Chapter: Psychiatric Mental Health Nursing : Abuse and Violence

Elder Abuse

Elder abuse is the maltreatment of older adults by family members or caregivers.



Elder abuse is the maltreatment of older adults by family members or caregivers. It may include physical and sexual abuse, psychological abuse, neglect, self-neglect, financial exploitation, and denial of adequate medical treatment. Estimates are that people over age 65 are injured, exploited, abused, or neglected by their caregivers and that only 1 in 14 elder maltreatment cases are reported (Muehlbauer & Crane, 2006). Nearly 60% of the perpetrators are spouses, 20% are adult children, and 20% are others such as siblings, grandchildren, and boarders.


Most victims of elder abuse are 75 years or older; 60% to 65% are women. Abuse is more likely when the elder has multiple chronic mental and physical health problemsand when he or she is dependent on others for food, medi-cal care, and various activities of daily living.


Persons who abuse elders are almost always in a caregiver position or the elders depend on them in some way. Most cases of elder abuse occur when one older spouse is takingcare of another. This type of spousal abuse usually happens over many years after a disability renders the abused spouse unable to care for himself or herself. When the abuser is an adult child, it is twice as likely to be a son as a daughter. A psychiatric disorder or a problem with substance abuse also may aggravate abuse of elders (Goldstein, 2005).


Elders are often reluctant to report abuse, even when they can, because the abuse usually involves family members whom the elder wishes to protect. Victims also often fear los-ing their support and being moved to an institution.


No national estimates of abuse of elders living in institu-tions are available. However, under a 1978 federal mandate, ombudsmen are allowed to visit nursing homes to check on the care of the elderly. These ombudsmen report that elder abuse is common in institutions (Goldstein, 2005).


Clinical Picture


The victim may have bruises or fractures; may lack needed eyeglasses or hearing aids; may be denied food, fluids, or medications; or may be restrained in a bed or chair. The abuser may use the victim’s financial resources for his or her own pleasure while the elder cannot afford food or medications. Abusers may withhold medical care from an elder with acute or chronic illness. Self-neglect involves the elder’s failure to provide for himself or herself.




Careful assessment of elderly persons and their caregiving relationships is essential in detecting elder abuse. Often, determining whether the elder’s condition results from deterioration associated with a chronic illness or from abuse is difficult. Several potential indicators of abuse require further assessment and careful evaluation. These indicators by themselves, however, do not necessar-ily signify abuse or neglect.

The nurse should suspect abuse if injuries have been hidden or untreated or are incompatible with the explana-tion provided. Such injuries can include cuts, lacerations, puncture wounds, bruises, welts, or burns. Burns can be cigarette burns, scaldings, acid or caustic burns, or friction burns of the wrists or ankles caused from being restrained by ropes, clothing, or chains. Signs of physical neglect include a pervasive smell of urine or feces, dirt, rashes, sores, lice, or inadequate clothing. Dehydration or mal-nourishment not linked with a specific illness also strongly indicates abuse.


Possible indicators of emotional or psychological abuse include an elder who is hesitant to talk openly to the nurse or who is fearful, withdrawn, depressed, and helpless. The elder also may exhibit anger or agitation for no apparent reason. He or she may deny any problems, even when the facts indicate otherwise.


Possible indicators of self-neglect include inability to manage money (hoarding or squandering while failing topay bills), inability to perform activities of daily living (per-sonal care, shopping, food preparation, and cleaning), and changes in intellectual function (confusion, disorientation, inappropriate responses, and memory loss and isolation). Other indicators of self-neglect include signs of malnutrition or dehydration, rashes or sores on the body, an odor of urine or feces, or failure to keep needed medical appointments. For self-neglect to be diagnosed, the elder must be evaluated as unable to manage day-to-day life and take care of himself or herself. Self-neglect cannot be established based solely on family members’ beliefs that the elder cannot manage his or her finances. For example, an older adult cannot be consid-ered to have self-neglect just because he or she gives away large sums of money to a group or charity or invests in some venture of which family members disapprove.


Warnings of financial exploitation or abuse may include numerous unpaid bills (when the client has enough money to pay them), unusual activity in bank accounts, checks signed by someone other than the elder, or recent changes in a will or power of attorney when the elder cannot make such decisions. The elder may lack amenities that he or she can afford, such as clothing, personal products, or a television. The elder may report losing valuable possessions and report that he or she has no contact with friends or relatives.


The nurse also may detect possible indicators of abuse from the caregiver. The caregiver may complain about how difficult caring for the elder is, incontinence, difficulties in feeding, or excessive costs of medication. He or she may display anger or indifference toward the elder and try to keep the nurse from talking with the elder alone. Elder abuse is more likely when the caregiver has a history of family violence or alcohol or drug problems.


All 50 states in the United States, District of Columbia, Guam, Puerto Rico, and the Virgin Islands have laws gov-erning adult protective services. This covers elder citizens and, in most states, includes adults who are considered dependent, disabled, or impaired and who must rely on others to meet basic needs. These laws provide a system for defining, reporting, and investigating abuse, as well as providing services to victims. However, abuse reporting for elders or dependent adults is not mandatory in all states and territories. Nurses should be familiar with the laws or statutes for reporting abuse in their own states. Many cases remain unreported. The local agency on aging can provide procedures for reporting abuse in accordance with state laws. To find a local agency, call the national information center at 1-800-677-1116.


Treatment and Intervention


Elder abuse may develop gradually as the burden of care exceeds the caregiver’s physical or emotional resources. Relieving the caregiver’s stress and providing additional resources may help to correct the abusive situation and leave the caregiving relationship intact. In other cases, the neglect or abuse is intentional and designed to providepersonal gain to the caregiver, such as access to the victim’s financial resources. In these situations, removal of the elder or caregiver is necessary.


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