) . This demonstrates that resident-to-resident abuse is normalized.

Care managers considered physical abuse to be the most serious form of resident-to-resident aggression, often leading to visible harm and despair. At the same time, all care managers had examples of residents who had been beaten, knocked down, or kicked by co-residents.

‘We have one resident now that is beaten a lot by the other residents. It’s a little extreme, but I think that such things can happen quite often in dementia care because, as in this case, the resident being beaten is not silent for a minute. She speaks and yells all day, and the other residents become annoyed since she disturbs them’ (Group 4).

Care managers described psychological abuse as acts of ‘everyday bullying’ and threats made among residents. They interpreted these situations as a normal consequence of the dementia disease in the individual resident. One care manager noted, ‘ What I think is the challenge is the everyday bullying. It is seen as normal behaviour for that group of residents’ (Group 1). When discussing psychological abuse connected to co-residents, all care managers provided examples of residents trespassing in other residents’ rooms. They interpreted this behaviour as a violation of residents’ privacy. At the same time, it was perceived as normal since it happened quite often. The care managers also reported that when residents trespassed and entered another resident’s room, the risk of other forms of abuse such as financial abuse increased. One care manager remarked , ‘We have some challenges related to residents who enter other residents’ rooms and destroy or take other residents’ possessions. It can be pictures and different things’ (Group 3).

Related to sexual abuse by co-residents, all care managers had examples of residents who had shown sexual interest in another resident. The care managers viewed this sexual interest as an ethical dilemma for them. On the one hand, they want residents to have a healthy sex life in the nursing home, but on the other hand, this is difficult when a resident has dementia and may not be competent to give consent. Several care managers experienced that what seemed to be voluntary sexual interest between residents could not be that, after all:

‘In that situation, she was very interested in him, and he was very interested in her. And it was like, yes, they were in the room together and so on. I remember it as very, very difficult because she often had a lot of pain. I do not know if there was penetration, but it was, in any case, an attempt, yes, it may as well have been that too. I had a lot of trouble because I was unsure whether she understood what happened and who it was happening with because it was often very difficult for her after they had been in the room together. I remember it as a huge ethical dilemma. But I never thought that it was a sexual . . . that it was an assault or something. But, right now, I think it was’ (Group 5).

During the focus group discussion, care managers reflected on the complexity of letting residents express themselves sexually and the risk of sexual assault. From their statements, it was clear that they had not reflected on this topic earlier. A summary of forms of harmful situations related to resident-to-resident aggression reported by participants is presented in Table 4 .

Abuse from relatives – ‘A private affair’

Abuse directed towards residents from their relatives was reported to be a particularly difficult problem. According to the care managers, relative-to-resident abuse was often hidden, occurring behind private closed doors when a relative was visiting the resident. Therefore, participants described it as difficult to discover and associated mainly with the private relationship between the resident and his or her relatives:

‘ It is very difficult. It is a relative who is going to visit her mother in the nursing home, she closes the door to the room and wants to be there alone with her mom, and we have very large rooms, so we thought they were having a nice time inside the rom. But then we discovered that the mom had some bruises, and then we understood that things were happening’ (Group 3).

Not all care managers had knowledge of or experience with relative-to-resident abuse, which highlights the private nature of these forms of abuse. Abuse from relatives was viewed as being linked to past family conflict, which continued inside the nursing home. The care managers deliberated over the extent to which they should interfere in the private relationship when they suspected this form of abuse. They reported that the problem was knowing what to do and when and how to interfere, especially when the resident has dementia or another form of cognitive impairment. One care manager remarked, ‘ It is very difficult. I have a patient who may not be competent to give consent. So, I have a responsibility I must take, but I think it’s challenging to know what to do’ (Group 2). Cases where the resident clearly did not want anyone in the nursing home to know about the abuse or to do anything about it and just wanted to maintain the relationship with his or her family member despite the abuse were reported to be particularly difficult. The care managers expressed that they lacked a strategy or authority in these situations, and harm to the resident being exposed was accepted.

‘ But it is not always that the resident wants us to do something, either. It may have been this way for a long time, and then, maybe it’s okay then. Well, I don’t know’ (Group 5).

Physical and sexual abuse from relatives was regarded as the most hidden form of abuse from relatives. Some care managers provided examples of physical abuse, but none had experienced sexual abuse. However, all care managers commented that when it happened, it took place behind private closed doors. In addition to past family conflict, abuse from relatives was often related to mental problems and/or drug abuse issues. One care manager said, ‘ I have experienced some older people who have children with drug issues and such things. And it is in those cases, I have experienced physical abuse towards residents from relatives’ (Group 4). Related to physical abuse from relatives, care managers also reported situations where a relative forced the resident to, for example, eat, get dressed, wash and groom, or exercise. These situations were linked to unrealistic expectations in relatives, and not trusting the staff is doing a good job.

‘After her husband had been there, we saw that she was so red around the cheek. We then found out that the husband squeezed her mouth open and poured cream into her’ (Group 3).

Care managers viewed psychological abuse from relatives as disrespectful communication with the resident. A participant stated, ‘We experience that relatives can be quite disrespectful to their loved ones. But, at the same time, it may have been this way their whole life’ (Group 6).

Care managers expressed that financial abuse from relatives was a common occurrence. They cited examples of stealing money from residents, threatening residents in order to get money from them, and unauthorized use of a resident’s finances. One participant stated, ‘ What I see most from the relative’s part is financial abuse. It is very common, actually’ (Group 1). Relatives’ economic problems were reported to be a causal factor related to financial abuse. At the same time, care managers indicated that financial problems and financial exploitation by relatives were private issues, and as such, they were reluctant to interfere.

Related to neglect, care managers described that some relatives made decisions on behalf of the resident without considering what the resident wanted and needed or would agree upon. Care managers stated that sometimes the health care staff also disagreed with the relative’s decision. One care manager noted, ‘ We have situations where relatives make decisions on behalf of the resident, which we do not agree upon, and which we might think the resident would not agree upon either’ (Group 3 ). Care managers also described experiences of relatives who refused to allow a resident to buy items the care managers considered necessary and not provided by a nursing home. These could be things such as clothes, hairdressing services, or podiatry, but it could also be related to taking part in activities that cost money. A care manager remarked:

‘ I have a resident who called her son to ask if she could go to a podiatrist because she really needed it, but her son refused and said she has no money for that’ (Group 5).

Thus, because of neglect by their relatives, residents might go without necessities of daily living and may not be able to participate in activities they would like to take part in. A summary of forms of harmful situations related to relative-to-resident abuse reported by participants is presented in Table 4 .

Abuse from direct-care staff – ‘An unthinkable event’

When care managers were prompted to talk about staff-to-resident abuse, they reframed the discussion to focus on the verbal and physical aggression they commonly experienced from nursing home residents. They interpreted aggression directed toward them as a risk to their health and safety. Moreover, they stated this phenomenon was a daily concern. One noted, ‘ We have the opposite focus in our units. We focus on staff being subjected to abuse by residents’ (Group 2). Several care managers also indicated that they understood that staff could become stressed and frustrated in their relationship with an aggressive resident:

‘We have a case that is extremely difficult, where there are many violations against staff by a resident. And then, to be in such a situation where you can quickly retaliate . . . this is difficult’ (Group 6).

Despite this, care managers expressed that elder abuse was not a topic they talked about in their daily work at the nursing home. They indicated that they wanted to trust the employees. Therefore, abuse from staff was difficult to talk about and almost unthinkable to them. One care manager said, ‘I think that no one who works in the nursing home started there just to be able to hurt someone, and that is perhaps why this is such a sensitive and difficult topic’ (Group 5) . The word ‘abuse’ was also reported to be a very strong term and mainly related to intentional physical acts. However, in the discussion, care managers also included unintentional acts in their examples of elder abuse and expressed that, to some degree, it could be difficult to know the full intention of a staff member’s actions. At the same time, they emphasised that staff’s intentions were mainly good, and therefore abuse was unthinkable:

‘Everyone who works in a nursing home is motivated by and has a desire to help someone. So, most of the [incidents] of abuse by staff . . . I think it may be those with a good intention at the heart of it. [For instance, thinking] “I thought he should have a shower, but I forgot to ask” (Group 5).

Care managers discussed examples of the use of physical and chemical forms of restraint and rough handling during care. Utilization of restraints and dilemmas related to their use was discussed in all focus groups, and care managers pointed out that the staff are sometimes compelled to use both physical and chemical restraints to help or protect the resident:

‘I think in relation to, well it is really both physical and psychological abuse. I think of cases, especially at night, where there is low staffing and many residents with aggressive behaviour, where it may be chosen to lock some residents into their rooms to prevent them from being exposed to abuse from co-residents so the staff can deal with the situation, but it is abuse to be locked inside’ (Group 2).

Rough handling was something that all care managers had experienced. This was thought to be mainly unintentional and something that could happen when caring for residents with aggression or those who resist care. Care managers expressed that, to define it as abuse, it had to be significant, or there needed to be visible signs of such handling, such as bruising. At the same time, the care managers also pointed out that residents in nursing homes often bruise easily, and it can be difficult to determine whether such marks are related to abuse:

‘Sometimes, we saw that she was so easy to bruise, and sometimes we clearly noticed hand marks on the bruises around her body. But it can be enough that you handle someone a little hard, and in the old ones, then they get bruises, although it can also indicate that there has been resistance, right. But then this happens all the time’ (Group 4).

Psychological abuse from staff members was linked to verbal abuse. Care managers cited examples of yelling at a resident in anger, speaking to a resident in a disrespectful tone, or being rude, which allegedly occurred in relation to resident-to-staff aggression. When discussing psychological abuse, some care managers also provided examples of violations of residents’ privacy by staff members, such as discussing residents’ health care issues and challenges in public areas in the nursing home:

‘If there has been a resident with a rejection of care responses, for example, that has been difficult to cooperate with, then that frustration can be expressed in public areas with other residents present. Without caution by staff, this is something other residents are going to hear’ (Group 5).

Financial abuse was thought to be related to stealing money or destroying a resident’s property. At the same time, care managers reported that their nursing home policies do not allow residents to keep much money in their rooms in order to protect residents from financial abuse by staff, visitors, or others, and hence, financial abuse from staff rarely happened. One said, ‘Financial abuse only happens if the residents have money laying around’ (Group 1).

When talking about sexual abuse, care managers offered examples of residents who stated that they were sexually assaulted by staff members. These were often female residents who expressed that male staff had sexual intentions towards them during care. At the same time, care managers reported that such statements from residents could be part of the dementia disease, and that resident could have hallucinated the abuse. Care managers indicated that sexual abuse by staff was unthinkable to them:

‘Sometimes, older people with cognitive impairment say things that we can become uncertain about. They say things, but we can’t be sure there has been an assault. Often, we think that it has not happened. It’s about us knowing them; they say a lot of these things and are very sexually oriented’ (Group 4).

Even so, a few care managers mentioned examples of sexual abuse by staff a long time ago that had been reported to the police, and the staff member was convicted.

Related to neglect, care managers reported that staff often did things for residents to save time instead of letting them do it independently. They also reported being aware that, in many situations, staff members do not pay attention to residents’ wishes and thereby neglect to include them in decisions concerning daily life in the nursing home. One care manager noted, ‘ It says on the duty list that you should shower today, so you should shower, even if you might say, “No, I don’t want to.” So, yes, it is your turn today’ (Group 3). Another form of neglect by staff was reported to be linked to health care neglect. Care managers referred to events such as not helping a resident with needed health care, giving a resident an incontinence product instead of helping them use the toilet, not calling for medical help when needed, and not following up on medical conditions:

‘To put on a pad instead of following the patient to the toilet, for those who still manage to use the toilet themselves . . . that can happen’ (Group 6).

The care managers reported that, because of low financial resources, staff must prioritize their work and tasks every day. For this reason, situations not specifically related to medical treatment and physical or health outcomes were given lower priority. This reprioritization was framed as acceptable and was not defined as neglect. One said, ‘ It is about our time. So, no, we don’t have time for you or that need is not important. It is about what we have to prioritize’ (Group 6). A summary of forms of harmful situations related to staff-to-resident abuse reported by participants is presented in Table 4 .

The aim of the study was to explore nursing home leaders’ perceptions of elder abuse and neglect. We found that most of the care managers were not explicitly aware of elder abuse in their daily work. However, when given keywords, they all came up with examples of situations they interpret as harmful or distressful to residents. This shows that care managers need time to reflect on complex aspects of care to become aware of abuse and neglect as a safety issue. At the same time, our findings revealed an ambiguity in the care managers’ examples. The situations, on the one hand, were described as harmful. On the other hand, they were rationalized as care managers attempted to excuse why it was happening. Three main categories are described in the finding: Abuse from co-residents – ‘A normal part of nursing-home life’, Abuse from relatives – ‘A private affair’, Abuse from direct care staff – ‘An unthinkable event’. These findings indicate that this cohort of nursing home care managers lack awareness of the abuse they observe or hear about. Particularly, these findings demonstrate that harm or distress to residents caused by abuse are an overlooked patient safety issue in these nursing homes.

Findings revealed that resident-to-resident aggression is a common form of abuse in nursing homes and a daily challenge. There is a high prevalence of residents with neuropsychiatric symptoms of dementia, including aggression, agitation and psychosis in nursing homes [ 25 , 26 ]. These symptoms impact on co-residents and staff safety, and resident-to-resident aggression is the most common form of abuse in nursing homes [ 16 , 17 ]. However, our findings revealed that harm resulting from resident-to-resident aggression was perceived as normal. This raises the question of whether care managers perceptions place the responsibility on the resident, without accounting for the complexity in the aggressive behaviour and the responsibility of the organization [ 22 ]. It is worth noting that in resident-to-resident aggression, both residents can suffer harm, since the initiator is likely to be confused and usually not responsible for the acts. For the victim, resident-to-resident aggression has both physical and psychological consequences [ 47 ]. However, previous research has also indicated that abusive behaviour can be understood as less abusive when the victim has dementia, and for that reason it is often not reported [ 17 , 48 ]. Recognising that aggressive behaviour has a multifactorial aetiology, best practice recommendations [ 49 ] and research evidence [ 50 , 51 ] call for a comprehensive biopsychosocial approach that investigates the resident’s unmet needs, medical conditions, environmental factors, and interactions between residents and caregivers and a tailored response [ 49 ]. Care managers’ perceptions of resident-to-resident aggression as normal and a foreseeable risk, places residents at risk and is also a failure to deliver much needed care to the initiator.

With respect to relative-to-resident abuse, findings demonstrate that care managers perceive negative events resulting in harm or distress as a private affair between the resident and his or her relatives, and that is difficult to intervene. Similarly, to resident-to-resident abuse, this indicates that the care managers place the responsibility of the observed abuse on the relationship between the resident and his or her relatives, without accounting for the complexity and their own responsibility in these situations. Care managers examples of relatives who force a resident to eat due to unrealistic expectations and distrust in nursing home staff’s care reveals that care managers find it difficult to interact with families. This finding points to potential communication difficulties between staff and resident’s relatives that could adversely affect the resident [ 52 , 53 ]. A Norwegian study that investigated quality of care from the perspective of families in long-term care found that family members saw themselves as an important link between staff and the resident, and an essential voice regarding the resident’s needs and wishes [ 53 ]. However, given the nature of the nursing home and the complexity of its organization and routines [ 22 , 23 ], it can be difficult for someone outside the organization to judge what is and is not adequate clinical practice. Collaboration and communication with the residents and their relatives depend on how the culture in the nursing home view these interactions; the relatives with right to an opinion, or professional as experts and in control [ 6 , 22 , 52 ]. This will in turn affect the quality and safety of the care that is delivered to the residents.

Although some care managers had experience of staff-to-resident abuse within all abuse categories, it was also difficult for them to admit to this form of abuse, and it was viewed as an ‘unthinkable event.’ Instead, care managers were mostly interested in talking about resident-to-staff aggression which they emphasised was a larger problem in their nursing homes. Resident- to-staff aggression can cause physical and psychological harm to staff, reduced job satisfaction, stress and burnout, emotional reactions including sadness, guilt and helplessness [ 28 ]. However, resident-to-staff aggression may also lead to reactive abuse and neglect, due to frustration in staff member being exposed to aggression [ 11 , 13 , 27 , 28 ]. Findings in the present study demonstrate that care managers lack awareness of the staff’s reactive responses to aggression from residents. This might raise the question if they perceive staff as victims in these situations and that abuse from staff is understandable. Unprovoked or intentional abuse towards a resident therefore is unthinkable with justification in their trust to the staff.

Difficulties in defining abuse in nursing home settings have been found in studies that include staff’s perceptions [ 39 , 54 ], where abusive situations are seen as normal in the nursing home culture [ 17 , 33 , 39 , 55 ]. However, these studies did not specifically focus on care managers’ or leaders’ understandings. Our study reveals important information related to detection and management of abuse in nursing homes, since care managers’ perception of abuse affects what they signal to staff as important to report. Care managers have the opportunity to influence the culture and care practice in the nursing home and are responsible for setting policies for the staff, it is therefore essential that they are aware of and able to face situations that constitute potential harm to the residents. But, to be able to define situations that can be experienced as harm and distress, it is essential to see situations from the perspective of the residents. Harm and distress are defined differently from the point of view of the one who causes the harm [ 39 , 54 ], the one observing or hearing about it [ 14 ], or the one who experiences a situation of harm or distress [ 20 , 21 ]. Our findings indicate that the care managers had difficulties in seeing potential harm caused by abuse and neglect from the perspective of the residents. Leaders’ abilities to promote a safety culture for both the resident and staff are linked to their leadership skills, knowledge of the resident’s needs and their capacity to implement effective safety care practices [ 6 , 31 , 32 ]. Care managers’ lack of awareness in identifying and following up on abuse will necessarily affect the safety culture in the organisation and, in the end, clinical outcomes such as quality and safe care for the residents [ 6 , 10 , 56 ].

A recent Norwegian study found that communication, openness and staffing were significant predictors of staff’s overall perception of patient safety in nursing homes, yet the nursing home staff scored low on these dimensions [ 56 ]. This finding aligns with our study, which revealed that care managers find it difficult to distinguish between prioritising and patient neglect. Low financial resources and low staffing can affect the perception of what constitutes harm and safety in the nursing home culture. Low finances, combined with the complexity of residents’ needs, the complex organisation, and demands for improved outcomes, puts great pressure on nursing home leaders [ 22 , 57 ]. The ambiguity in their examples can be understood as an attempt to rationalize abuse and diminish their personal and professional accountability. People in complex social systems will try to make sense of tasks and orders by adapting to internal and external demands [ 22 , 23 ]. Health care policies that mandate efficiency, cost saving, and nursing home care managers’ focus on prioritising contribute to lowering the limit for what is perceived as quality and safety, resulting in low quality and unsafe environment as the norm and accepted in nursing homes.

Strengths and limitations of the study

A strength of this study is that it involves participants who are in leader positions in different nursing homes and municipalities in Norway, which could increase the transferability of these findings. The research team consists of members from two countries, all with broad research experience, which contributed to multiple perspectives and discussions during analyses of the data. This strengthens the trustworthiness of our findings, and the credibility of the research. Three of the authors have worked several years in nursing homes as care managers, but none of those nursing homes participated in this study. The researchers’ backgrounds as care managers has both advantages and disadvantages. A variety of aspects of participants’ experiences was discovered by posing in-depth questions that might not have been possible without the background knowledge. However, the background knowledge can influence the type of follow-up questions that were asked. To counterbalance this possible bias, two researchers were always present during the interview, and the analyses were also independently coded by two researchers (JM and SN). Each focus group consisted of three to six participants, which can be perceived as small groups and a limitation. However, the participants gave a rich description of the phenomenon. Therefore, we decided to include data from the smallest groups.

The examples of abuse and neglect our participants described in the present study could be second-hand information because leaders are not always part of the direct hands-on care residents receive. At the same time, this study has sought to understand the nature of elder abuse from care managers’ perspective, which is of great importance due to their responsibility for creating a safe environment for both residents and staff. Even though the examples are second-hand information, the findings are representative of the care managers’ perceptions of the information and what we thought was important to study.

Many nursing home residents have dementia, neuropsychiatric symptoms, and complex needs, which increases the risk of their being exposed to abuse and neglect. At the same time, little is known about the nature of elder abuse in nursing homes and compared to research on other forms of interpersonal abuse, the study of elder abuse in nursing homes is still in its infancy. Care managers influence the culture and care practice in nursing homes and set policies for staff. Knowledge about their empirical understanding of the phenomenon is important to form more effective intervention and prevention strategies. The present study shows an ambiguity in the nursing home leaders’ examples of abuse and neglect. On the one hand, the situations were described as harmful. On the other hand, they were rationalized with an attempt to excuse their occurrence. Our study revealed that elder abuse and neglect is an overlooked patient safety issue in nursing homes. Care managers lack knowledge and strategies to identify and adequately manage abuse and neglect in nursing homes, and this warrants further research.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to format of the data not allowing for completely anonymizing data but are available from the corresponding author on reasonable request.

Abbreviations

Research Council of Norway

Registered Nurse

World Health Organization

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Acknowledgements

We would like to express our gratitude to our participants for sharing their experience and thoughts on the topic of elder abuse and neglect in nursing homes. Thanks to Anja Botngård and Stine Borgen Lund for contributing to data collection as co-moderators.

Ethical approval for this study was given by the Norwegian Center for Research Data (NSD), Registration No: 60322. All the participants were provided with written information about the study. They gave written consent to participate in the interviews and for the use of the data from the interviews.

Authors details

JM: RN, MSc, PhD candidate, at Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway.

SS: RN, MSc, PhD, Associate professor at Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway.

WM: RN, MSc, PhD, Associate professor at Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway.

JO: RN, GCert Cont Prom, GCertHE, MNurs-Res, PhD, Research Fellow, Centre for Quality and Patient Safety Research, School of Nursing and Midwifery, Institute for Healthcare Transformation, Deakin University, Geelong, Australia.

SN: RN, MSc, PhD, Professor at Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway

The study is funded by the Research Council of Norway (NFR) project number: 262697.

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Janne Myhre, Susan Saga, Wenche Malmedal & Sigrid Nakrem

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JM wrote the manuscript. JM, SS, WM, JO and SN developed the study design. JM transcribed the interviews, and JM and SN performed the analysis of the interviews, with discussion including all authors. SN supervised the project. All authors did critical revisions of the manuscript for important intellectual content and read and approved the final manuscript.

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COREQ checklist.

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Myhre, J., Saga, S., Malmedal, W. et al. Elder abuse and neglect: an overlooked patient safety issue. A focus group study of nursing home leaders’ perceptions of elder abuse and neglect. BMC Health Serv Res 20 , 199 (2020). https://doi.org/10.1186/s12913-020-5047-4

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Experiences of elder abuse: a qualitative study among victims in Sweden

• Mikael Ludvigsson 1 , 2 ,
• Nicolina Wiklund 1 ,
• Katarina Swahnberg 3 &
• Johanna Simmons 1  

BMC Geriatrics volume  22 , Article number:  256 ( 2022 ) Cite this article

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Elder abuse is underreported and undertreated. Methods for prevention and intervention are being developed, but the knowledge guiding such measures is often insufficiently based on the victims’ own voices due to a paucity of studies. The aim of this study was therefore to explore experiences of elder abuse among the victims themselves.

Consecutive inpatients ≥ 65 years of age at a hospital clinic in Sweden were invited to participate, and 24 victims of elder abuse were identified. Semi-structured qualitative interviews were conducted, and transcripts were analyzed using qualitative content analysis.

The analysis generated four themes that together give a comprehensive picture of elder abuse from the participants’ subjective perspectives. The participants’ experiences of abuse were similar to previous third-party descriptions of elder abuse and to descriptions of abuse among younger adults, but certain aspects were substantially different. Vulnerability due to aging and diseases led to dependance on others and reduced autonomy. Rich descriptions were conveyed of neglect, psychological abuse, and other types of abuse in the contexts of both care services and family relations.

Conclusions

Elder abuse is often associated with an individual vulnerability mix of the aging body, illnesses, and help dependence in connection with dysfunctional surroundings. As individual differences of vulnerability, exposure to violence, and associated consequences were so clear, this implies that components of prevention and intervention should be individually tailored to match the needs and preferences of older victims.

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Abuse of older adults is recognized as a pervasive and serious problem in society. Prevalence estimates have ranged from 10% upwards in cognitively intact persons from North and South America, with large variations between different countries and subcategories of the population [ 1 , 2 , 3 ]. Elder abuse is defined by the World Health Organization (WHO) as “a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person”. It includes five different types of abuse: physical abuse, psychological abuse, sexual abuse, economic abuse, and neglect [ 4 ]. Elder abuse is associated with various adverse health outcomes including psychosocial distress, morbidity, and mortality [ 1 ]. Exposure to more than one type of abuse or by more than one perpetrator is called poly-victimization, and this common condition is generally associated with even worse health outcomes than single exposure to abuse [ 5 , 6 ]. It is also increasingly acknowledged that elder abuse is associated with previous experiences of violence in childhood and adulthood, motivating a life-course perspective in research on elder abuse [ 7 , 8 ].

The causes and mechanisms of elder abuse are important to understand, to prevent its occurrence more effectively in society. The socio-ecological model (Fig.  1 ) of abuse describes how abuse can be understood as a complex interplay between risk factors on different social levels (individual, relationship, community, or societal level) for the victim [ 5 , 9 ]. By analyzing and handling abuse with help of this model, the circumstances of abuse are concretized which facilitates practical interventions. However, experiences of elder abuse differ between professionals, other surrounding persons, and the older adults themselves [ 10 , 11 ], and the varying conceptions and definitions used have consequences for the types and forms of interventions planned. If supportive resources are not adapted to the victims’ conceptualizations of elder abuse or to their perceived needs, the resources risk being ineffective [ 1 , 12 , 13 ]. Thus, the voices of the victims themselves are important to truly understand their associated needs as well as the causes and mechanisms of elder abuse, in order to develop more effective interventions.

The socioecological model inspired by Bronfenbrenner [ 9 ] and Heise [ 14 ] as a mean to understand the complexity of elder abuse

Furthermore, qualitative studies have been proposed to better understand conceptual and cultural variations of elder abuse [ 1 ]. Some qualitative studies on abuse of older adults have been undertaken within a theoretical framework of intimate partner violence (IPV; [ 15 , 16 ]), but this framework differs from the framework of elder abuse for example by underestimating the categories of abused men, neglect, and abuse by personnel in healthcare or long-term care [ 17 , 18 , 19 ]. Abuse in healthcare and long-term care are particularly relevant for a comprehensive picture of elder abuse as increasing proportions of the population encounter such institutions due to increasing age, frailty, and social dependence [ 2 , 20 ].

Within the framework of elder abuse, several qualitative studies have asked professionals or other third parties about elder abuse [ 11 , 21 , 22 ], but only few have asked the victims themselves [ 21 , 23 , 24 ]. However, these few previous studies do not offer a sufficiently comprehensive picture of the matter which is why we conducted the present study.

The aim of this study was to explore experiences of elder abuse among the victims themselves. By asking the victims directly, our understanding of elder abuse can hopefully deepen and this in turn is essential for adequate prevention and intervention.

Design, setting and sample

Semi structured qualitative interviews were conducted and analyzed using content analysis. The sample was 24 participants from the larger REAGERA (Responding to Elder Abuse in GERiAtric care) project, which included developing and validating the screening instrument REAGERA-S for detecting elder abuse in healthcare [ 25 ]. Consecutive older adults ≥ 65 years of age admitted to a hospital clinic for both acute geriatric and acute medical patients were eligible for inclusion. The consecutive sampling was chosen in the pursuit of naturalistic openness, and this sampling was expected to lead to a wider range of abuse (including mild forms of abuse), compared to alternative purposeful sampling strategies. A parallel goal of gathering information-rich data was reached through a relatively large number of participants. Exclusion criteria were insufficient somatic, cognitive, or linguistic capacity to answer the screening instrument either independently or with the help of healthcare personnel. Patients at the clinic were mostly admitted from the emergency department, and the mean duration of stay for patients over 65 years was 10 days at the acute geriatric ward and 4 days at the acute medical ward during the study period. The setting is described in greater detail elsewhere [ 25 ]. Between January and June 2018, 306 potential participants were asked to participate by nurses on the ward. The screening instrument was completed by 191 participants, of which 135 were interviewed. Of these 135 participants, 24 had been victims of elder abuse and all their 24 recorded interviews were included for this qualitative study. Descriptive data about the 24 included participants are presented in Table 1 . Typically for the setting of the hospital clinic, the mean age was rather high, as were the number of medications and the degree of social dependence for managing activities of daily living—compared to an average patient in health care.

Before the interview, a nurse on the ward distributed a questionnaire to potential participants including the screening instrument REAGERA-S [ 25 ], as well as information about voluntary participation and informed consent. The screening instrument included nine questions about different kinds of abuse (e.g." Has anyone attempted to control you, limit your contact with others, or decide what you may or may not do?”;”Have you been subjected to any form of physical violence, for example being shoved, pinched, held down, hit or kicked?”), and one question about associated suffering. The instrument in total is available elsewhere [ 25 ]. No precise definition of elder abuse was presented for the participants before the interviews. Rather the information preceding the interviews included rather vague descriptions of elder abuse (e.g. “to be subjected to negative actions”) to prevent steering the participants’ thoughts or stories for the data collection. Later that same day or the following day, a qualitative interview was conducted in a private room. The interview was semi-structured using a prepared interview guide (see Supplement 1 ), with four main topics to cover (experiences of abuse, associated thoughts and feelings, effects of the abuse, and support after the abuse). The informants’ experiences of abuse are presented in this study, while their experiences of coping with abuse and their desired support are presented in a separate paper.

For the interviews, we used open-ended questions such as “Can you tell me some more about what you were exposed to?” and “What are your feelings when you think about this today?”. Probing and supplementary questions were also asked. The interviews were audio recorded and transcribed verbatim. The length of the interviews varied between 12 and 97 min. Field notes were written during or after the interviews. Just after each formal interview, the previously completed questionnaire was quickly checked for severe depression or suicidal risk. In two cases, this check – together with the interview – resulted in a referral to an appropriate care unit for support connected to being abused. The individual’s responses from the REAGERA-S were used at a later stage when classifying cases of elder abuse after the interview, described in more detail elsewhere [ 25 ]. All participants received both oral and written information about support services to contact in case of need. In addition to checking the participants’ psychological wellbeing and perceptions of participation in the interviews, additional follow-ups were carried out by phone by the researchers about 1–2 weeks after the interviews. All participants gave written informed consent at the time of participation. A potential ethical problem of the consent process was the principal vulnerability of the participant in the hospital care setting. The interviewers (three of the researchers: JS, NW and ML) usually work as physicians but were not involved in the formal care of the participants, and this was communicated to the patients orally and through a civilian clothing. By signaling thus that the interviewers were separate from the formal health care personnel, elements of vulnerability and potential dependency of the participant was prevented in the participation. Also, security and rapport were built in the meeting through active listening and validation. The study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Regional Ethics Review Board in Linköping, Sweden (2017/181–31; 2017/564–32).

Transcripts were analyzed using qualitative content analysis, based on Graneheim and Lundman [ 26 ] and a hermeneutic standpoint with an intermediate level of abstraction and interpretation [ 27 ]. For the purpose of exploring individual experiences, the qualitative content analysis was considered an appropriate method with a focus on subject, context and variation of the data [ 27 ]. The process of analysis involved the following steps: 1) repeated preliminary readings of unique interviews to obtain a sense of the whole; 2) dividing the text into units of meaning; 3) giving codes to condensed meaning units; 4) abstraction within and between interviews by aggregating codes into tentative subcategories/categories (manifest content), and subthemes/themes (latent interpretive content); 5) discussion and revision of tentative codes, subthemes/themes, and subcategories into more definitive ones. The analysis included both a search for convergent patterns and a mirror analytical strategy to investigate divergence (consideration of data that did not fit the dominant patterns) [ 28 ].

Six interviews were coded separately and were then discussed together by all the authors. For the remaining interviews, the coding and development of tentative subcategories and themes were carried out by two of the authors (ML and JS; steps 1–4). The tentative themes/subthemes were then discussed and revised (step 5) by all the authors together. This validation within the research group aimed to strengthen the research design, not by identical statements or consensus but as a form of reflexivity through contesting and supplementing each other’s readings [ 29 ]. The QSR International’s NVivo 12 software program was used as a means for sorting and managing data during the process.

The qualitative analysis generated four themes which are presented in detail below: vulnerability in old age; experiences from earlier in life; perceptions of abuse; consequences and suffering from the abuse. An overview of the themes subthemes and subcategories is depicted in Fig.  2 .

Coding tree as an overview of the themes, subcategories, and subthemes of the qualitative content analysis

Vulnerability in old age

The participants described their life situations as contexts for the adverse events they had been subjected to, and these descriptions expressed a general pattern of vulnerability. This vulnerability largely consisted of different kinds of dependence on other people: social, physical, and medical dependence. Social dependence sometimes reflected efforts to avoid loneliness, conflicts, sorrow, or other adversities for the family members.

Physical dependence could be the need to get a ride to visit friends, or a need for assistance with putting on socks due to reduced mobility, while medical dependence could be a need for assistance with injection treatment. The participants’ vulnerability was due to the natural consequences of normal aging, including a lack of energy or reduced mobility, or the consequences of illness, with reduced capacity for activities and participation. It was also a result of social relationships that had evolved over the course of a long lifetime. When participants asked for help or received help from those around them, they consequently had reduced defense against or increased vulnerability to abuse.

“Well, I’m not a happy person any longer, I’m hardly allowed to laugh, because he doesn’t like that really. […] And I also don’t get outdoors like I did before. Then I could take the bus downtown and go shopping and do whatever I wanted. Now he’s behind my wheelchair, checking me all the time, and that’s not fun.” (Woman, ID 9, 71 years).

The participants often expressed a desire to overcome their dependence, either by managing on their own or by finding alternative helpers. Thus, the dependency was often related to a specific perpetrator, but also in general related to any potential helper. However, a lack of energy or failing capacities during old age often resulted in dependence remaining. As a part of their vulnerability, the participants also expressed that it was hard to defend themselves when exposed to abusive situations:

“… if you have employees who behave a little badly to you, that’s different [that’s one thing]… But if you encounter resistance in healthcare, that’s another story.” (Man, ID 19, 85 years).

How the participants related to their vulnerability or their dependence varied, although a common approach was the desire not to bother their helpers (relatives or personnel).

“[There were] times when they [the care personnel] didn’t come. They have… they had a shortage of staff, and when some of them got sick they skipped [visiting some patients], and I was probably the one they cared about the least, as I was the most alert of us.” (Man, ID 1, 85 years).

Reduced autonomy was also described as an aspect or a consequence of dependence on help, whereby the older adults were not allowed to decide, or could not decide, about their life situation. Their autonomy was sometimes reduced by the limited willingness or ability of those around them to meet their needs. On other occasions, their autonomy was reduced by their physical or social impairments. For example, they were sometimes not allowed to decide where to live, or which activities to engage in.

“And they’re talking about putting me there again [in the nursing home], and I don’t want that, but what the hell can I do [about it]?” (Man, ID 1, 85 years).

The participants also expressed their perceptions of limited autonomy when they were treated like objects rather than individuals, or when the personnel did not show any interest or engagement in their personal needs, desires, or personality. For instance, all residents at the nursing home were invited – or sometimes rather forced – to participate in certain specific activities, due to the mistaken ageist notion that all older adults enjoy the same sort of activities. Thus, the older adults perceived reduced autonomy when grudgingly participating in bingo competitions.

The participants also conveyed their theories about why their dependence became so problematic, and these theories were often about specific members of staff being perceived as unfriendly or incompetent. Other theories related to how structural deficiencies of society – or of healthcare, or of certain organizations – contributed to a general lack of humanity among the older adults’ potential helpers. An example of such a perceived structural deficiency is when financial savings made by an organization are allowed to trump care quality or staff competence in healthcare. Accordingly, a recurrently suggested intervention to prevent elder abuse would be to educate the care staff:

Interviewer: “How would it be possible to … [prevent age-discriminatory care by the assisted living]? Participant: “By educating the care staff, of course…. So to [that they would] understand that an older adult has a background whatever that may be./…/. Perhaps education [for them], to understand the individual, so to say”. (Woman, ID 3, 84 years).

Experiences from earlier in life

In addition to the above descriptions of vulnerability during old age, the participants also spoke about their earlier lives, including time of adversity and joy. Several older participants described that, during old age and beforehand, they could receive strength or support from a friend or a partner, from family members, or by participating in an organization. These surrounding supporting elements helped to create security and meaningfulness, despite the adversities of life.

“She [my wife] was valuable to me… in all kinds of ways. And I have always encountered love through church, and these things have been very valuable to me.” (Man, ID 19, 85 years).

Some participants highlighted their activities or professional experiences that had provided support in life, while others highlighted important insights or mental attitudes that had helped to form their identities, their inner strengths, or their sense of meaning in life.

“When I grew up […] I had to do as I was told. And with this attitude I have managed.” (Man, ID 6, 76 years)

Alongside the participants’ stories about positive experiences and support throughout life, they also conveyed rich stories about difficulties and adversities in life. These stories were often about being a victim of violence during childhood, for example being subjected to school bullying or experiencing different types of violence in the family.

“I was five years old when I saw my father threaten her [my mother] with a loaded rifle, then she was wedged into a corner and he stood in the middle of the floor. […] Then my childhood ended, that day.” (Woman, ID 8, 73 years).

The participants told their stories about being subjected to violence in the past with such passion and emphasis that it became clear during the interviews how violence – even many years ago – could have just as strong an impact on health as recent events of victimization.

Perceptions of abuse

In the interviews, the participants described all five types of abuse. Patterns of neglect and psychological violence were most prominent in their stories, while economic, physical, and sexual violence were generally less prominent.

Neglect occurred in relation to different helpers that the participants were dependent on, and the neglect was related to a variety of needs. Hygiene needs were neglected when the participants had limited access to help with showering, cleaning or washing services, or clothing. Insufficient assistance with buying food or medication was described in association with staff shortages at the care organizations, which could prevent the older adults from initiating treatment prescribed by a doctor.

Neglected medical needs could involve sloppy or incompetent wound dressing, or when staff often forgot to administer medications. Several stories related to how care staff dismissed the older adults’ medical needs or symptoms, on the incorrect ageist assumption that the symptoms were signs of normal aging. The following quotation was interpreted as an example of age discrimination, and at the same time neglect of medical needs when a woman was refused a regular treatment regime. It was unclear whether the neglect was intentional or not.

“I was in France last year. I went down a mountain, skiing, it was slippery. [I] was going down and then got stuck in a fence, and so I twisted my knee. […] [I waited two days to seek healthcare until I came home from the journey.] And then they tell me ‘Well, because of your age you’ll have to wait for six months [to receive care]’, oh my god, and ‘You’ll have to do physiotherapy and attend to the osteoarthritis school’.” (Woman, ID 18, 69 years).

Examples of social needs being neglected varied in nature. This could involve older adults being frequently forgotten, after staff had said “I’ll be right back” in response to a request for help. Alternatively, social needs could be neglected when older residents at a nursing home were forced to attend social activities that were not in line with the individual’s specific preferences or abilities. A lack of staff continuity could mean that the participants were deprived of steady relationships with other people. In such ways, the participants expressed a lack of a meaningful existence, secondary to the social neglect.

“And the nursing home was so… well, it was so boring, damn it! It was as if a lot of… I don’t know what to call it… zombies [demented people] went around. They didn’t talk. That [living situation] wasn’t stimulating, either for me or for them.” (Man, ID 1, 85 years).

Psychological abuse was often connected to neglect and occurred in healthcare as well as in nursing homes and in family environments. The psychological abuse was often perceived as a means by which to control or manipulate the participant’s actions. This control could be about small matters, like the choice of which food to eat, but it could also be about more important matters like whether or not to request home service. Sometimes the abuser used aggressive speech if the participant did not live up to the abuser’s expectations or demands.

“I’ve talked to him about it [getting home service], but he doesn’t want that, because he thinks it’s too expensive. But I just feel I don’t have energy to do anything. And he says [to me]: ‘You’re so damned lazy.’” (Woman, ID 9, 71 years).

Control was sometimes exerted verbally, but often involved more subtle non-verbal expressions, such as constant surveillance in daily activities, or expressing a non-verbal tone of disapproval if the participant met friends. In one case, a woman had even been prevented from seeing her mother on her death bed:

“So when my mother was dying, they called me [from her town] and told me to come as there was not much time left. […] I’ll come right away I said, I’ll get on the first flight. And then my husband told me I couldn’t go as it was the weekend, and that I should wait until Monday. […] I wanted to say goodbye [to her] anyway, I wanted to be with her. But I never got there in time, they called me on Monday morning and said she was gone. […] And I hate this.” (Woman, ID 7, 66 years).

The controlling behavior often turned into direct threats against the participant from a child or a partner. These threats could be related to physical violence or not being allowed to see their grandchildren anymore. Psychological abuse also occurred in care environments, although the expressions were generally less explicit. In healthcare, just as in family environments, the abuse was perceived as an attempt to control the older participant’s behavior. Often the intent of the staff seemed to be well-meaning, but the expression was perceived aggressive or otherwise negative by the participant. One example was the following situation, where the participant had just completed a cardiac exercise test at the hospital:

“… I had cycled very fast, I was in severe pain and I was lying on the bed. […] and then she [the member of staff] would, at the physician’s request, spray nitro medication under my tongue, which she did and said to me: ‘Shut your mouth and swallow’, but I couldn’t because I was just in cramp… so she says again ‘Shut your mouth and swallow!’ but I still couldn’t do it, and then she turns away and says ‘Well then, forget that shit!’.” (Woman, ID 8, 73 years).

The descriptions of economic abuse that emerged during the interviews were many and rich in character. Sometimes the perception of economic abuse was not primarily associated with the lost financial value, but rather with the feeling of deception after a theft within a relationship of trust, or the feeling of sorrow when the lost item had great sentimental value.

“I felt terrible [when the jewelry was stolen by service staff], and after that I have never again… asked [them] for help. […] Yes, I think a lot about the jewelry being gone… it was a necklace that I had inherited from my mother, and a bracelet…” (Woman, ID 23, 73 years).

Stories about physical abuse during aging were few, but there were more examples of this from earlier in life. Examples of physical violence in old age including a robbery necessitating hospital care, being pushed by an official during a home visit, physical violence from a fellow passenger during transportation services, and one participant being hit by hospital staff.

“I’ve been hit on the head with a pillow. Just because I was cranky, she [the nurse] said. And I didn’t like that… And I said: ‘Now you get out of here, because you shouldn’t be working with people.’ […] [I] think it is frightening when you have to go to a care facility to receive care, and then you get hit! I don’t think it is acceptable.” (Man, ID 6, 76 years).

There were several stories about sexual abuse from earlier in life, but only few from old age. In one case the participant had been recurrently raped within the marriage, but the raping had ended some years before the age of 65. In another case, sexual abuse in contact with healthcare staff had obviously occurred during old age.

“Once, there was a physician that made some – it sounds weird now that I’m 84, I think I was ten years younger then – he really made sexual invitations [to me]. Yes, I think it sounds weird, but I felt very awkward.” (Woman, ID 3, 84 years).

The participants’ stories of sexual abuse expressed clearly feelings of shame and disgust.

Consequences and suffering from the abuse

The abuse that the participants had been exposed to led to various consequences. Psychological consequences included uncomfortable or painful feelings or thoughts that tormented the participant long after the abuse. For example, this could include nervousness, depression, disappointment, or guilt on the part of the abuser or the victim. The intensity of these uncomfortable feelings and thoughts varied over time, with a common gradual decrease as time, ordinary life, or support measures had helped to sooth the remaining discomfort. However, even a long time after the abuse had ended, the painful feelings and thoughts could be brought back by events or conversations, so that the intensity became strong again. Even if the interviews themselves evoked such painful feelings, the participants generally perceived the interviews as positive.

“… Because I sense this, how can somebody just do that? It’s [the painful experience]… Yes, it’s inside me. I try to get rid of it when it comes, but it isn’t so easy, sometimes it just comes and yes, it’s just there.” (Woman, ID 10, 67 years).

The participants described feelings of inferiority or uselessness, even though they tried to convince themselves that such feelings or thoughts were not truthful. Feelings of nervousness and fear increased again when experiencing new threats of abuse, for example when facing a new need for hospital care after previous negative experiences of abuse in healthcare.

“I hate being admitted [to hospital] like this, you don’t know which department you will be admitted to or which staff you will meet. […] You’re always prepared for the worst. You never know who you will meet when you’re admitted… Of course, I’m always on my guard… against a punch or such things.” (Man, ID 6, 76 years).

The fear of being robbed again made the participants vigilant and distrustful toward staff, strangers, and authorities. Lasting harm from abuse could include aches due to internal tension. Although the participant conveyed that the physical symptoms were caused by the abuse or medical errors, such causal relationships or physical consequences sometimes seemed uncertain for the researchers.

Social effects of the abuse could include loneliness, avoiding going outdoors due to fear of violence, or social isolation caused by reduced self-confidence or an abuser limiting their personal freedom. Social effects could also include a reluctance to accept care service due to fear, even though the older adult needed such services. Regardless of whether the abuse was ongoing or in the past, the suffering could be so intense that the person had lost the will to live or even planned to take their own life.

“I wouldn’t be alive if I didn’t have them [the children]. Then [without the children] I’d have been gone [dead] a long time ago. Then, I wouldn’t be alive. I don’t like life that much.” (Woman, ID 7, 66 years).

The participants commonly expressed feelings of abandonment and lack of control, in association with the abuse and their situation. By contrast, a few participants instead conveyed how they continued to defend their autonomy and strove to keep control of the situation through different strategies, despite their limited physical condition due to old age.

Discussion and implications

This aim of this study was to explore experiences of elder abuse among the victims themselves, as their own descriptions can help us to better understand how to develop prevention and interventions against elder abuse. The qualitative analysis resulted in four different themes (vulnerability in old age; experiences from earlier in life; perceptions of abuse; and consequences and suffering from the abuse), which describe different aspects of abuse from the participants’ subjective perspectives. In all, many of the participants’ perceptions of abuse were similar to previous descriptions by third party of elder abuse [ 11 , 21 , 22 ]. Some aspects of the descriptions of elder abuse in this study were also similar to previous descriptions of abuse among younger adults, but other aspects were substantially different [ 30 , 31 , 32 ], as discussed below.

Vulnerability in old age and experiences from earlier in life

Vulnerability to abuse during old age was described as different sorts of dependence on other people, and a lack of autonomy. Due to the effects of normal aging or accumulated diseases, the participants had limited mobility and an increasing need for care in everyday life, which meant dependence on care and vulnerability to abuse from others.

When the participants were exposed to abuse, their ability to defend themselves was also low for the same reasons. In general, this contributed to a submissive attitude toward the helper, together with inner reactions of anger, sorrow, and resignation. These descriptions of vulnerability have similarities with descriptions of vulnerability and powerlessness among younger adult victims of abuse in healthcare and other settings [ 32 , 33 ]. At the same time, the context of the aging body is characteristically different for the older adult, with decreasing capabilities and increasing dependence on care. The participants’ vulnerabilities were very varying and unique to each individual in terms of aging, morbidity, and life experiences.

The descriptions of vulnerability in old age were similar to those recounted by Y Mysyuk, RG Westendorp and J Lindenberg [ 23 ]. Dependence was described as a reciprocal process between the abuser and the victim in Mysyuk et al., something that was not spontaneously conveyed from the participants of this study. Nor did we identify the pattern described in Mysyuk et al., whereby increased weakness or dependence would provoke more violence.

The participants’ stories about previous stages of their life contributed to comprehensive individual pictures of how specific abuse in old age had had impact on their health. It was particularly evident that abuse in the past could have a great impact on health in old age, for example when psychological abuse in childhood had additive or synergistic effects on the perception of elder abuse. This is in line with previous literature on poly-victimization, and underlines that understanding elder abuse presupposes considering previous victimization as well as personality and the victims’ experiences of support, attachment styles, and challenges in life [ 5 , 8 , 34 ]. According to the socio-ecological model of abuse (Fig.  1 ), vulnerability can occur on all levels of an individual’s life, although previous experiences of life mainly correspond to the individual and interpersonal levels for the older adult [ 5 , 9 ]. Previous life experiences are important not only for understanding the individual’s unique vulnerability to abuse, but also for considering the victim’s individual strengths and resources when designing interventions and the prevention of elder abuse [ 35 ]. Hence, our results agree well with previous findings that a life-course perspective is essential when trying to understand the causes and consequences of elder abuse [ 6 , 7 , 8 ]. However, our findings also underline that abuse occurs in a context, and factors on all levels of the socioecological model influence the experience of abuse, e.g., ageist attitudes and dysfunctional care organizations described further on. By paying attention to and validating the older adult’s own life story, staff can indirectly contribute to interventions at community level in accordance with the socio-ecological model, as this level includes how the victim is treated by organizations [ 19 ].

Different kinds of elder abuse, ageism, and perceived causes of elder abuse

Neglect was a common kind of abuse in this study, and there were rich descriptions of this from healthcare settings and long-term care institutions. Not only were physical and medical needs neglected – so, too, were social needs, with consequent intense feelings of abandonment and lack of control among the participants. These descriptions were partly similar to those found in previous studies [ 36 ], although the examples of neglect in this study were often modest in character, meaning potentially mild physical adverse effects in the short term. Nevertheless, also modest shortcomings with hygiene or cleaning could have serious or even life-threatening consequences, as they meant an increased risk of serious wound infections. Ageist attitudes were obvious in different types of abuse, and especially in the descriptions of neglect, in which for example all older adults were treated like objects in a routine way without respect for their individual characters, needs, or preferences.

The psychological abuse occurred in both family and care environments and seemed to correspond to the abusers’ attempts to control the participants’ behaviors. In care environments, the abuse could be a way for staff to control behaviors in line with specific care routines or comfortable forms of work for the staff. The descriptions of psychological abuse in this study were similar to previous descriptions of psychological abuse in younger victims in healthcare and in younger persons in other environments [ 30 , 33 , 37 ].

The participants often added their own personal explanations for the abuse. In addition to descriptions of vulnerability and self-blame, common explanations included individual staff members being unfriendly, care organizations being structurally dysfunctional (with a lack of competence and resources), general greed at all levels of society, and discriminatory (ageist) attitudes and actions leading to neglect. Similar explanations have been described in previous studies, with ageism probably corresponding to all levels of the socio-ecological model [ 11 , 23 , 38 , 39 ]. Some people would perhaps think that structural deficiencies are not relevant to abuse, but the very definition of elder abuse by WHO clarifies that also “lack of appropriate action” in a dysfunctional environment can constitute elder abuse [ 4 ].

A general issue from the analysis of the interviews was whether the WHO definition of elder abuse is too narrow since it limits elder abuse to relations of trust. In several examples there was no identified relation of trust in a reported situation, but rather a “situation of trust” in which the abusive action would best be described as an example of elder abuse. For example, when an older adult is exposed to abuse during transportation services, there would be a situation of trust regardless of whether there are any relations of trust. The older adult would typically be vulnerable in this situation due to the physical limitations of ageing. With a narrow interpretation of the WHO definition, this abuse would dysfunctionally not be classified as elder abuse, although the theoretical framework of elder abuse would fit for an adequate understanding and prevention of the same abuse [ 40 ].

Consequences of the abuse

The participants described consequences of abuse in a way that resembled how consequences of trauma have been previously described among both older and younger adults [ 3 , 30 , 41 ]. Whereas patterns of psychological consequences (with negative thoughts and feelings of shame and fear) were rather like descriptions from previous studies among younger adults, the behavioral consequences were different and related to various social and physical preconditions among the older adults compared to younger adults. Social isolation and loneliness were natural consequences of limited mobility in normal aging or disease, and when abuse also contributed to these limitations the sense of isolation grew particularly strong. When participants chose not to receive home-care services because of the fear of recurrent abuse – despite their needs for assistance – the limiting consequences of abuse were particularly evident. There were also examples from the interviews of how neglect could have serious potential physical consequences, as many of the older adults were less physically able to withstand medical mistreatment.

Implications for the prevention of and intervention into elder abuse

Our findings have several implications for the prevention of and intervention into elder abuse. In terms of the socio-ecological model, preventive measures at community (including hospital level) and societal levels could be to ensure a minimum standard (for example by using legislation or economic incentives) for the care of older adults. According to the participants' voices, higher minimum standards of staff competence and resources would be likely to reduce the tendencies toward neglect, psychological abuse, or other kinds of abuse. Vulnerability and abuse could according to the participants also be prevented through education to care staff about different aspects of elder abuse and about aging. Such educational measures were suggested to promote person-centredness and prevent ageist attitudes, as these attitudes seem to contribute to both the vulnerability and elder abuse [ 39 ]. In addition, support units are also needed to offer individual assistance to victims of elder abuse as the negative consequences are substantial. According to a bifocal ecological approach, the assistance should not only be directed to the victim for an effective prevention but also to the perpetrator [ 42 ]. However, an important principle should be to adapt the preventive measures to the individual, as both vulnerability and abuse perceptions vary significantly according to the individual’s unique biopsychosocial conditions and experiences from earlier life. This also underlines the need for a life-course perspective on elder abuse [ 34 , 43 ].

Limitations

In order to minimize bias introduced by the researchers’ preconceptions and instead promote reflexivity, four researchers with different backgrounds have cooperated in the study. Three of the authors work as physicians within geriatrics and psychiatry, while the fourth author works with research, mostly outside hospital environments.

The fact that the sample was selected from inpatient care could be regarded as a disadvantage, as some older adults might have had too little energy to participate actively in interviews while suffering from an acute illness with associated physical exhaustion. On the other hand, the decision to recruit participants from inpatient care meant certain advantages, for example offering the participants a secure context for the interviews while their home or other environments might have been less secure, or more easily controlled by an abuser.

The results are likely to be transferable to older adults in Sweden but should be transferred with caution to countries with other cultures or societal structures.

This is one of few studies to date in which qualitative interviews have been used to explore experiences of elder abuse among the victims themselves. Their stories had similarities with both previous third-party descriptions of elder abuse and previous descriptions of abuse among younger adults. There were also substantial differences, with the consequence that elder abuse needs to be understood and managed by partly different means compared to abuse among younger adults. Vulnerability to elder abuse is often associated with an individual mix of the aging body, illnesses, and a dependence on secondary help. A life-course perspective considering experiences from the individual’s past would be beneficial when designing support for older victims, as such experiences are important to the degree of suffering and disability that the victim develops in relation to elder abuse. Prevention ought to include individually tailored help or support to reduce vulnerability, specific education, and ensuring an acceptable minimum standard of care for older adults in general [ 14 ].

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available and are not available from the corresponding author on request due to reasons concerning participant privacy and confidentiality.

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Acknowledgements

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Open access funding provided by Linköping University. This work was supported by the Swedish Crime Victim Fund, grants no. 3322/2017, 2944/2018, and 03384/2019. The funding source had no involvement in the study design, data collection, analysis, interpretation of the data nor in writing the manuscript.

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Contributions

All authors contributed to the design of the study. JS, NW and ML performed the interviews and performed proofreading of transcripts. Six interviews were coded separately and were then discussed together by all the authors. For the remaining interviews, the coding and development of tentative subcategories and themes were carried out by ML and JS. Tentative themes/subthemes were then discussed and revised by all the authors together. ML wrote the first draft of the manuscript, and all authors contributed to and approved the final manuscript.

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The study was approved by the Regional Ethics Review Board in Linköping, Sweden (2017/181–31; 2017/564–32) and was conducted in accordance with the principles of the Declaration of Helsinki. All participants gave written informed consent at the time of participation.

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  Supplement 1. INTERVIEW GUIDE (for two parallel studies).

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Ludvigsson, M., Wiklund, N., Swahnberg, K. et al. Experiences of elder abuse: a qualitative study among victims in Sweden. BMC Geriatr 22 , 256 (2022). https://doi.org/10.1186/s12877-022-02933-8

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Get the Facts on Elder Abuse

Related Topics

• Aging Services for Advocates

What is elder abuse?

The Centers for Disease Control & Prevention defines elder abuse as “an intentional act or failure to act that causes or creates a risk of harm to an older adult” (age 60 or older). 1

Elder abuse includes physical abuse, emotional/psychological abuse, sexual abuse, financial exploitation, neglect, and abandonment. Perpetrators include children, other family members, and spouses—as well as staff at nursing homes, assisted living, and other facilities.

• Physical abuse  means inflicting physical pain or injury upon an older adult.
• Sexual abuse  means touching, fondling, intercourse, or any other sexual activity with an older adult, when the older adult is unable to understand, unwilling to consent, threatened, or physically forced.
• Emotional/psychological abuse  means verbal assaults, threats of abuse, harassment, or intimidation.
• Confinement  means restraining or isolating an older adult, other than for medical reasons.
• Passive neglect  is a caregiver’s failure to provide an older adult with life’s necessities, including, but not limited to, food, clothing, shelter, or medical care.
• Willful deprivation  means denying an older adult medication, medical care, shelter, food, a therapeutic device, or other physical assistance, and exposing that person to the risk of physical, mental, or emotional harm—except when the older, competent adult has expressed a desire to go without such care.
• Financial exploitation  means the misuse or withholding of an older adult’s resources by another.

Learn more about the  types of abuse  from the National Center on Elder Abuse (NCEA).

How many older Americans are abused?

While pre-pandemic sources estimated approximately one in 10 Americans age 60+ have experienced some form of elder abuse, 2 a more recent study found that 1 in 5 older adults reported elder abuse during the COVID-19 pandemic. 3 Another study estimated that only 1 in 24 cases of abuse are reported to authorities. 4

Who are the abusers of older adults?

Abusers are both women and men, and people of all ages. An analysis of calls to the National Center on Elder Abuse resource line found that family members were the perpetrators in nearly 47% of incidents. Medical (non-family) caregivers were perpetrators in almost 13% of cases, while only 6.7% of callers did not know their abuser. 5

What makes an older adult vulnerable to abuse?

Social isolation  and mental impairment (such as  dementia or Alzheimer’s disease  ) are two factors. Recent studies show that nearly half of those with dementia experienced abuse or neglect. Interpersonal violence also occurs at disproportionately higher rates among adults with disabilities.

What are the warning signs of elder abuse?

• Physical abuse, neglect, or mistreatment:  Bruises, pressure marks, broken bones, abrasions, burns

• Emotional abuse:  Unexplained withdrawal from normal activities; a sudden change in alertness, or unusual depression; strained or tense relationships; frequent arguments between the caregiver and older adult

• Financial abuse:  Sudden changes in financial situations

• Neglect:  Bedsores, unattended medical needs, poor hygiene, unusual weight loss
• Verbal or emotional abuse:  Belittling, threats, or other uses of power and control by individuals

What are the effects of elder abuse?

Abuse and neglect can have serious physical and psychological effects on older adults. Survivors report higher rates of depression and social withdrawal, leading to increased hospitalization and premature death. 6

The annual losses incurred by older adults who are victims of financial abuse total over $28 billion each year . Elder financial abuse extends beyond the immediate losses as well; family caregivers and social safety net programs often have to assist with paying for care when an older loved one is exploited. 7

Are there criminal penalties for the abusers?

Most states have penalties for those who victimize older adults. Increasingly, across the country, law enforcement officers and prosecutors are trained on elder abuse and ways to use criminal and civil laws to bring abusers to justice. Review state-specific elder justice laws on the Elder Abuse Guide for Law Enforcement (EAGLE) website .

If an older adult is in immediate, life-threatening danger, call 911. Anyone who suspects that an older adult is being mistreated should contact a local  Adult Protective Services  office, Long-Term Care Ombudsman, or police. NCEA describes various ways to Get Help if you suspect abuse, and more information is available from the Eldercare Locator  online  or by calling 1-800-677-1116.

How can elder abuse be prevented?

It’s important to remember that elder abuse can happen to anyone, regardless of socioeconomic status, race, health/disability status or living situation. Educating seniors, professionals, caregivers, and the public on abuse is critical to prevention. If you’re an older adult, you can stay safe by:

• Taking care of your health.
• Seeking professional help for drug, alcohol, and depression concerns and urging family members to get help for these problems.
• Attending support groups for spouses and learning about domestic violence services.
• Planning for your own future. With a power of attorney or a living will, you can address health care decisions now to avoid confusion and family problems later. Seek independent advice from someone you trust before signing any documents.
• Staying active in the community and connected with friends and family. This will decrease social isolation, which has been connected to elder abuse.
• Posting and opening your own mail.
• Not giving personal information over the phone.
• Using direct deposit for all checks.
• Having your own phone.
• Reviewing your will periodically.
• Knowing your rights. If you engage the services of a paid or family caregiver, you have the right to voice your preferences and concerns. If you live in a nursing home, call your Long-Term Care Ombudsman . The ombudsman is your advocate and has the power to intervene.

Where can I learn more?

• Administration for Community Living (ACL): Protecting Rights and Preventing Abuse
• National Center on Law & Elder Rights
• USC Center on Elder Mistreatment  
• Consumer Financial Protection Bureau Office of Financial Protection for Older Americans
• Department of Justice Elder Justice Initiative
• Federal Trade Commission Scam Alerts
• Elder Justice Coalition
• Women’s Institute for a Secure Retirement  (WISER)
• National Adult Protective Services Association
• National Long-Term Care Ombudsman Resource Center
• NCEA and United Nations resources
• World Health Organization

NCOA's role

The National Council on Aging (NCOA) is proud to champion the rights of older Americans—especially women, people of color, the LGBTQ+ community, people with low income, and those living in rural areas. NCOA strives to ensure that every American can age with dignity and respect and be free from abuse or exploitation.

Our work to combat elder abuse takes several forms:

• Each year on June 15 NCOA recognizes World Elder Abuse Awareness Day , a chance to spotlight this global challenge and the steps that individuals and society need to take to eradicate elder abuse.
• NCOA is a strong advocate for continued reauthorization and funding for services under the Elder Justice Act , a critical piece of legislation first passed in 2010 that supports research and innovation to advance elder justice, and helps to enhance Adult Protective Services.
• NCOA also advocates for the reauthorization of the Older Americans Act , which includes support for the Long-Term Care Ombudsman program as elder abuse screening and prevention efforts.

1. CDC. About the abuse of older persons. April 24, 2024. Found on the internet at: https://www.cdc.gov/elder-abuse/about/index.html

2. Rosay, A. B., & Mulford, C. F. Prevalence estimates and correlates of elder abuse in the United States: The national intimate partner and sexual violence survey. Journal of elder abuse & neglect. January 2017. Found on the internet at https://nij.ojp.gov/library/publications/prevalence-estimates-and-correlates-elder-abuse-united-states-national-0

3. Chang, E. & Levy, B. High Prevalence of Elder Abuse During the COVID-19 Pandemic: Risk and Resilience Factors. American Journal of Geriatric Psychiatry. January 2021. Found on the internet at https://pubmed.ncbi.nlm.nih.gov/33518464/

4. Storey, J. E. Risk factors for elder abuse and neglect: A review of the literature. Aggression and Violent Behavior. January-February 2020. Found on the internet at https://www.sciencedirect.com/science/article/abs/pii/S1359178918303471?via%3Dihub

5. Weissberger, G. H., et al. Elder abuse characteristics based on calls to the National Center on elder abuse resource line. Journal of Applied Gerontology. October 2020. Found on the internet at https://pubmed.ncbi.nlm.nih.gov/31364442/

6. ACL. Elder Abuse: A public health issue that affects us all. June 15, 2018. Found on the internet at: https://acl.gov/news-and-events/acl-blog/elder-abuse-public-health-issue-affects-all-us-0

7. AARP. The Scope of Elder Financial Exploitation: What It Costs Victims. June 27, 2023. Found on the internet at: https://www.aarp.org/pri/topics/work-finances-retirement/fraud-consumer-protection/scope-elder-financial-exploitation.html

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Elder abuse: How to spot warning signs, get help, and report mistreatment

Older people today are more visible, active, and independent than ever before. As the population of older Americans grows, it’s necessary to ensure they have appropriate care resources.

• Physical Abuse and Violence
• Older Adults and Aging

Every person, no matter how old, deserves to be safe from harm by those who live with them, care for them, or have daily contact with them. Yet, approximately one in 10 people aged 60 and older who live at home experience abuse, including mistreatment and exploitation, according to the Centers for Disease Control and Prevention. Some evidence even indicates that the prevalence of abuse of older people in both the community and in institutions has increased during the COVID-19 pandemic .

Over time, elder abuse can harm an individual’s physical and psychological health, destroy social and family ties, and cause devastating financial loss. Research also suggests that older people who have been abused tend to die earlier than those who have not been abused, even in the absence of chronic conditions or life-threatening disease.

What does elder abuse look like?

There is no single pattern of elder abuse. It’s a complex problem that can stem from multiple causes, such as a history of violent interactions within the family, lifestyle adjustments, and tensions that can arise as a result of new living arrangements. A caregiver's personal problems—for example, caregiver stress, mental or emotional illness, addiction to alcohol or other drugs, job loss, or other personal crises can lead to the abuse of an older person. Certain societal attitudes may also contribute to violence against older people and make it easier for abuse to continue without detection or intervention. For example, older people are often regarded as insignificant, leading society to fail to recognize the importance of assuring dignified, supportive and nonabusive life circumstances for every older person. These factors include the devaluation of and lack of respect for older adults and society's belief that what goes on in the home is a private, “family matter.”

Elder abuse can take many different forms, including:

• Physical abuse , which can range from slapping or shoving to severe beatings and restraining with ropes or chains. When a caregiver or other person uses enough force to cause unnecessary pain or injury, even if the reason is to help the older person, the behavior can be considered abusive. Physical abuse also encompasses behaviors such as hitting, beating, pushing, shoving, kicking, pinching, burning or biting. It also includes the inappropriate use of medications and physical restraints and physical punishment of any kind.
• Verbal, emotional or psychological abuse, including yelling, swearing, threatening, making insulting or disrespectful comments or repeatedly ignoring the older adult. Psychological abuse involves any type of coercive or threatening behavior that sets up a power differential between the older adult and his or her family member or caregiver. It can also include treating the older person like a child and isolating the person from family, friends, and regular activities .
• Sexual abuse, which includes inappropriate touching, photographing the older adult in suggestive poses, forcing the person to look at pornography, and any unwanted sexualized behavior.
• Financial abuse and exploitation, which can range from misuse of an older person's funds to embezzlement. It can include forging checks, taking someone else's retirement or Social Security benefits, or using a person's credit cards and bank accounts without their permission. It also includes changing names on a will, bank account, life insurance policy, or title to a house without permission.
• Caregiver neglect, which can be intentional or unintentional, and involves intentionally failing to meet the physical, social, or emotional needs of the older person. Neglect can include failure to provide food, water, clothing, medications, and assistance with activities of daily living or help with personal hygiene.

Who is most affected by elder abuse?

Like other forms of abuse, elder abuse is a complex problem, and it is easy for people to have misconceptions about it. The truth is that:

• Most elder abuse and neglect takes place at home. The majority of older adults live in the community, either on their own or with their spouses, children, siblings, or other relatives, rather than in institutional settings. As a result, the home is where most abuse happens. Family members commit elder abuse in nearly 6 out of 10 cases , according to the National Council on Aging.
• Anyone can be vulnerable. Older individuals who are frail, alone, or depressed as well as those with a physical disability or mental illness are vulnerable to abuse. Even those who are not affected by these more visible risk factors can find themselves in abusive situations and relationships. Elder abuse affects people across all socioeconomic groups, cultures, races, and ethnicities.

What are the signs of elder abuse?

While many of these symptoms may be the result of disease conditions or medications, their appearance should prompt further investigation to determine and remedy the cause. Cues that cannot be explained medically may signal elder abuse.

• Unexplained bruises, burns, cuts, or scars
• Lack of basic hygiene, adequate food and water, or clean and appropriate clothing
• Lack of medical aids (glasses, walker, teeth, hearing aid, medications)
• Sunken eyes or unexplained weight loss
• Untreated bedsores
• Dismissive attitude or statements about injuries
• Unreasonably fearful or suspicious
• Lack of interest in social contacts
• Unexplained or uncharacteristic changes in behavior
• Unexplained vaginal or anal bleeding
• Venereal diseases or vaginal infections
• Signs of insufficient care or unpaid bills despite adequate financial resources
• Large withdrawals from bank accounts or other unusual ATM activity

Where should I go for help with elder abuse?

If you suspect someone you know is being abused or neglected, don't let your fear of meddling in someone else's business stop you from reporting your suspicions. Your first step should be to try and talk with the older adult when the two of you are alone. You could tell them that you think something might be wrong and that you're worried and offer to take them to get help.

Every state has a service designated to receive and investigate allegations of elder abuse and neglect, also known as Adult Protective Services . In addition, the Eldercare Locator is a nationwide service sponsored by the U.S. Administration on Aging that connects older Americans and their caregivers with information on services for older adults. If you know the zip code of an older person being abused, the website can refer you to the appropriate agency in the area to report the suspected abuse.

Don’t put the older adult in a more vulnerable position by confronting the abuser yourself unless you have their permission and are able to help the person experiencing abuse immediately by moving them to a safe place.

If you feel you are being abused or neglected, help is available. If you can safely talk to someone about the abuse, such as your physician, a trusted friend, or a member of the clergy, who can remove you from the situation or find help for the abuser, do so at once. Your physician has a legal obligation to report the abuser and help you find safety.

You can also contact Adult Protective Services , and they will help you find safety and find help for the person who is abusing you. In addition, the Eldercare Locator is a nationwide service sponsored by the U.S. Administration on Aging that connects older Americans with information on senior services. You can put in your zip code and the website will refer you to the appropriate agency in your area to report the abuse. To speak with someone for support, hotlines such as National Domestic Hotline and the Institute on Aging's Friendship Line (for people 60+ and adults living with disabilities) are available toll-free. You can also contact the Centers for Medicare and Medicaid Services if you suspect healthcare fraud.

If you feel you have been abusive or are in danger of abusing an older person in your care, one solution may be to find ways of giving yourself a break and relieving the tension of having total responsibility for an older person who is dependent on you. Area Agencies on Aging are a local resource for services that might help family caregivers find respite and in-home help with difficult care tasks such as bathing, dressing, and cooking.

If you recognize that abuse, neglect, or violence is a way you often solve problems, you will need expert help to break old patterns. Talk with someone who can help—a trusted friend or family member, a counselor, or your pastor, priest, or rabbi. If alcohol or drugs are a problem, consider contacting Alcoholics Anonymous or some other self-help group. You can also contact a professional, such as a counselor, psychologist, or therapist who specializes in helping people change destructive behaviors. To find a competent therapist, ask your physician or your health plan representative for a recommendation. APA can help you find a local psychologist through its Psychologist Locator .

How can I prevent elder abuse?

The first and most important step toward preventing elder abuse is to recognize that no one should be subjected to violent, abusive, humiliating, or neglectful behavior. In addition to promoting this social attitude, individuals can take positive steps such as educating people about elder abuse, increasing the availability of respite care, promoting increased social contact and support for families with dependent older adults, and encouraging counseling and treatment to cope with personal and family problems that contribute to abuse.

Education is the cornerstone of preventing elder abuse. Media coverage of abuse in nursing homes has made the public knowledgeable about —and outraged by —abusive treatment in those settings. However, as most abuse occurs in the home by family members or caregivers, there needs to be a concerted effort to educate the public about the special needs and problems of older adults and the risk factors for abuse.

Respite care is an essential way to help reduce caregiver stress, and as a result, prevent elder abuse. Every caregiver needs time alone, free from the worry and responsibility of looking after someone else’s needs, and having someone else care for an older adult, even for a few hours each week, is crucial. Respite care is especially important for caregivers of people suffering from Alzheimer’s disease or other forms of dementia, or of older people who are disabled. The National Institute on Aging and other organizations offer a variety of resources on finding and paying for respite care.  

Social contact and support can be a boon to older adults and to family members and caregivers as well. When other people are part of the social circle, tensions are less likely to reach unmanageable levels. Many times, families in similar circumstances can band together to share solutions and provide informal respite for each other. In addition, when there is a larger social circle, abuse is less likely to go unnoticed.

Counseling for behavioral or personal problems in the family or for the individual with mental health and/or substance abuse problems can play a significant role in helping people change lifelong patterns of behavior or find solutions to problems emerging from current stresses. If there is a substance abuse problem, treatment is the first step in preventing violence against the older individual. In some cases, a nursing home may be a more appropriate living environment than living with someone who is not equipped emotionally or physically to handle the responsibility. Even in situations in which it is difficult to tell whether abuse has really occurred, counseling can be helpful in alleviating stress.

This free online resource is an updated and condensed version of APA’s 2013 document Elder Abuse and Neglect: In Search of Solutions (PDF, 681KB) created by the organization’s Committee on Aging .

• Aging and older adults
• Physical abuse and violence

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ROBERT M. HOOVER, MD, AND MICHOL POLSON, PhD

Am Fam Physician. 2014;89(6):453-460

Author disclosure: No relevant financial affiliations.

Elder mistreatment includes intentional or neglectful acts by a caregiver or trusted person that harm a vulnerable older person. It can occur in a variety of settings. One out of 10 older adults experiences some form of abuse or neglect by a caregiver each year, and the incidence is expected to increase. Although the U.S. Preventive Services Task Force found insufficient evidence that screening for elder abuse reduces harm, physicians in most states have professional and legal obligations to appropriately diagnose, report, and refer persons who have been abused. Screening or systematic inquiry can detect abuse. A detailed medical evaluation of patients suspected of being abused is necessary because medical and psychiatric conditions can mimic abuse. Signs of abuse may include specific patterns of injury. Interviewing patients and caregivers separately is helpful. Evaluation for possible abuse should include assessment of cognitive function. The Elder Abuse Suspicion Index is validated to screen for abuse in cognitively intact patients. A more detailed two-step process is used to screen patients with cognitive impairment. The National Center on Elder Abuse website provides detailed, state-specific reporting and resource information for family physicians.

The National Center on Elder Abuse defines elder abuse as “intentional or neglectful acts by a caregiver or ‘trusted’ individual that lead to, or may lead to, harm of a vulnerable elder.” 1 Although some authors draw distinctions among mistreatment, abuse, and neglect, this article uses the terms inclusively and interchangeably. The major manifestations of elder abuse are described in Table 1 . 2

Abuse appears to occur most often in domestic home situations, and may be perpetrated by adult caregivers, family members, or other persons. 3 It may also occur in institutional settings such as long-term care facilities, nursing homes, or hospice. 4 , 5 Older patients (older than 75 years) tend to have more risk factors (i.e., shared living arrangements, cognitive impairment with disruptive behaviors, social isolation from family and friends, caregiver mental illness [e.g., major depression], alcohol misuse, and caregiver dependency on the older person [e.g., financial]). 6 These same risk factors can be barriers to detection of abuse. Not all patients who experience abuse readily demonstrate or express risk factors, and, conversely, many patients with risk factors are not being mistreated.

U.S. estimates indicate that one out of 10 older adults experiences abuse or neglect by a caregiver each year. 7 , 8 In addition, it appears that only a fraction of cases are reported to authorities, although reported and investigated cases have increased. A study of state Adult Protective Services (APS) cases found that investigated reports increased by 16.3% and that substantiated reports increased by 15.6% from 2000 to 2004. 9

A Growing Problem

Over the next 20 years, the geriatric proportion of the U.S. population is projected to increase from 12% to 31%. 10 – 12 Family physicians can expect more instances of elder abuse because larger numbers of older persons will need medical care. 12 , 13 As more states mandate reporting by physicians (most already do), there will be increasing obligations for detection and assessment. 14 Despite this expected increased demand for expertise, physicians generally lack training, experience, education, and adequate guidelines for the assessment and management of abuse. Less than 2% of reports of elder abuse and neglect to state APS agencies come from physicians. 15 A 2005 survey of family physicians and internists found that more than 80% of them could not recall any medical school or residency training in this area. 16 , 17 Another survey showed that 44% of residency program directors report actively screening patients for elder abuse. 18

The U.S. Preventive Services Task Force found that current evidence is insufficient to assess the balance of harms and benefits of screening all older or vulnerable adults for abuse and neglect. At this time, there does not appear to be supportive evidence that screening and early detection of elder abuse and neglect reduce exposure to abuse, or physical or mental harm from abuse. 19 The Joint Commission, National Center on Elder Abuse, National Academy of Sciences, and American Academy of Neurology recommend routine screening, and the American Medical Association recommends routine inquiry. 20 Identification of and intervention in abuse are considered by many to be a professional responsibility for physicians and are an accreditation requirement for hospitals. The University of Maine Center on Aging, Maine Partners for Elder Protection recommends screening once or twice yearly. 21

It is not clear if using specific screening protocols decreases the incidence or impact of elder abuse any more than simply having a generally increased threshold of suspicion. 5 Validated screening instruments are available for physicians to consistently and systematically inquire about abuse. If a family physician chooses, preventive health visits may function as a reasonable occasion for screening. 20 , 21

THE ELDER ABUSE SUSPICION INDEX

Few instruments designed to detect risk of or suspected abuse have been validated in primary care settings. 22 The Elder Abuse Suspicion Index (EASI) was validated in a primary care setting and can be used by physicians to screen cognitively intact patients during routine visits ( Figure 1 ) . 23 It has a sensitivity of 0.47 and a specificity of 0.75. The EASI includes five patient-answered items, plus one physician question that can identify patients who are at risk. At least one “yes” response to questions 2 through 6 indicates a need for further assessment. 23

Screening older patients for mistreatment may follow a one- or two-step process, depending on the patient's level of cognitive function. When the physician has known a normally functioning, cognitively intact patient over time, one-step screening using the EASI is recommended. When the physician does not know the patient or suspects dementia, the two-step process begins with screening for cognitive impairment with the Mini-Cog. 24 It can be administered in less than five minutes and has comparable sensitivity and specificity to the well-known Mini-Mental State Examination. 24 , 25 If the Mini-Cog is negative for dementia, the physician may administer the EASI. If the Mini-Cog is positive, further assessment should clarify cognitive impairment before screening for abuse. Cognitive deficits may be limited to specific domains, and a patient may retain memory and capacity in others.

Medical History

Patients who present with injuries or signs of abuse should be evaluated, treated, and appropriately referred. The physician should begin by asking open-ended questions, such as “Can you tell me what happened?” and “What do you remember about how this injury occurred?”

A complete medical and surgical history, as well as a complete medication review, should be obtained, including identification of who is responsible for supplying and managing the patient's medications. Specifically, old trauma, evidence of metabolic bone disease, and use of anticoagulants should be noted. A brief functional assessment should assess activities of daily living (e.g., hygiene, toileting, dressing) and instrumental activities of daily living (e.g., shopping, managing finances, managing medications). 26 , 27 Next, the patient should be asked about the safety of the home environment. Lastly, questions such as those in the EASI assess the patient's experiences and perceptions of personal safety. When abuse or neglect is strongly suspected, referral for complete multidisciplinary functional assessments may include home visits by local social workers, concerned family or friends, or APS authorities.

While assessing for suspected elder abuse, physicians must differentiate disease processes or normal aging from signs of injuries ( Table 2 ) . 28 Underlying conditions that mimic intentional injury or predispose the patient to injury should be noted. Adverse reactions to home remedies and prescription and nonprescription medications can resemble intentional injuries. Some ethnic groups use traditional healing methods, such as cupping, moxibustion, or coin rubbing, which may cause skin lesions resembling intentional injury. 29

INTERVIEW PATIENT AND CAREGIVER SEPARATELY

An older patient's neurologic, cognitive, or psychiatric conditions and family dynamics may create barriers to obtaining a reliable history. Fear of retaliation, shame, dependency on the caregiver, and lack of privacy may hinder disclosure. Using neutral, nonjudgmental questions, family physicians should encourage patients and caregivers to provide detailed information. Interviewing the patient alone, when possible, is paramount. 21 Some older persons have such high dependency on caregivers for navigating health care systems that they are unable to give a one-on-one interview. A potential red flag for the possibility of elder mistreatment is a caregiver who often interrupts the patient to answer questions for him or her. However, such behavior does not always indicate elder mistreatment, and it could be a compensatory behavior for a patient with cognitive impairment. A hovering and protective caregiver does not imply patient intimidation. Some families may not trust health care professionals based on past experiences. Responding with reassurance and sensitivity overcomes patient and family resistance in many, if not most, cases.

Physical Signs of Abuse

Physical findings specific to abuse are rare. Patterns of injury such as ligature marks; multiple burns; and bruises on the abdomen, neck, posterior legs, or medial arms do not generally originate from unintentional trauma such as falls. Physicians might not be able to accurately determine the age of bruises or burns; however, particular sizes, patterns, and locations may suggest intentional injury ( Table 3 ) . 28 – 30 The presence of unusual or unexplained fractures (e.g., spiral long bone fractures, first rib fractures) requires a more thorough skeletal survey and evaluation for metabolic bone disease.

No laboratory tests exist to definitively detect abuse. Undetectable levels of prescribed drugs may indicate medication withholding, which, in the case of a dependent older person with cognitive impairment, constitutes neglect. Caregivers may divert controlled substances for illicit use. Elevated therapeutic drug levels without medical explanation may indicate intentional or unintentional overdose. The presence of drugs or other toxins that are not prescribed may indicate poisoning. Coagulation studies and a platelet count can rule out a medical reason for abnormal or excessive bruising.

Body charts or clinical photographs (obtained with appropriate consent) are useful to document the location and shape of injuries such as bruises, skin tears, burns, and other skin conditions. If a recent sexual assault is reported or suspected, a forensic examination should be performed by a person with appropriate training and expertise. 31 The central question for differentiating unintentional from intentional injuries is: “Is the explanation provided reasonably consistent with the physical findings?”

Management and Intervention

Depending on the acuity of the presentation, hospitalization may be necessary to provide treatment and protection during further evaluation or pending legal investigation. 32 , 33 In the case of positive results on screening tests or other suspicion of abuse, actions are dictated by statutory reporting requirements. Family physicians will need to involve local social services and APS to determine options for disposition.

No consensus exists for a single standard algorithm for the evaluation and management of elder abuse. However, the general algorithm provided in Figure 2 is acceptable for most practice settings. 34 Physicians may insert the statutory requirements for their practice location into the appropriate sections. A safety plan ( Table 4 35 ) is an important element of the care plan in all situations.

Table 5 provides a list of resources about elder abuse. The Administration on Aging's National Center on Elder Abuse website ( http://www.ncea.aoa.gov ) is the most comprehensive online resource available on elder abuse. It provides specific information on each state's laws defining elder abuse and mandatory reporting requirements; information on local contact agencies and numbers; links for state or local intervention resources; and information for caregivers and patients. Specific resources for each state are also available weekdays via the Eldercare Locator (telephone: 800-677-1116). Even when APS or law enforcement becomes involved, family physicians still bear significant responsibility for follow-up medical care of patients. Relationship continuity can support the patient and family in the process of healing and recovery.

Data Sources : The search included Agency for Healthcare Research and Quality Evidence Reports, Cochrane Database of Systematic Reviews, Clinical Evidence, National Guidelines Clearinghouse, Institute for Clinical Systems Improvement, U.S. Preventive Services Task Force, PubMed, and Google Professional. We used electronic libraries from the University of Tennessee Health Sciences Center, and the Oregon Health and Sciences University. Key terms: elder abuse and neglect; screening instruments for elder abuse, neglect; injury, wound, bruise patterns for elder abuse; mandatory reporting for elder abuse, neglect; and safety plans for elder abuse, neglect. Search date: May 1, 2010, and October 6, 2013.

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Bond MC, Butler KH. Elder abuse and neglect: definitions, epidemiology, and approaches to emergency department screening. Clin Geriatr Med. 2013;29(1):257-273.

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Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364(9441):1263-1272.

Acierno R, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. Am J Public Health. 2010;100(2):292-297.

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Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies

Karl pillemer.

1 Department of Human Development, Cornell University, Ithaca, New York.

David Burnes

2 Factor-Inwentash Faculty of Social Work, University of Toronto, Canada.

Catherine Riffin

3 Department of Internal Medicine and Geriatrics, Yale School of Medicine, New Haven, Connecticut.

Mark S. Lachs

4 Division of Geriatrics and Palliative Medicine, Weill Cornell Medical College, New York.

Elder mistreatment is now recognized internationally as a pervasive and growing problem, urgently requiring the attention of health care systems, social welfare agencies, policymakers, and the general public. In this article, we provide an overview of global issues in the field of elder abuse, with a focus on prevention.

Design and Methods:

This article provides a scoping review of key issues in the field from an international perspective.

By drawing primarily on population-based studies, this scoping review provided a more valid and reliable synthesis of current knowledge about prevalence and risk factors than has been available. Despite the lack of scientifically rigorous intervention research on elder abuse, the review also identified 5 promising strategies for prevention.

Implications:

The findings highlight a growing consensus across studies regarding the extent and causes of elder mistreatment, as well as the urgent need for efforts to make elder mistreatment prevention programs more effective and evidence based.

Elder abuse is now recognized internationally as an extensive and serious problem, urgently requiring the attention of health care systems, social welfare agencies, policymakers, and the general public. Reports from the World Health Organization, United Nations, and other international bodies have prominently featured elder abuse and highlighted the range of harmful activities subsumed under this rubric throughout the world ( World Health Organization, 2011 , 2014 ; OHCHR, 2010 ; Podnieks, Anetzberger, Wilson, Teaster, & Wangmo, 2010 ). With a global explosion in the older adult population, elder abuse is expected to become an even more pressing problem, affecting millions of individuals worldwide. Elder abuse is associated with devastating individual consequences and societal costs, meriting attention as a serious public health issue.

In this article, we provide an overview of global issues in the field of elder abuse, with a focus on prevention. This emphasis is appropriate because elder abuse is likely the most widespread problem of older people that is largely preventable (unlike many disease conditions of old age). Therefore, a better understanding of causes and prevention of elder abuse should be a major international priority. Fortunately, an improving international scientific literature has accompanied this growing concern, including prevalence studies in a number of countries and international comparative projects. In addition, prevention strategies have been increasingly documented in some countries.

Methods of the Review

Scoping reviews are used to provide a broad overview of a subject and to help map commonalities, themes, and gaps in the literature ( Armstrong, Hall, Doyle, & Waters, 2011 ). We conducted a scoping review to gain an overview of the literature on elder abuse prevalence and risk factors. We restricted the review to high-quality elder abuse prevalence studies in order to synthesize and advance the most valid and reliable knowledge available. To this end, we only included population-based elder abuse prevalence studies using random or exhaustive sampling and that collected data directly from older adults. We excluded studies based on convenience, clinical, or social service agency samples, as well as studies that collected data from caregivers, professionals, or agency records to identify cases of elder abuse. We focused on regional or national-level studies unless this scale of research was unavailable in a given country (e.g., in some cases, the only surveys were conducted in an individual city). Our scoping review initially drew from existing systematic and comprehensive literature reviews on elder abuse ( Cooper, Manela, Katona, & Livingston, 2008 ; De Donder et al., 2011 ; Johannesen & LoGiudice, 2013 ; Sethi et al., 2011 ; Sooryanarayana, Choo, & Hairi, 2013 ). These prior reviews covered elder abuse studies until 2011 and identified 12 records satisfying our inclusion/exclusion criteria. To retrieve records from 2011 onwards, we conducted title/abstract searches in four major databases (PubMed, MEDLINE, PsycINFO, and Social Work Abstracts) between 2011 and 2014 with the following search terms: [(elder abuse OR elder neglect OR elder mistreatment OR elder maltreatment) AND (incidence OR prevalence)]. This database search resulted in 211 records overall, which was reduced to eight studies after omitting duplications and records that did not satisfy inclusion/exclusion criteria. The 20 studies informing our scoping review of elder abuse prevalence and risk factors are described in Supplementary Table . In addition, we consulted international comparative documents regarding the state of elder abuse programing in different countries. Special characteristics of the review of prevention programs are described in that section.

Definitions

Research and intervention strategies regarding any form of interpersonal abuse depend on a case definition that withstands the criteria of research operationalization, clinical applicability, and policy formulation. A major barrier to improving our understanding elder abuse has been the use of widely varying, and sometimes poorly constructed, definitions of the phenomenon. Fortunately, consensus is now emerging regarding both the general definition of elder abuse as well as the major types of mistreatment encompassed by the term.

The U.S. National Academy of Sciences ( Wallace & Bonnie, 2003 ) proposed a widely accepted scientific definition of elder abuse that we employ in this article. Elder abuse is defined as: “(a) 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, or (b) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.” This definition includes two major points: that an older person has suffered injury, deprivation, or unnecessary danger, and that another person (or persons) in a relationship of trust was responsible for causing or failing to prevent the harm.

Within the overarching framework of elder abuse, there is general agreement on the scope of actions that fall under this rubric ( Council, 2003 ; Lachs, Williams, O’Brien, Hurst, & Horwitz, 1997 ; Laumann, Leitsch, & Waite, 2008 ; Phelan, 2013 ). Researchers, practitioners, and most legal statutes recognize the following types of abuse: (a) physical abuse , which includes acts carried out with the intention to cause physical pain or injury; (b) psychological abuse , defined as acts carried out with the intention of causing emotional pain or injury; (c) sexual assault ; (d) material exploitation , involving the misappropriation of the elder’s money or property; and (e) neglect , or the failure of a designated caregiver to meet the needs of a dependent older person.

Although elder abuse generally falls into one or more of these five types, reports have documented extensive cultural variation in the circumstances and context of elder abuse. For example, widows in some traditional societies risk having their property seized and being abandoned by their families. In some regions of India and Africa, mourning activities expected of widows would elsewhere be considered abusive, such as being forced into marriage or being expelled from their homes ( Kumari, 2014 ; McFerson, 2013 ). Reports have also identified devastating effects of accusations of witchcraft in some cultures, typically directed at older women ( Kabole & Kioli, 2013 ; Krug, Mercy, Dahlberg, & Zwi, 2002 ; Schnoebelen, 2009 ). Thus, significant cultural variation exists in these five forms in which elder abuse appears.

Data from a number of countries about the extent of elder abuse justify urgent attempts to address the problem. Although some population surveys suffer from unclear or overly broad definitions or questionable methods, evidence is now available from a number of well-conducted, large-scale population surveys of community-dwelling individuals in a number of countries. Elder abuse research tends to be subdivided into typologies based on community or institutional living older adult populations ( Acierno et al., 2010 ). In the following review of elder abuse prevalence, we focus on community-based surveys. Elder abuse prevalence in institutional settings is not covered because of the lack of research in this area; no reliable prevalence studies have been conducted of such mistreatment in nursing homes or other long-term care facilities.

Elder abuse prevalence rates for separate and aggregate forms of mistreatment described in this section are based on a synthesis of results from 18 studies in Supplementary Table that reported prevalence rates using a 1-year period. More specifically, two studies ( Brozowski & Hall, 2004 , 2010 ) from Supplementary Table were excluded from prevalence calculations because these two studies measured prevalence over a different, 5-year period. Among the remaining 18 studies using a 1-year prevalence period, not all studies collected data on every form of elder abuse. Therefore, the synthesized elder abuse subtype prevalence rates were based on the subsets of studies with relevant data.

Physical Abuse

Elder physical abuse was the most consistently measured mistreatment type. Screening was commonly based on the Conflict Tactic Scale (CTS) or a modified version of the CTS as developed in Pillemer and Finkelhor’s (1988) prevalence study. In nearly all studies, physical abuse caseness was defined as one or more events within a designated prevalence period. Figure 1 shows the distribution of 1-year physical abuse prevalence rates across studies, which ranged from 0.2% to 4.9% (outlier 14.6%) with a mean of 2.8% (95% CI: 1.0%–4.6%). Worldwide, Canada (0.5%) and the United States (1.4%) reported the lowest prevalence rates of elder physical abuse, followed by Europe (1.67%). Two studies from Asia reported somewhat higher physical abuse rates (India: 4.3%, China: 4.9%), whereas a single study from Nigeria found by far the highest rate (14.6%).

International prevalence rates according to elder abuse type.

Sexual Abuse

Although one study incorporated the Revised CTS ( Soares et al., 2010 ), researchers have generally developed their own set of questions to screen for elder sexual abuse. Studies consistently operationalized sexual abuse caseness as one or more events occurring in a given time period. Across studies, 1-year elder sexual abuse prevalence ranged from 0.04% to 0.8% (outlier 3.3%), with a mean of 0.7% (95% CI: 0%–1.5%; see Figure 1 ). Unlike physical abuse, Nigeria reported the lowest prevalence of sexual abuse (0.04%), followed by the United States (0.5%), Mexico (0.8%), and Europe (1.0%).

Financial Abuse

Standardized tools have been unavailable to screen for elder financial abuse. Therefore, a wide range of measurement approaches were employed across prevalence studies to assess this mistreatment type. However, studies consistently defined elder financial abuse caseness as one or more mistreatment events within a given prevalence period. Across studies, 1-year prevalence of financial abuse ranged from 1.0% to 9.2% (outlier 13.1%; Figure 1 ) with a mean of 4.7% (95% CI: 2.8%–6.5%). Studies from Nigeria and Israel reported the highest prevalence of financial abuse at 13.1% and 6.4%, respectively. Mexico had the lowest prevalence of financial abuse (2.6%), whereas mean rates across Europe (3.8%) and the United States (4.5%) fell in the middle.

Emotional/Psychological Abuse

The CTS (or a modified version) was the most common tool used to measure elder emotional/psychological abuse, although several studies also developed their own screening questions. Overall, studies reported a very wide range in 1-year emotional/psychological abuse prevalence rates (0.7%–27.3%), with a mean of 8.8% (95% CI: 4.4%–13.1%). However, studies should be subdivided by those that defined emotional/psychological abuse caseness according to substantive threshold criteria and those that defined caseness simply as one or more events. This definitional/operational distinction appears to account for much of the variation in emotional/psychological abuse prevalence rates, as depicted in Figure 1 .

Studies using substantive threshold criteria typically defined emotional/psychological abuse caseness as 10 or more events in the past year, and some studies added a criterion that the mistreatment be perceived as somewhat or very serious by the older adult. Among studies that used substantive threshold criteria, 1-year emotional/psychological abuse prevalence ranged from 0.7% to 6.3% (outlier 10.8%), with a mean of 3.3% (95% CI: 0.4%–6.3%). Studies that did not use substantive threshold criteria reported 1-year emotional abuse prevalence ranging from 4.6% to 27.3%, with a mean of 13.6% (95% CI: 7.0%–20.2%). Defining emotional abuse caseness as one or more events (without thresholds) is likely oversensitive because it captures one-time scenarios that ought not to be characterized as elder abuse (e.g., a single insult between 60-year-old spouses in the last year). Among studies that used threshold criteria, India reported relatively high emotional abuse prevalence (10.8%), whereas Canada, United States, and Europe had lower mean rates of 1.4%, 1.5%, and 2.9%, respectively.

The majority of researchers generated their own set of questions to screen for elder neglect, although a few studies used standardized tools (Duke OARS, Katz ADL Index). Studies either defined neglect caseness as one or more events within a given time period or according to substantive threshold criteria based on event frequency and elder self-perceived seriousness. Studies using substantive thresholds typically defined positive neglect as 10 or more events in the past year, whereas some studies added the criterion that the events be perceived as somewhat or very serious by the elder. Across all studies, 1-year neglect prevalence ranged from 0.2% to 5.5% (outlier 15.8%), with a mean of 3.1% (95% CI: 0.6%–5.5%; see Figure 1 ). The difference in 1-year neglect prevalence between studies that used threshold criteria (mean = 1.1% [95% CI: 0%–2.3%]) and those that did not (mean = 5.7% [95% CI: 0.01%–11.3%]) was not significant (although this is based on a low sample of studies). However, it is worth noting that neglect caseness defined as one or more events is likely oversensitive because it captures onetime scenarios that most experts would agree should not be characterized as elder abuse (e.g., a child forgetting to clean the older adult’s house once in the last year). Among studies that incorporated threshold criteria, Canada reported the lowest rate of elder neglect (0.4%), followed by Europe (0.5%) and the United States (1.1%), whereas India reported the highest neglect prevalence (4.3%).

Several studies reported an aggregated elder abuse prevalence that incorporated all forms of mistreatment. Overall, studies reported an aggregated elder abuse prevalence ranging from 2.2% to 36.2%, with a mean of 14.3% (95% CI: 7.6%–21.1%). Across all studies, the highest aggregated prevalence was reported in China (36.2%) and Nigeria (30.0%), followed by Israel (18.4%), India (14.0%), Europe (10.8%), Mexico (10.3%), United Sates (9.5%), and Canada (4.0%). After excluding studies that did not use substantive thresholds to screen for emotional abuse, aggregated elder abuse prevalence ranged from 2.2% to 14.0%, with a mean of 7.1% (95% CI: 2.9%–11.2%). Among these studies using emotional abuse threshold criteria, India had the highest aggregated elder abuse prevalence (14.0%), followed by the United States (7.6%), Europe (6.03%), and Canada (4.0%).

It should be emphasized that prevalence rates reported in existing population-based elder abuse studies likely underestimate the true population prevalence. Older adults tend to underreport personal problems such as interpersonal violence ( Wallace & Bonnie, 2003 ). More important, elder abuse prevalence surveys carried substantial participation bias in that they generally excluded a group of older adults that is potentially most vulnerable to the problem: individuals with cognitive impairment. A number of smaller studies using convenience clinical/social service samples have been conducted on dementia caregivers, using a time frame of mistreatment within the past year ( Cooney, Howard, & Lawlor, 2006 ; Cooney & Wrigley, 1996 ; Cooper et al., 2008 ; Coyne, Reichman, & Berbig, 1993 ; Paveza et al., 1992 ; Pillemer & Suitor, 1992 ; Pot, van Dyck, Jonker, & Deeg, 1996 ; Wiglesworth et al., 2010 ). In these studies, physical abuse prevalence ranged from 1.0% to 23.1% with a mean of 10.9% (95% CI: 4.8%–16.9%). Elder emotional abuse prevalence ranged from 27.9% to 62.3% with a mean of 39.5% (95% CI: 27.6%–51.5%). Elder neglect prevalence ranged from 4.0% to 15.4% with a mean of 11.1% (95% CI: 0%–26.5%). Studies did not report on the prevalence of elder sexual abuse or financial exploitation. Aggregated elder abuse prevalence ranged from 27.9% to 52.0% with a mean of 38.4% (95% CI: 25.2%–51.6%). Thus, it appears that elder abuse prevalence is much higher among cognitively impaired older adults in the community compared with their cognitively intact counterparts. Also excluded from population-based prevalence studies are individuals in nursing homes; although prevalence estimates do not exist for institutional care, preliminary evidence suggests that rates may be higher than in the community ( Castle, 2012 ; Goergen, 2001 ; Pillemer & Moore, 1989 ; Pot et al., 1996 ).

These results suggest that the extent of elder abuse is sufficiently large that social service and health professionals who serve older adults are likely to encounter it on a routine basis. For example, using the prevalence rates just described, a clinician seeing 20 older adults a day may encounter a victim of elder abuse daily ( Lachs & Pillemer, 2004 ). Further, as our discussion of risk factors below shows, some subpopulations that are overrepresented in the elder service system (e.g., dementia patients) have higher risk of abuse. If prevalence rates remain the same, the absolute number of elder abuse incidents will rise in accordance with a rapidly growing older adult population. Countries will experience this rise in elder abuse cases differently depending on differential rates of population growth. Nevertheless, prevention programs in all countries are well-justified to help reduce prevalence and buffer the effect of a global aging population.

Risk Factors

The development of effective prevention programs is predicated on an understanding of risk factors for mistreatment. In this section, we follow the ecological model ( Wallace & Bonnie, 2003 ) in reporting the main risk factors, focusing on the levels of the individual (victim and perpetrator), relationship, community, and society that are associated with risk of elder abuse. We focus on population-based studies ( Supplementary Table ), selected case-comparison studies, and systematic reviews to identify risk factors. Similar to the approach used by Sethi and colleagues (2011) , risk factors were assigned to one of three categories based on the strength of evidence: (a) strong risk factors validated by substantial evidence, (b) potential risk factors for which the evidence is mixed or limited, and (c) contested risk factors for which there is lack of clear evidence ( Table 1 ).

Risk Factor Strength of Evidence

Notes: Strong : risk factors validated by substantial evidence that have unanimous or near unanimous support from several studies. Potential : risk factors for which the evidence is mixed or limited. Contested : risk factors for which there has been a hypothesis concerning increased risk, but for which there is a lack of clear evidence.

Individual-Level Risk Factors (Victim)

Functional dependence or disability.

Across countries, older adult functional dependence or physical disability has consistently been found to be associated with greater risk of elder abuse, including emotional and financial abuse in the United States and China ( Acierno et al., 2010 ; Amstadter et al., 2011 ; Burnes et al., 2015 ; Laumann et al., 2008 ; Peterson et al., 2014 ; Wu et al., 2012 ), physical abuse in the United States ( Burnes et al., 2015 ), and aggregate elder abuse in Mexico and Portugal ( Gil et al., 2015 ; Giraldo-Rodríguez & Rosas-Carrasco, 2013 ).

Poor physical health

Poor health has also been consistently associated with elder abuse across countries ( Chokkanathan & Lee, 2005 ; Giraldo-Rodríguez & Rosas-Carrasco, 2013 ; Lowenstein, Eisikovits, Band-Winterstein, & Enosh, 2009 ; Naughton et al., 2010 ; Pillemer & Finkelhor, 1988 ), including financial abuse in the United States, United Kingdom, and Canada ( Laumann et al., 2008 ; O’Keeffe et al., 2007 ; Podnieks, 1993 ); physical, sexual, and emotional abuse in Israel ( Lowenstein et al., 2009 ); and neglect in the United States, Canada, and Israel ( Acierno et al., 2010 ; Amstadter et al., 2011 ; Burnes et al., 2015 ; Lowenstein et al., 2009 ; Pillemer & Finkelhor, 1988 ; Podnieks, 1993 ).

Cognitive impairment/dementia

Although most population-based studies of elder abuse excluded individuals with cognitive impairment, other research has found relatively high rates of mistreatment committed by dementia caregivers (as outlined above) or identified cognitive impairment as a strong risk factor ( Lachs et al., 1997 ; Sethi et al., 2011 ).

Poor mental health

Studies across countries have found a relationship between poor mental/emotional health of the victim and elder abuse, including overall mistreatment in Mexico ( Giraldo-Rodríguez & Rosas-Carrasco, 2013 ) and Ireland ( Naughton et al., 2010 ). Depression or depressive symptoms have been associated specifically with emotional and physical abuse in the United Kingdom ( O’Keeffe et al., 2007 ), China ( Wu et al., 2012 ), and Canada ( Podnieks, 1993 ).

Low income/SES

Low income has predicted aggregated elder abuse in Mexico ( Giraldo-Rodríguez & Rosas-Carrasco, 2013 ), Ireland ( Naughton et al., 2010 ), and India ( Chokkanathan & Lee, 2005 ); financial ( Peterson et al., 2014 ), emotional and physical abuse ( Burnes et al., 2015 ), and neglect ( Acierno et al., 2010 ) in the United States; and physical and sexual abuse in Canada ( Brozowski & Hall, 2004 , 2010 ).

International studies, including reports from Portugal ( Gil et al., 2015 ), India ( Chokkanathan & Lee, 2005 ), Ireland ( Naughton et al., 2010 ), Israel ( Lowenstein et al., 2009 ), and Mexico ( Giraldo-Rodríguez & Rosas-Carrasco, 2013 ), indicate that women are more likely than men to experience elder abuse; specifically, emotional ( Laumann et al., 2008 ) and financial abuse ( Lowenstein et al., 2009 ). However, a recent study conducted in Seoul, Korea ( Oh, Kim, Martins, & Kim, 2006 ) found that men were more likely to experience emotional and financial abuse.

In the United States, younger age has been consistently associated with greater risk of elder abuse, including emotional, physical, financial abuse, and neglect ( Acierno et al., 2010 ; Burnes et al., 2015 ; Laumann et al., 2008 ). However, studies from Mexico and Europe report that older individuals are at heightened risk ( Gil et al., 2015 ; Giraldo-Rodríguez & Rosas-Carrasco, 2013 ; Naughton et al., 2010 ).

Financial dependence

Evidence from studies conducted in Europe, Asia, and Africa suggest that financial dependence is linked to elder abuse and neglect ( Lachs & Pillemer, 2004 ; Olofsson, Lindqvist, & Danielsson, 2012 ; Pot et al., 1996 ).

Race/ethnicity

Findings related to race/ethnicity come from the United States and Canada and suggest that specific racial/ethnic groups have divergent risk trends in relation to different types of elder abuse. Compared with Caucasians, African American older adults may be at increased risk of financial abuse and psychological abuse ( Beach, Schulz, Castle, & Rosen, 2010 ; Laumann et al., 2008 ) and aboriginal older adults have demonstrated higher risk of physical and sexual abuse ( Brozowski & Hall, 2010 ), whereas Hispanic older adults have shown lower risk of emotional abuse, financial abuse, and neglect ( Burnes et al., 2015 ; Laumann et al., 2008 ).

Individual-Level Risk Factors (Perpetrator)

Knowledge about elder abuse perpetrator risk factors remains a major gap. To date, population-based elder abuse studies have collected data from older adults, as opposed to trusted others. Without generating a random sample of individuals who are in a trusting relationship with an older adult, it is difficult to ascertain actual factors that place these trusted others at risk of perpetrating elder abuse. Information about perpetrators available from existing population-based elder abuse studies is also restricted by methodological specifications that are often put in place to protect older adult respondents (e.g., closed-ended questions over the phone). Despite these limitations, several studies describe perpetrator characteristics and we are able to construct a preliminary profile of elder abusers.

Mental illness

Poor psychological health ( Cooney et al., 2006 ; Vandeweerd, Paveza, & Fulmer, 2006 ) including depression and anxiety ( Pot et al., 1996 ; Wiglesworth et al., 2010 ) are common among elder abuse perpetrators ( Sethi et al., 2011 ). In the United States, studies show that caregiver depression is predictive of physical ( Coyne et al., 1993 ; Paveza et al., 1992 ) and verbal abuse ( Vandeweerd et al., 2006 ) and, further, that abusers are more likely to experience psychiatric hospitalization than nonabusers ( Pillemer & Finkelhor, 1988 ).

Substance misuse

Drug or substance misuse is also common among elder abuse perpetrators ( Anetzberger, Korbin, & Austin, 1994 ; Homer & Gilleard, 1990 ; von Heydrich, Schiamberg, & Chee, 2012 ; Wolf & Pillemer, 1989 ). Alcohol and drug problems have been linked with verbal and financial abuse in Canada ( Podnieks, 1993 ) and financial abuse in Ireland ( Naughton et al., 2010 ) and the United Kingdom ( O’Keeffe et al., 2007 ).

Abuser dependency

Studies have also shown that abusers are likely to be dependent on their victims for emotional support, financial help, housing, and/or other assistance ( Anetzberger, 1987 ; Greenberg, McKibben, & Raymond, 1990 ; Iborra, 2008 ; Pillemer, 1986 , 2004 ; Sethi et al., 2011 ; Wolf, Strugnell, & Godkin, 1982 ).

Victim–Perpetrator Relationship-Level Risk Factors

Relationship type.

Perpetrator relationship type appears to vary according to mistreatment type and culture. In the United States, Israel, and Europe, the most common perpetrator of elder emotional and physical abuse is a spouse/partner ( Amstadter et al., 2011 ; Burnes et al., 2015 ; Laumann et al., 2008 ; Lowenstein et al., 2009 ; O’Keeffe et al., 2007 ; Pillemer & Finkelhor, 1988 ; Soares et al., 2010 ), whereas the most common perpetrators of these mistreatment types in Asian countries are children and children-in-law ( Chokkanathan & Lee, 2005 ; Oh et al., 2006 ).

Marital status

Some studies from the United States, Canada, and Europe indicate that being married is associated with aggregated elder abuse ( Pillemer & Finkelhor, 1988 ), emotional and physical abuse ( Podnieks, 1993 ; Soares et al., 2010 ). However, other studies from the United States, Europe, Mexico, and China have found that being single, separated/divorced, or widowed is associated with higher odds of aggregated elder abuse ( Giraldo-Rodríguez & Rosas-Carrasco, 2013 ; Naughton et al., 2010 ; O’Keeffe et al., 2007 ) and each of the individual mistreatment types ( Burnes et al., 2015 ; Laumann et al., 2008 ; O’Keeffe et al., 2007 ; Podnieks, 1993 ; Wu et al., 2012 ).

Community-Level Risk Factors

In addition to characteristics of the victim, perpetrator, and victim–perpetrator relationship, community contexts may also place certain individuals at greater risk for abuse.

Geographic location

Studies conducted in Canada ( Brozowski & Hall, 2004 , 2010 ) and Southwestern Nigeria ( Cadmus & Owoaje, 2012 ) reported that individuals living in urban areas were at greater risk for elder abuse. Residing in a specific country may also be a risk factor for abuse. For example, a prevalence study of seven European countries found that residing in Greece was associated with increased risk of sexual abuse, whereas residing in Portugal was associated with increased risk of financial abuse ( Soares et al., 2010 ).

Societal-Level Risk Factors

Speculation has also been made about societal-level factors that may place individuals at higher risk of elder abuse. Although data are lacking, two factors are frequently cited in the literature.

Negative views on aging (ageism)

Some authors have suggested that negative attitudes and stereotypes about older people may contribute to societal acceptance of elder abuse ( Nelson, 2005 ; Sethi et al., 2011 ). Older individuals may be perceived as fragile, dependent ( Bytheway, 1994 ), or burdensome, making it more permissible for younger generations to mistreat them ( Penhale, Parker, & Kingston, 2000 ).

Social and cultural norms

Although empirical evidence remains limited, scholars speculate that the normalization of violence may further perpetuate violent behavior toward older people ( Browne, 1989 ; Penhale, Parker, & Kingston, 2000 ).

Protective Factors

There is limited empirical evidence regarding factors that may protect individuals from elder abuse or promote resilience after mistreatment. However, a body of research suggests that two factors may confer protection from elder abuse.

Social Embeddedness/Social Support

Studies conducted in the United States ( Acierno et al., 2010 ; Amstadter et al., 2011 ; Schafer & Koltai, 2015 ; von Heydrich et al., 2012 ), Canada ( Podnieks, 1993 ), Europe ( Chokkanathan & Lee, 2005 ; Garre-Olmo et al., 2009 ; Melchiorre et al., 2013 ; Naughton et al., 2010 ; Soares et al., 2010 ), India ( Chokkanathan & Lee, 2005 ), and Israel ( Lowenstein et al., 2009 ) have found that higher levels of social support and greater embeddedness in a social network lower the risk of elder abuse.

Living Arrangement

Studies from the United States and Europe have shown that a shared living environment is a major risk factor for aggregated elder abuse and, more specifically, physical and financial abuse ( Naughton et al., 2010 ; Peterson et al., 2014 ; Pillemer & Finkelhor, 1988 ).

The most pressing need in the field of elder abuse is for interventions that have the potential to prevent mistreatment. Selecting and evaluating prevention options poses a considerable challenge, however, because reliable evaluation data do not exist on any of the options ( Ploeg, Fear, Hutchison, MacMillan, & Bolan, 2009 ; Sethi et al., 2011 ; Stolee, Hiller, Etkin, & McLeod, 2012 ). Indeed, it is unfortunate that the greatest gap in knowledge about elder abuse lies in the area of prevention, given the pressing nature of the problem. Only approximately 10 intervention studies have been conducted with even minimally acceptable methods, and the results of most of these efforts have been negative or equivocal ( Ploeg et al., 2009 ). No international comparative studies of prevention programs have been conducted. Further, no information exists on the cost-effectiveness of programs; indeed, there are virtually no descriptive data of any kind of the costs incurred by any elder abuse interventions.

Despite the lack of effectiveness data from rigorous controlled designs, the seriousness and scope of the problem of elder abuse require countries and communities to take action to prevent it. We have, therefore, identified five interventions as “promising” based on the evidence from multiple case studies or program descriptions that report beneficial effects of the program. We do so with the caveat that program initiators must proceed with caution, given the absence of randomized, controlled intervention studies in elder abuse. However, we believe that guidance from the descriptive literature can be useful in identifying programs that merit further testing.

Caregiver Interventions

Caregiver interventions were among the first models used to prevent elder abuse. These interventions provide services to relieve the burden of caregiving, such as housekeeping and meal preparation, respite care, education, support groups, and day care and are promoted as abuse-prevention strategies. There is suggestive evidence that these interventions, when directed specifically to abusive caregivers, may help prevent revictimization ( Nahmiash & Reis, 2001 ; Reay & Browne, 2002 ). Further, there is some indication that the potential for the onset of abuse may be reduced by caregiver support interventions ( Livingston et al., 2013 ; Sethi et al., 2011 ). Caregiver interventions therefore are a promising approach to prevention.

Money Management Programs

Extensive case study reports suggest that individuals vulnerable to financial exploitation can be helped through money management programs ( Nerenberg, 2003 ; Sacks et al., 2012 ). Such programs feature daily money management assistance, including help with paying bills, making bank deposits, negotiating with creditors, and paying home care personnel. These programs are targeted to groups at high risk for financial exploitation and in particular individuals with some degree of cognitive impairment and who are socially isolated. This intervention is also promising, as the preventive potential is high and with well-trained and accredited money managers, the risks of adverse outcomes are low.

The most widely used intervention across countries is telephone “helplines,” which allow individuals to seek advice and assistance regarding elder abuse. There is considerable case study evidence suggesting that helplines facilitate early intervention that can prevent or forestall mistreatment. Such helplines are typically staffed by trained volunteers or professionals. Because many elders experience shame about the abusive situation, helplines have the advantage of allowing callers to remain anonymous if they choose. In some countries, existing helplines have been expanded to support elder abuse victims. In other countries, hotlines have been established specifically for elder abuse victims, such as the “Helpline for Abused Older People” in Milan, Italy, which counsels abuse victims ( Van Bavel, Janssens, Schakenraad, & Thurlings, 2010 ). The most extensive helpline system is a national network of helpline centers created by ALMA France that provides both immediate counseling and longer-term follow-up ( Sethi et al., 2011 ). Helplines should be considered a promising intervention, given the positive case reports and lack of evidence of any adverse outcomes.

Emergency Shelter

The provision of emergency shelter is a hallmark of intervention for battered women, providing a safe haven to both escape abuse and to plan for the next stage of life ( Moracco & Cole, 2009 ). Shelters, however, are underutilized by older women, who are often unaware of them ( Straka & Montminy, 2006 ). Additionally, battered women’s shelters typically are not designed to accommodate older women with physical health problems or dementia, and they do not offer services to abused men. Therefore, specialized shelter programs for elder abuse victims have been developed. These programs offer temporary relocation for victims, providing not only a safe environment but also a medically appropriate one. As such, they may prevent permanent relocation to a nursing home, providing security while allowing a plan for safety at home to be put in place. Descriptive studies of shelter programs suggest positive results ( Heck & Gillespie, 2013 ; Reingold, 2006 ), indicating that this is a promising program option.

Multidisciplinary Teams

In all countries, effective elder abuse prevention requires the coordination of available services. The responses required for elder mistreatment cut across many systems, including criminal justice, health care, mental health care, victim services, civil legal services, adult protective services, financial services, long-term care, and proxy decision making. Case study and quasi-experimental evidence show that multidisciplinary teams (MDTs) are likely to be an effective response to coordinating care and reducing fragmentation, leveraging resources, increasing professional knowledge, and improving outcomes ( Blowers et al., 2012 ; Navarro, Gassoumis, & Wilber, 2013 ; Rizzo, Burnes, & Chalfy, 2015 ; Teaster, Nerenberg, & Stansbury, 2003 ; Ulrey & Brandl, 2012 ). These teams can also drive collaboration between the elder justice field and other allied fields involved with older adults ( Nerenberg, 2002 ). As one of the field’s most promising practices, MDTs should be implemented and tested internationally. However, it should be noted that MDTs are at present more appropriate in higher-income nations, given that services must first be available in order to be coordinated. In lower-income countries, a higher priority is likely to be establishment of basic elder abuse services, with later attention to coordination.

In summary, given both a scarcity of resources in many countries and the lack of a solid evidence base, efforts to create comprehensive prevention approaches to elder abuse are still in their infancy. Substantial differences exist among nations; there are clearly much more expansive elder abuse service systems in high-income countries ( Krug et al., 2002 ). Although there is a paucity of evaluation data, there is consensus in the field internationally regarding the need to expand the range of services for elder mistreatment. However, there are several prevention options that are supported by preliminary evidence of their effectiveness and no reports of adverse outcomes. Programs with the greatest promise based on clinical, quasi-experimental, or single case study evidence are: (a) MDT approaches (particularly in countries where the service system is sufficiently developed to require coordination); (b) helplines for potential victims; (c) financial management for elders at risk of financial exploitation; (d) caregiver support interventions; and (e) emergency shelter for victims.

Although the literature on elder abuse interventions is not sufficiently developed to offer extensive guidance to countries and localities, this review suggests an important role for practitioners in promoting prevention and treatment approaches. It is vitally necessary that practitioners follow developments in the field, making them able to adopt evidence-based approaches as they are tested and disseminated. Practitioners can also play a critically important role as collaborators in applied research projects, providing locations for intervention studies and access to participants. Further, a key role for service providers engaged in the issue of elder abuse is to serve as advocates for service development in their regions and in their countries. In areas where such concerted advocacy has occurred, improvements in elder abuse intervention have often followed ( World Health Organization, 2014 ).

Elder abuse is a growing international problem with different manifestations in different countries and cultures. Substantial variation in legal and legislative approaches to the problem also exists between different countries. Similarly, resources available to prevent and intervene in elder abuse, and the degree to which they are coordinated, vary considerably throughout the world. Promising prevention and intervention strategies are being developed primarily in higher-income countries (e.g., MDTs) that may have applicability to other societies, but these should be tested in the context of available resources and the local manifestations of elder abuse. In some countries, awareness campaigns may first take precedent over intervention and prevention efforts given limited public understanding of the problem. Irrespective of the local strategies employed, cases of elder abuse will only increase given the aging of the population worldwide, making it a public health problem of global importance.

The most urgent need at present is for a widely expanded research base that uses high-quality methods. There is a paucity of information about the nature and extent of elder abuse in low-income countries, and most studies have taken place in high-income nations. Culturally specific forms of elder abuse and cultural attitudes toward prevention and treatment (including potential barriers) remain virtually unexplored. Further, the applicability of transferring service models from high-income to low-income countries requires serious study, as resource-intensive options such as adult protective services may not be feasible in nations where the aging services sector is underdeveloped. Although multicountry studies have taken place in Europe, they should be expanded to low-income countries as well. Improved scientific knowledge about elder abuse is the key to developing effective prevention and treatment strategies and should be promoted worldwide.

Supplementary Material

Please visit the article online at http://gerontologist.oxfordjournals.org/ to view supplementary material.

This research was supported by funding from the National Institute on Aging through an Edward R. Roybal Center grant ( 1P30AG022845 ;) and by grant AG014299-06A2 .

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Unmasking Elder Abuse: Depression and Dependency in the Post-Pandemic Era

Affiliation.

• 1 Meb Lab, Faculty of Psychology, Universidad Católica de Valencia San Vicente Mártir, Avenida de la Ilustración 2, Burjassot, 46100 Valencia, Spain.
• PMID: 39120179
• PMCID: PMC11311356
• DOI: 10.3390/healthcare12151476

The aim of this study was to analyze elder abuse in people over 65 years of age and its relationship with some risk factors-depression symptoms, dependency, gender and age-in the Spanish population.

Methods: A battery of questionnaires was administered to a sample of 167 participants electronically ( M = 72.42; SD = 6.46), including the Abbreviated Yesavage Scale to assess depression, the Katz Index for Basic Activities of Daily Living to assess dependency, and the American Medical Association and the Canadian Task Force Questionnaire to assess suspicion of abuse.

Results: A prevalence of 40.72% of suspected abuse, of 5.99% of established depression, and of 1.20% of severe dependence was obtained. The prevalence of abuse was higher in the population with dependency (75%) than without dependency (37%). In the case of depression, the prevalence of abuse was 70% for people with established depression and 35.4% for people without depression.

Conclusion: Women have higher rates of abuse than men, although this difference is not statistically significant. The same occurs with age. Nevertheless, having established depression and dependency are confirmed risk factors for suffering abuse.

Keywords: COVID-19; dependence; depression; elderly; elderly abuse; pandemic.

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Conflict of interest statement

The authors declare no conflicts of interest.

Cluster comparison between the two…

Cluster comparison between the two profiles stipulated. Group 1 (abuse) and group 2…

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