Elder Abuse – What is it and How to Recognize it

It can be difficult to imagine someone abusing an elderly person, but it is more common than you think. About 1 in 6 older people will experience abuse every year, and these rates of abuse are higher for people living in institutions. As a CNA you have a close relationship with your patients and are often the person they have the most interaction with. As a result, you are many times the first person to recognize if something is wrong. Knowing the signs of abuse is very important in early detection as is understanding what to do if you suspect abuse.

What is Elder Abuse

The World Health Organization 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 causes harm or distress to an older person.”It often happens when there is an imbalance of control. The abuser either limits or takes over the rights and freedoms of the elderly person or uses physical violence to intimidate, humiliate or frighten the senior.

Elder abuse can be:

• Financial Abuse – misusing funds without full knowledge or consent, forging signatures, identity theft
• Physical Abuse – causing bodily injury or pain
• Emotional/Psychological – social isolation, intimidation, humiliation or ridicule, ignoring, terrorizing or menacing
• Neglect – intentionally withholding care or necessities of living
• Sexual Abuse – sexual acts done without full knowledge or consent

And it can involve the following actions:

• Being controlling – isolating them from friends, family, and community supports
• Using their property or belongings without their permission or knowledge
• Treating them like a child
• Leaving them alone for long periods of time if they are unable to get around themselves.

Abusive acts in institutions include physically restraining patients, depriving them of dignity (for example, leaving them in soiled clothes), depriving them of choice over daily affairs, intentionally providing inadequate care, over and under medicating, withholding medications, and emotional neglect.

Abuse can lead to physical injuries, from cuts and bruises to broken bones. Elderly people are more fragile than their younger counterparts; bones may break easier and healing from these injuries may take longer. A seemingly small injury in an older person, such as a broken arm, can lead to that person’s eventual death. That is why victims of elder abuse tend to die at a younger age than those not experiencing abuse.[1]

Who are the abusers?

Abusers can come from any aspect of an elderly person’s life. It can come from the family, such as a spouse or child, or from the community, such as friends or neighbors. It can even happen from health professionals such as caregivers in a nursing home or home care providers.

Elder abuse is particularly prevalent in nursing homes and assisted living facilities. In a shocking survey of nursing home staff 36% witnessed at least 1 incident of physical abuse of a resident in the past year, 40% admitted to psychologically abusing residents, and 10% committed at least 1 act of physical abuse.[2] Often a culture of neglect and abuse exists in some institutions, so it is particularly crucial for CNAs in a nursing home environment to be aware of the signs of abuse and what to do if you witness it.

Risk Factors for Elder Abuse

Any situation in which there is an imbalance of power carries an increased risk of abuse for people of any age. Several studies have been done looking at key risk factors for elder abuse, with the following results.

Abusers often look for people who are either unlikely to be believed or do not have a strong advocate in their life. People with dementia are far more likely to be abused, with nearly half of people with dementia experiencing some form of abuse. Also, people who have few social supports often have no one to turn to, and it is easier for the abuser to go unnoticed.

Elder abuse often occurs from an imbalance of power. Those who are frail or are in poor physical health have a higher risk of abuse as they usually are dependent on someone else for activities of daily living, such as bathing or dressing.

Financial abuse is more likely when seniors are living in larger households where there may be increased demands for financial resources. Other socioeconomic demographics such as low income and being a woman also carry a higher risk of abuse.

How to Recognize Elder Abuse

The warning signs of abuse can be hard to identify right away, and people are often left wondering why they didn’t see it right away. Sudden changes in mood or behavior, such as no longer wishing to participate in social activities, are early warning signs and should be further investigated.

New injuries should be carefully examined, especially if they are not able to explain how they happened. Also, injuries that appear on both sides of the body are particularly noteworthy. Consider the difference between an arm that was accidentally knocked on a wall or two wrists that were grabbed and twisted. It would be extremely rare to injure both sides of the body from falling or running into something. Also, rope marks or other signs of restraint should be carefully examined or questioned. If you are working in an institution, any restraints that were authorized for use would be unlikely to cause injury and would be thoroughly documented.

Changes in hygiene, wearing dirty clothing, or wearing clothing that is unsuitable for the weather are also warning signs of neglect. Furthermore, untreated medical conditions, such as bed sores, unexplained weight loss, malnutrition, or dehydration should also be red flags for abuse and neglect.

Financial abuse can be more difficult to detect. Failure to meet financial obligations such as paying rent, suspicious changes in a patient’s will or power of attorney, or sudden changes in living arrangements – new people moving in or other caregivers forced out – are all signs of financial abuse.

Finally, as with any abuse, the caregiver’s refusal to allow you to see the elderly person alone should cause concern.

What to do

If you think an elderly person is being abused, what do you do about it?

If you witness an elderly person being abused at your facility, you must report the event to a supervisor immediately. Abuse in institutions tends to go underreported so even if you are not sure it is better to say something. Sometimes all a co-worker requires is some extra education or emotional support for caregiver burnout.

If you suspect someone is being abused in the community, there are many resources and strategies available. If you are concerned that the senior is in immediate danger, notify police.

If you are concerned that someone you care for or know in the community is being abused but are not forthcoming, try asking the person targeted questions such as:

• How they are doing
• If they are having trouble at home
• If there is someone you can call that might help them
• If there is any way you can help

If an elderly person tells you they are being abused, it is crucial that you believe them. Even if that person may have dementia or the perpetrator may be someone you know, you may be the first person that the elderly person is confessing to. Don’t try to tell them what to do, respect their decision to act even if you disagree with it. Keeping the lines of communication open is imperative. Understand that making a change to get out of an abusive situation is incredibly difficult and the decision to leave may take a long time. Encourage them to seek help and provide them with local resources.

Social Support

Social support can be extremely beneficial to elderly people suffering abuse. Connecting the older person to community programming can not only help reduce the isolation that leads to abuse but can reduce the risk of further abuse. Also, setting family members up to supportive services can help them deal with caregiver burnout, resolving some of the significant causes of abuse.

Elder abuse is not something we like to think about, but it is essential to know what it is and recognize its signs. If you think someone is being abused, speak to your supervisor, and if you are concerned about their safety, talk to the police. Under your excellent care as a CNA elder abuse can be detected early or even prevented.

[1] Lachs, Williams, O’Brien, Pillemer, Charlson. (1998). The mortality of elder mistreatment. JAMA 280(5):428-32

[2] Pillemer, Moore. (1989) Abuse of patients in nursing homes: Findings from a survey of staff. The Gerontologist. 29:314-320