Elder and vulnerable adult abuse/neglect

Overview
Federal and state definitions of elder abuse may vary from one jurisdiction to another. They were designed to help identify elder abuse and neglect, not for enforcement purposes. According to the definitions, domestic elder abuse is the maltreatment of an older adult who is living in his or her own home or the home of a caregiver. Institutional elder abuse is the maltreatment of an elderly adult living in a residential facility, such as a nursing home, group home, board and care home, or foster home. Self-neglect or self-abuse is any behavior of an older adult living alone that threatens his or her safety, health or well-being.
By definition, there are two categories of vulnerable adults. A functional vulnerable adult is someone who is at least age 18; has physical, mental or emotional functional impairments; and has impaired ability. Impaired ability is defined as the inability to care for your basic needs, which can impair the ability to protect yourself from maltreatment, such as financial or legal exploitation, neglect, and physical or sexual abuse. A categorical vulnerable adult is someone who is at least age 18 and receives services from a licensed care facility, a licensed home care provider or a personal care assistant. This definition is not dependent on the person's physical or mental capacity. An elderly adult may be considered a vulnerable adult.

Although there are national statistics surrounding elder abuse -- which may or may not fall under the category of vulnerable adult abuse -- no statistics about reported vulnerable adult cases are currently available.

Elder and vulnerable adult abuse are often described as "silent crimes." Most perpetrators of elder abuse are family members of the elders who are typically in a caregiving role. Abused vulnerable adults often have limited contact with professionals or others who might be able to help them. Health problems often further isolate them from outside contact that could help identify the abuse. Due to dementia or other physical or mental illnesses, many who are abused lack the capacity to complain or communicate about the things that are happening to them and may need assistance getting needed services. Ageism may cause elder abuse to go unrecognized, and health care providers often overlook injuries caused by elder abuse.


Common types of elder and vulnerable adult abuse
Physical abuse is the use of physical force that may result in physical pain, bodily injury or impairment. This type of abuse may include hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, burning, inappropriate drug use, inappropriate physical restraining, force-feeding or other types of inappropriate physical behavior. Emotional or psychological abuse is infliction of mental anguish, emotional pain or distress through threats, intimidation, insults, humiliation or harassment. Ignoring the person or treating him or her like an infant or child is also considered emotional abuse. Sexual abuse is nonconsensual sexual contact of any kind or sexual contact with any person incapable of giving consent. Sexual abuse includes unwanted touching, coerced nudity, sexually explicit photography, sodomy, rape, and other types of sexual assault and battery.
Neglect is the refusal or failure to fulfill a person's responsibilities or obligations to a vulnerable adult, including necessities such as food, water, clothing, shelter, personal hygiene, medicine, comfort and personal safety. Often, neglect of an elder by a caregiver is unintentional and based on the caregiver's lack of skills, resources or knowledge about how to care for the elder. Abandonment is the desertion of an elder or vulnerable adult by a person who has assumed caregiving responsibility for him or her.

Financial abuse or material exploitation is the illegal or improper use of an elderly or vulnerable adult's property, assets or funds. Examples of this type of abuse include cashing checks without permission or authorization, forcing the person's signature, and coercing or deceiving an elder or vulnerable adult into signing a legal document, such as a contract or will. Financial abuse may be subtle and orchestrated by a variety of people who have contact with the vulnerable adult, such as sitters, housekeepers, financial advisors, insurance salespersons or distant relatives. Misusing or stealing an elder or vulnerable adult's possessions or funds, closing long-standing accounts, opening new accounts jointly, payable-on-death or transferable-on-death, and the improper use of power of attorney, conservatorship or guardianship status are also considered financial abuse.

Abuse can be active (when a caregiver consciously withholds care) or passive (when a caregiver is unable to provide adequate care). An eldery adult may experience multiple types of abuse.


Risk factors
Vulnerable adults and elders who have physical health problems, cognitive impairment, a history of mental illness or a lack of financial resources have a higher risk of being abused. Other potential risk factors include a family history of violence, substance abuse, a prior history of being abused, and lacking access to other people, transportation, financial resources, a telephone or social support. Being inappropriately dependent on a caregiver or having shared living arrangements with the caregiver are also factors. For an elder, the loss of friends or relatives through death or moving may be additional risk factors. Elderly women have a slightly higher risk of being abused, especially those who are widowed or advanced in age.
People who become abusive toward elders or vulnerable adults are more likely to have a history of mental illness and a lack of financial or social support. Other potential risk factors include being abused as a child and a history of violence or substance abuse. Antisocial behaviors, gambling problems, extreme fatigue, and lack of adequate financial resources, transportation, social support or community resources are also risk factors. Living with the elder or vulnerable adult, an overcrowded living situation, being inappropriately dependent on the vulnerable adult, or facing stressful life events (such as a job loss or divorce) may also be risk factors.


Characteristics of an abused elder or vulnerable adult
Physically, an elder or vulnerable adult who is being abused or neglected may have bruises, welts or internal injuries. The injuries may be "accidental" or unexplained, and the seriousness of the injuries may not correspond with the explanations. The vulnerable adult may have broken or twisted eyeglasses, a missing or unrepaired hearing aid, poor dental health or missing dentures, and head or body lice. Prescriptions may be unrenewed or exhausted. Stripping of the skin or bruising on the ankles or wrists may suggest the use of restraints.
Psychologically, an elder or vulnerable adult may be withdrawn or isolated. He or she may feel ashamed, angry or helpless. He or she may be confused or in denial. The person may be emotionally unresponsive and distrustful. He or she may have an increased startle response. The elder or vulnerable adult may also experience loneliness and low self-esteem, as well as grief and loss issues.

Socially, an elder or vulnerable adult may have sudden changes in behavior or appearance. He or she may have timid or hostile behavior and soiled, inappropriate clothing. He or she may miss medical or dental appointments, have inconsistent medical and dental care, or use medications inappropriately. The person may be reluctant to seek treatment for injuries, deny the existence of injuries, or change doctors often. The person may appear fearful or edgy in the presence of a caregiver or family member, as well as reluctant to discuss concerns in front of the caregiver. He or she may display increased dependency or clingy behavior, or have a marked change in his or her communication pattern.

The elder or vulnerable adult may have a sudden loss of financial resources or change in financial status or a standard of living below his or her income level. Sudden revisions to the person's will, consistently unpaid bills or expenses, or an inexplicable power of attorney may also occur.

Keep in mind that these characteristics can indicate a variety of concerns. Avoid making a determination about elder or vulnerable adult abuse or neglect based on individual factors alone.


Characteristics of an abuser
An abusive caregiver may have an indifferent attitude toward the elder or vulnerable adult or express anger and resentment toward him or her. The caregiver may exclude the elder or vulnerable adult from major decisions, treat him or her like a child or make verbal assaults. He or she may show signs of self-neglect, and have substance abuse problems or multiple sources of stress. The caregiver may also be defensive, have sudden affluence or an elevated financial status, or have an excessive concern with the costs or "inconvenience" of treatment. He or she may have a preoccupation with his or her own problems (especially financial troubles) and may not allow the vulnerable adult to be alone with other people. He or she may insist on providing all of the information relevant to the elder or vulnerable adult's history, seek inappropriate institutionalization of the person, or refuse to provide institutionalization of the person when appropriate to do so.

Coping strategies
Protection plan
If a competent elderly adult decides to stay in an abusive situation, it's wise to develop a protection plan. Everyone has the right to be safe and ensure the protection of personal belongings and assets. Acknowledge and discuss limitations that may impact the elder's ability to take action during an abusive episode, such as diminished mobility, communication barriers or health concerns.

Also consider the elder's support system. Are there trusted friends, family members or neighbors the elder could call if he or she is feeling threatened or afraid? Does the person have access to a phone, a directory or a personal list of emergency numbers? Discuss how the elder could retreat from a situation that appears to be escalating toward possible abuse. For example, could the elder call a support person to be picked up? Could the elder go to his or her room or a trusted neighbor's house? Make sure the elder has the number for a local elder abuse or domestic abuse hotline, adult protective services or Area Agency on Aging. Encourage the elder to call for support or help if needed, and call the police or 911 if he or she feels threatened by anyone -- even a caregiver or family member. If the elder is not capable of following through on a protection plan, you'll need to take appropriate action for him or her.

Reporting abuse
In most states, health care professionals are required to report abuse or neglect of a vulnerable adult to the state Adult Protective Services (APS) agency. Typically, representatives from APS are authorized to protect and provide services to vulnerable, incapacitated or disabled adults. In the few states that don't have APS, the responsibility falls to the state units on aging. APS investigates reports of abuse and intervenes to ensure the safety of the vulnerable adult. Individuals who report suspected abuse and neglect in good faith are protected from any liability related to making the report. An elder has the right to refuse such services unless the courts have declared him or her incapacitated and appointed a legal guardian.

Abuse or neglect that occurs to a resident of a long-term care facility may need to be reported to an agency other than APS, such as the state department of health, a local licensing agency or an ombudsman's office. Consult your local resources for state-specific requirements.

Advocacy and community resources
Legal advocacy through an attorney or court-appointed guardian may be needed to protect a vulnerable adult's financial assets from exploitation. Alternative housing such as a nursing home may provide a way to meet the vulnerable adult's care needs in a safe and secure environment and reduce burden on the at-risk caregiver. Community resources such as abuse hotlines, home health care services, adult day care, respite services or support groups may be helpful for both the vulnerable adult and the abuser. Elder or domestic abuse shelters may provide a means for meeting the elder's needs, reduce burden on the caregiver, and provide a safe and secure environment for the elder. Mental health treatment for mental disorders related to abuse may be needed, as well as collaboration of a multidisciplinary team including a social worker, nurse, psychiatrist, primary care physician, lawyer and law enforcement professionals.

Respect individual needs
Be sensitive to the language you use and avoid labels or words that may trouble the elder or vulnerable adult, such as victim, abuse, neglect, battered or perpetrator. It's important to focus on what's happening and how it impacts the elder or vulnerable adult. Help him or her understand that the frequency and severity of abuse tends to increase over time if left unreported. Remember that elder and vulnerable adult abuse is often shrouded in secrecy and the vulnerable adult may resist talking about it or answering questions for many reasons, including shame, family loyalty, fear of reprisal, abandonment or placement in a care facility, dependency on the abuser, or denial. Allow the elder or vulnerable adult's individual needs to guide your responses and interventions, and remain nonjudgmental. Build trust with the elder or vulnerable adult and treat him or her with dignity.


Summary
Elder and vulnerable adult abuse or neglect requires immediate attention to protect the rights of the individual and prevent future abuse or neglect. Remember, it's OK to ask for help. There are services and people who are able to help.