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Types & Signs of Elder Mistreatment
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Definitions
Though there is increasing consensus on the core components of elder mistreatment, the field has not adopted a universally accepted definition of abuse.38 Several reasons have been suggested for the lack of uniformity. Different professional disciplines, each with their own objectives, interests, and perspectives may use distinct approaches to classify elder abuse.
Conceptual understandings may also vary based on differing cultural and social norms among communities. Socio-cultural orientations may derive from numerous factors including faith, family, circumstances,
context, and community, resulting in diverse descriptions and perceptions of, and responses to, mistreatment.
Notably, in the United States legal definitions of abuse vary by state statute. Internationally, definitional variability is observed both between and within countries.39 A lack of consistency in definitions and data elements on elder mistreatment across jurisdictions makes it challenging for researchers to measure elder mistreatment and identify trends.40
Notwithstanding deficits in classification, the following definitions are commonly cited by researchers in their studies on elder mistreatment.
Types of Elder Mistreatment
Elder mistreatment typically takes one of five forms: physical abuse, psychological or emotional abuse, sexual abuse, financial abuse, and neglect.44 As with the broader definition of elder mistreatment, understandings of specific types of maltreatment may vary. They are often impacted and informed by socio-cultural orientations and may be differently construed by diverse constituencies and individuals.
The intentional or reckless use of physical force or physical coercion that may result in bodily injury, physical pain, or impairment. Acts of physical violence include, but are not limited to, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. Physical abuse also embraces any unlawful, excessive, or unnecessary use of physical or chemical means to restrain or confine an elder, such as force-feeding and physical punishment.45 46
Non-consensual sexual contact of any kind with an older adult, perpetrated through force, threats, or the exploitation of authority. Sexual abuse includes, but is not limited to, unwanted touching, sexual assault or battery, sexual harassment, and sexual interaction with elders who lack the capacity to give consent.47 48
The infliction of anguish, pain, or distress through verbal or nonverbal acts including, but not limited to verbal assaults, insults, threats, intimidation, humiliation, isolation, and harassment.49 50
The illegal or improper use of an elder's funds, property, or assets including, but not limited to misusing or stealing an older person's money or possessions, coercing or deceiving an older person into signing any document (e.g., contracts or will), and the improper use of conservatorship, guardianship, or power of attorney.51
The refusal or failure to fulfill any part of a person's obligations or duties of care to an elder which include, but are not limited to, life necessities such as food, water, clothing, shelter, personal hygiene, medicine, comfort, and personal safety.52
Self-neglect is a phenomenon related to but distinct from elder neglect.53 Self-neglect is a form of self-harm that may co-occur with, provoke, or be triggered by elder mistreatment. It is characterized as the behavior of an older person that threatens their own health or safety, including but not limited to the refusal or failure to provide themselves with life necessities.54
Abandonment is oftentimes considered a subtype of neglect and other times believed to constitute a separate category of mistreatment.55 By definition, it is the desertion of an older adult by an individual who has physical custody of an elder, or who has assumed responsibility for providing care for that elder.
Signs of Elder Mistreatment
The most frequently observed signs of mistreatment are referenced below. Please note that indicia of abuse may present differently based upon multiple factors, including the type, degree, duration, and context of abuse experienced. 56 Manifestations of abuse may also be impacted by the older adult’s physical and cognitive condition, social connectedness, and emotional state.
Psychological Abuse
- Emotional distress or agitation
- Withdrawal from activities of daily life
- Uncommunicative or non-responsive
- Unusual behaviors commonly attributed to dementia (e.g., sucking, biting, rocking)
- Lack of self-care
- Lower self-esteem, feelings of despair, or a sense of worthlessness57
Physical Abuse
- Bruises, abrasions, welts, lacerations, or rope marks
- Head trauma and/or bone fractures
- Open wounds, cuts, punctures, untreated injuries in various stages of healing
- Sprains, dislocations, and internal injuries/bleeding
- Bite, strangulation, burn marks, or patterns of injury
- Falls, including broken eyeglasses or frames
- Physical indicia of punishment, including evidence of physical restraints
- Medication overdose or chemical restraints
- Sudden behavioral changes58 59 60
Financial Abuse
- Sudden changes in bank account or banking practices, including an unexplained withdrawal of large sums of money or the addition of signatories to an older person’s bank signature card
- Abrupt changes to a will or other financial documents
- The unexplained disappearance of funds or valuable possessions, or sudden transfer of assets
- Substandard care provision, unpaid bills, or eviction proceedings
- The provision of unnecessary services
- Depression or anxiety
- Evidence of poor financial decision making
- Malnutrition61
Neglect
- Dehydration or malnutrition
- Untreated bed sores
- Poor personal hygiene
- Unattended or untreated health problems
- Unsafe living conditions
- Unsanitary living conditions62
Sexual Abuse
- Bruises, abrasions, or lacerations around the breasts or genital area
- Unexplained sexually transmitted disease or genital infection
- Unexplained vaginal or anal bleeding or incontinence
- Increased anxiety or depressive symptoms
- Sleep disturbances, agitation, or restlessness63
Abuse in Institutional Settings
Older residents of long-term care facilities who have disabilities or otherwise experience frailties may be at heightened risk of mistreatment and less able to safeguard themselves from environmental harm or extricate themselves from danger.64 Abuse within institutions may be observed in the forms outlined above but may also be discerned in other ways. For example, physical abuse may appear as hygiene neglect, which results in skin abrasions and breakdown such as pressure ulcers. Other means of institutional abuse are medication withholding, food deprivation, treatment neglect, and chemical restraints. Psychological mistreatment may be also employed and expressed as threats of death or harm.
Impacts of Elder Mistreatment
Like the signs of abuse, the impact of elder mistreatment may be experienced differently by older adults. The effects of maltreatment are often related to the scope, nature, type, and degree of abuse. They are also influenced by the many multifactorial, intersecting medical, mental health, and socio-cultural components that comprise the elder’s life. Contextual factors, including a prior history of trauma, may also play a role in determining the impacts perceived and manifested by the individual who was abused. For elders who live with several types of abuse, the reactions may be overlapping and complex.
Among the devastating effects of abuse, older adults may sustain physical injuries, psychological harms, and financial losses. Traumas may lead to compromised health, hospitalization, and mortality. Elders may also experience deteriorated family relationships, diminished autonomy, and institutionalization, which may result in a diminished quality of life.65
Below is a partial, representative list of abuse-related consequences by type of mistreatment experienced.
- Feelings of shame and guilt
- Loss of self-esteem and compromised sense of self-worth
- Physical decline
- Loss of attachment to the perpetrator, who may be a family member caregiver
- Diminished psychological wellness
- Increased morbidity and mortality
- Emotional distress, loneliness, and isolation
- Depression, post-traumatic stress disorder, and other adverse psychological health outcomes66
- Psychosocial consequences
- Physical trauma
- Increased hospitalization and mortality
- Depression and anxiety67
- Cognitive decline68
- Malnutrition and dehydration
- Unmet basic physiological needs, including hygienic conditions and living quarters
- Functional impairment
- Lower quality of life
- Psychological distress and depression
- Poor physical health
- Increased disability and mortality69
- Compromised physical wellness
- Diminished independence in later life
- Monetary loss, financial dependence
- Psychological decline
- Loneliness70
- Depression, anxiety, and sleep disorders71 72
- Post-traumatic stress syndrome
- Sleep disturbances
- Depression and/or anxiety
- Dissociative symptoms
- Changes in self-image
- Increased hospitalization and poor health
- Feelings of shame and guilt73
38 Storey, J. E. (2020). Risk factors for elder abuse and neglect: A review of the literature. Aggression and violent behavior, 50, 101339.
39 Wallace, R. B., & Crabb, V. L. (2017). Toward definitions of elder mistreatment. Elder Abuse, 3-20.
40 Carney, A. (2020). Epidemiology of elder abuse and neglect. Elder Abuse, 1-17.
41 Centers for Disease Control and Prevention, (2020, May). Violence prevention: Preventing elder abuse. Retrieved from
https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html
42 World Health Organization. (2020). Ageing and life-course: Elder Abuse. Retrieved from https://www.who.int/ageing/projects/elder_abuse/en/
43 National Research Council. (2003). Elder mistreatment: Abuse, neglect, and exploitation in an aging America. Panel to Review Risk and Prevalence of Elder Abuse and Neglect. Committee on National Statistics and Committee on Law and Justice, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press.
44 Storey, J. E. (2020). Risk factors for elder abuse and neglect: A review of the literature. Aggression and violent behavior, 50, 101339.
45 Wallace, R. B., & Crabb, V. L. (2017). Toward definitions of elder mistreatment. Elder Abuse, 3-20.
46 Storey, J. E. (2020). Risk factors for elder abuse and neglect: A review of the literature. Aggression and violent behavior, 50, 101339.
47 Wallace, R. B., & Crabb, V. L. (2017). Toward definitions of elder mistreatment. Elder Abuse, 3-20.
48 Band-Winterstein, T., Goldblatt, H., & Lev, S. (2019). Breaking the Taboo: Sexual Assault in Late Life as a Multifaceted Phenomenon—Toward an Integrative Theoretical Framework. Trauma, Violence, & Abuse, 1524838019832979.
49 Wallace, R. B., & Crabb, V. L. (2017). Toward definitions of elder mistreatment. Elder Abuse, 3-20.
50 Neuhart, R., & Carney, A. (2020). Psychological Abuse. Elder Abuse, 163-182.
51 Phelan, A. (2020). Financial Abuse of Older People. Advances in Elder Abuse Research, 101-119
52 Wallace, R. B., & Crabb, V. L. (2017). Toward definitions of elder mistreatment. Elder Abuse, 3-20.
53 Centers for Disease Control and Prevention. (2016). Elder abuse surveillance: Uniform definitions and recommended core data elements. Retrieved from https://www.cdc.gov/violenceprevention/pdf/ea_book_revised_2016.pdf
54 Day, M. R. (2020). Self-Neglect in Older Adults. Advances in Elder Abuse Research, 85-99.
55 Centers for Disease Control and Prevention. (2016). Elder abuse surveillance: Uniform definitions and recommended core data elements. Retrieved from https://www.cdc.gov/violenceprevention/pdf/ea_book_revised_2016.pdf
56 Neuhart, R., & Carney, A. (2020). Psychological Abuse. Elder Abuse, 163-182.
57 Neuhart, R., & Carney, A. (2020). Psychological Abuse. Elder Abuse, 163-182.
58 Heisler, C. J. (2017). Elder Abuse Forensics: The Intersection of Law and Science. Elder Abuse, 387-416.
59 Rosen, T., LoFaso, V. M., Bloemen, E. M., Clark, S., McCarthy, T. J., Reisig, C., ... & Sharma, R. (2020). Identifying injury patterns associated with physical elder abuse: Analysis of legally adjudicated cases. Annals of Emergency Medicine.
60 Yonashiro-Cho, J., Gassoumis, Z. D., Homeier, D. C., University of Southern California, & United States of America. (2019). Forensic markers of physical elder abuse: Establishing a medical characterization and identifying the criminal justice approach to investigation and prosecution.
61 Lachs, P. (2015). Elder Abuse. The New England Journal of Medicine, 373(20), 1947–1956.
62 Friedman, L. S., Avila, S., Liu, E., Dixon, K., Patch, O., Partida, R., ... & Meltzer, W. (2017). Using clinical signs of neglect to identify elder neglect cases. Journal of Elder Abuse & Neglect, 29(4), 270-287.
63 Heisler, C. J. (2017). Elder Abuse Forensics: The Intersection of Law and Science. Elder Abuse, 387-416.
64 Carney, A. (2020). Identification of Elder Abuse. Elder Abuse, 19-54.
65 Jackson, S. L., & Hafemeister, T. L. (2016). Theory-based models enhancing the understanding of four types of elder maltreatment. International review of victimology, 22(3), 289-320.
66 Neuhart, R., & Carney, A. (2020). Psychological Abuse. In Elder Abuse, 163-182.
67 Ernst, J. S., & Maschi, T. (2018). Trauma-informed care and elder abuse: A synergistic alliance. Journal of elder abuse & neglect, 30(5), 354-367.
68 Li, M., & Dong, X. (2020). Association Between Different Forms of Elder Mistreatment and Cognitive Change. Journal of Aging and Health, 0898264320976772.
69 Ayalon, L. (2015). Reports of elder neglect by older adults, their family caregivers, and their home care workers: a test of measurement invariance. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 70(3), 432-442.
70 Wong, J. S., & Waite, L. J. (2017). Elder mistreatment predicts later physical and psychological health: Results from a national longitudinal study. Journal of elder abuse & neglect, 29(1), 15-42.
71 Weissberger, G. H., Mosqueda, L., Nguyen, A. L., Samek, A., Boyle, P. A., Nguyen, C. P., & Han, S. D. (2020). Physical and mental health correlates of perceived financial exploitation in older adults: Preliminary findings from the Finance, Cognition, and Health in Elders Study (FINCHES). Aging & mental health, 24(5), 740-746.
72 Acierno, R., Watkins, J., Hernandez-Tejada, M. A., Muzzy, W., Frook, G., Steedley, M., & Anetzberger, G. (2019). Mental health correlates of financial mistreatment in the national elder mistreatment study wave II. Journal of Aging and Health, 31(7), 1196–1211.
73 Band-Winterstein, T., Goldblatt, H., & Lev, S. (2019). Breaking the Taboo: Sexual Assault in Late Life as a Multifaceted Phenomenon—Toward an Integrative Theoretical Framework. Trauma, Violence, & Abuse, 1524838019832979.
Last Modified: 02/28/2024