Type
Signs and symptoms
Physical
• Injuries, scars, or other signs of physical trauma: e.g. Old or new bruises, lacerations, abrasions, black eyes, welts, sprains, dislocations, fractures of bone or skull, broken bones; internal injuries and/or bleeding
• Untreated/unexplained or inadequately explained injuries in different stages of healing: e.g. Open wounds, cuts, punctures
• Physical signs of being punished: e.g. Broken eye glasses/frames or other medical aid, burns
• Signs of being restrained: e.g. Rope marks, pressure or imprint marks
• Evidence of prescription drugs/medication underuse or overdose based on laboratory results
• Sudden change in elder’s behavior or ability to walk or sit
• Caregiver refuses/is reluctant to allow visits with elder alone
• Report by elder of being hit, kicked, harmed or mistreated
Sexual
• New or old bruises around breasts or genital area
• Unexplained genital infections, sexually transmitted disease, or vaginal or anal bleeding/pain
• Presence of bloody, stained or torn underwear/clothing
• Flinching from touch
• Report of sexual assault or rape made by an elder
Emotional/
psychological
• Emotional agitation, upset, or unexplained fear
• Extreme withdrawal, non-responsive or non-communicative behavior
• Isolation
• Exhibiting behavior such as biting, sucking, rocking, or other behavior usually attributed to dementia
• Report of verbal or emotional mistreatment made by an elder
Neglect
• Dehydration: e.g. Dizziness, dry mouth, skin, or eyes; little or no urination
• Unattended or untreated health problems: e.g. bed sores, depression
• Malnutrition: e.g. Weight loss, lack of food
• Poor personal hygiene and care: e.g. Looking unkempt, dirty, clothing that is soiled, torn, or inadequate for the weather
• Unclean and unsanitary environment/living conditions: e.g. Evidence of dirt, garbage; insect/rodent/pest infestation, soiled bedding, fecal/urine smell, spoiled food
• Unsafe or hazardous environment/living condition: e.g. Lack of amenities (electricity, heat, water), faulty wiring or fire hazards
• Report of neglect or mistreatment made by an elder
Financial or material exploitation
• Sudden or unexplained changes in bank account or banking practice: e.g. a person accompanying an elder makes an unexpected/unexplained withdrawal of large sums of money
• Financial mismanagement or poor financial stewardship: e.g. Using an elder’s ATM card to make an unauthorized withdrawal of funds; presence of unpaid bills despite the sufficiency of financial resources
• Unexpected changes to legal or financial documents: e.g. Changes to a Will; inclusion of additional names as signatories on an elder’s bank account/card
• Provision of services that are not necessary or substandard care: e.g. Making payment for unneeded services; overpayment for care; unnecessary or unauthorized purchases
• Sudden appearance of unknown or previously uninvolved relatives or “new” friends: e.g. Person claiming rights to an elder’s affairs and possessions; unanticipated or unexplained transfer of assets to a family member or someone outside the family; giving generous “gifts”
• Fraud: e.g. Unexplained disappearance or misuse of funds or valuable possessions; forgery of an elder’s signature for financial transactions or to obtain title to possessions
• Report of financial exploitation made by an elder
Self-neglect
• Dehydration: e.g. Dry eyes, mouth, skin; infrequent or no urination
• Malnutrition: e.g. Lack of food, weight concerns
• Untreated or poorly addressed medical conditions: e.g. Non-compliance with or refusing medication
• Unsanitary or unclean environment/living quarters: e.g. Hoarding, garbage, animal/insect infestation, lack of working bathing/toilet facilities, smell of feces or urine
• Poor personal hygiene: e.g. Unkempt appearance, dirty skin and nails; soiled or torn clothing
• Poor personal care: e.g. Inadequate or inappropriate clothing; lack of required medical devices or supports such as dentures, hearing aids, eye glasses, cane/walker; drug/alcohol dependence
• Challenging living arrangements: e.g. Inadequate housing, homelessness, lack of social support, isolation
• Unsafe or hazardous environment /living conditions: e.g. Absence of light, heating, plumbing, running water; fire risks or other dangers, home in state of disrepair
From research on adults in community settings only and conducted by Acierno et al. (2010) the prevalence of physical abuse was 1.6 %. Similar studies of abuse by family members of community dwelling elders by Laumann et al. (2008) reveal its prevalence to be 0.02 %, and Lachs et al. (2011) found 22.4 per thousand. The most recent national study of elder abuse reporting to APS (Teaster et al. 2006b) revealed 10.7 % of reports of physical abuse substantiated over a year’s time.
Sexual Abuse
Sexual abuse, thought to be the most hidden of the abuses (Ramsey-Klawsnik and Teaster 2012; Teaster and Roberto 2004) is defined by the NCEA (n.d.) as “non-consensual sexual contact of any kind with an elderly person. Sexual contact with any person incapable of giving consent is also considered sexual abuse. It includes, but is not limited to, unwanted touching, all types of sexual assault or battery, such as rape, sodomy, coerced nudity, and sexually explicit photographing.” Acierno et al. found its prevalence to be 0.06 %, Lachs et al. found 0.03 per thousand for a documented case study, and Teaster et al. (2006b) found 1.0 substantiated reports to APS. Occurring in community and facility settings, sexual abuse is difficult to prove when an allegation is not followed up on immediately. For example, Ramsey-Klawsnik and Teaster et al. (2007) found that very few allegations involved a physical examination, let alone an examination by a Sexual Abuse Nurse Examiner (SANE).
Emotional Abuse/Psychological Abuse
According to the National Center on Elder Abuse (n.d.), emotional or psychological abuse involves infliction of anguish, pain, or distress through verbal or nonverbal acts. This form of abuse includes but is not limited to verbal assaults, insults, threats, intimidation, humiliation, and harassment. Infantilizing an older person; isolating elders from family, friends, or regular activities; giving elders the “silent treatment;” and social isolation are examples of emotional/psychological abuse. In the Acierno et al. study (2010), its prevalence was 4.6 %, in Laumann’s study, it was 9 %, and in the Lachs study (2011), it was found to be 16.4 % per thousand. In the Teaster et al. (2006b) study, there were 14.8 % substantiated reports of neglect in one year’s time.
Neglect
Neglect, which can be either active or passive, is defined by the NCEA “as the refusal or failure to fulfill any part of a person’s obligations or duties to an elder. Neglect may also include failure of a person who has fiduciary responsibilities to provide care for an elder (e.g., pay for necessary home care services ) or the failure on the part of an in-home service provider to provide necessary care. Neglect typically means the refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-upon responsibility to an elder.” For neglect, Acierno et al. (2010) found a prevalence of 5.1 %, in the Lachs study (2011), it was found to be 18.3 % per thousand, and in the Teaster et al. (2006b) study, there were 20.4 % substantiated reports of neglect in one year’s time.
Exploitation
This form of abuse is much the object of study in recent years because of its association with other forms of abuse. Financial or material exploitation is defined as the illegal or improper use of an elder’s funds, property, or assets. Examples include, but are not limited to, cashing an elderly person’s checks without authorization or permission; forging an older person’s signature; 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. Concerning exploitation, Acierno et al. (2010) found a prevalence of 5.2 % by a family member, in the Lachs study (2011), it was found to be 42.1 % per thousand, in the Laumann et al. study 3.5 %, and in the Teaster et al. (2006b) study, there were 14.7 % substantiated reports of exploitation in a year’s time.
The Context of Exploitation
For the first time, a study conducted by the MetLife Mature Market Institute (2009) revealed that exploitation that was captured by the news media cost $2.6 billion a year. A follow-up study in 2011 revealed that the dollar amount had escalated to $2.9 billion per annum. When financial exploitation occurs in community settings, it usually involves a family member who has mental health or substance abuse problems or both. Other forms of exploitation can involve persons designated as an elder’s power of attorney or court-appointed guardian. When the exploitation occurs in facility settings, about which less has been studied than in community settings, it can also involve residents of the facility or staff members, in addition to family members. Less examined exploitation by individuals and entities include magazine subscription scams, paving scams, telephone scams, Internet scams, and religious scams.
One way to differentiate the types of exploitation was conceived by the authors of the MetLife Mature Market Institute study (2011): crimes of occasion, desperation and predation. Crimes of occasion or opportunity occur when a victim is merely a barrier in the way of what the perpetrator wants. For instance, an elder has money, assets, and the like, and an occasion presents itself for the perpetrator to access the resource. An occasion scenario was seen in the case of the holiday crime in which a woman was electrocuted with a stun gun and robbed after allowing someone into her home whom she thought was a pharmacist delivering medications. The occasion was the open door and a person whom she thought she could trust.
Crimes of desperation are typically those in which perpetrators are so desperate for money that they will do whatever it takes to get it. Many perpetrators are dependent on an elder parent for housing and for income. The desire for more money may be heightened due to the need for drugs, alcohol, and their gender, or some combination. The exploiter comes to believe that, in return for care, he or she is due compensation (money or possessions), and often on a continuing basis.
Finally, crimes of predation or occupation occur when trust is established for the purpose of financially abusing later. A relationship is built, either through a bond of trust created though developing a relationship (romantic or otherwise) or as a trusted professional advisor. Taking assets is accomplished by stealth and cunning.
Self-neglect
Though not regarded as elder mistreatment because it does not involve abuse by a trusted other, elder self-neglect is one of the most vexing of the abuses encountered, precisely because its origin is difficult to pinpoint and because, in its most extreme form, the problem devolves into a public health risk and can result in removal of the elder from his or her home and concomitant loss of the individual’s civil rights. According to NCEA (n.d.), self-neglect occurs when the behavior of an elder threatens his or her own health or safety and manifests itself as a refusal or failure to provide himself/herself with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions. An elder is not self-neglecting if he or she is mentally competent, understands the consequences of decisions, and makes a conscious and voluntary decision to engage in acts that threaten his/her health or safety as a matter of personal choice.
Self-neglect is reported to be the bulk of APS caseloads (Teaster et al. 2006b). When self-neglect of a community member is purported to occur, some of the thorniest of problems emerge. This situation could be an example of triple jeopardy for an LGBT elder who may become isolated due to his or her age, his or her sexual minority status, and because of fears about coming out to those who might help the situation. Because LGBT elders may have reduced social networks as they age, they may be susceptible to self-neglectful situations. The following scenario is emblematic: on the one hand, the LGBT elder and his or her deplorable situation is revealed and he or she, including all the animals and putrid food, stacks of newspaper and boxes are removed and given appropriate care (the appreciative community scenario). Alternately, the elder is forced, by the heavy hand of government, to do something that is abhorrent to him or her, and due to being LGBT , may suffer more intrusions because she is lesbian, old, and vulnerable. The long and intrusive arm of the state has interfered, once again, with a helpless citizen, and he or she is powerless in the face of this unique form of government intrusion (the elder/community as victim of government intervention).
Federal Legislation that Addresses Elder Abuse
The Older Americans Act
The Older Americans Act (1965) was the first federal level initiative aimed at providing comprehensive services for older adults. Based on a model of active aging, the Act created the National Aging Network, which is composed of Administration on Aging (now, the Administration for Community Living (federal level), State Units on Aging (state level), and Area Agencies on Aging (local level). The Act must be continually reauthorized by Congress, which has never allocated funding commensurate with its lofty aspirations. Though services are supposed to be provided based on age of the recipients (generally 60 years of age and older), they have become more and more focused due to historically flat or slight increases in funding. Notably, the Act has funded nutrition and supportive home and community-based services , disease prevention/health promotion services, training for employment, the National Family Caregiver Support Program and the Native American Caregiver Support Program, and elder rights programs (Title VII or the Vulnerable Elder Rights Protection Title). The purpose of Title VII was to strengthen and coordinate the Long-Term Care Ombudsman Program; Programs for the Prevention of Abuse, Neglect and Exploitation; State Elder Rights and Legal Assistance Development Programs; and Insurance/Benefits Outreach, Counseling and Assistance Programs. Two of the programs are discussed below in greater detail: the National Center on Elder Abuse and the Long-Term Care Ombudsman Program, predominantly local programs that are usually housed in Area Agencies on Aging.
The National Center on Elder Abuse
Directed by the U.S. Administration on Aging, the National Center on Elder Abuse (NCEA) is a resource for policy makers, social service and health care practitioners, the justice system, researchers, advocates, and families (National Center on Elder Abuse, n.d.). Operated under the Department of Health and Human Services, it provides such resources as training, advocacy information, research findings, interpretation of elder abuse statutes, a hotline, and celebration of World Elder Abuse Awareness Day (WEEAD). The Center is re-established through a competitive request for proposals every four years. The newest iteration of the NCEA was awarded to the Keck School of Medicine of the University of Southern California, along with the USC Davis School of Gerontology, the American Bar Association and other organizations dedicated to supporting the aging in America. Through these organizations, the NCEA will provide technical assistance and training to states and community-based organizations to develop effective prevention, intervention and response efforts addressing elder abuse as well as conduct research and advocate for policy changes on behalf of older adults (Snelling 2014).
Long-Term Care Ombudsmen
Area Agencies on Aging (AAA) are a nationwide network of state and local programs that help older people plan and care for their needs. Area Agencies on Aging receive funds through the Administration for Community Living (ACL) and were established by the Older Americans Act, with their goal being to keep elders living independently in their own homes for as long as possible. Over 600 AAAs exist nationwide and provide social services and nutrition services for elders, as well as support for caregivers of elders. In addition, AAA is a useful resource for professionals and practitioners who care for or provide services for elders. AAAs typically house the long-term care ombudsman, which is discussed in greater detail below (Smith 2010; Stupp 2000).
Existing in all states, Long-Term Care Ombudsmen (LTCO), are advocates for residents of nursing homes, board and care homes, assisted living facilities and similar adult care facilities. They work to resolve problems of individual residents and to bring about changes at the local, state and national levels that will improve residents’ care and quality of life. The Long-Term Care Ombudsman Program is authorized and funded under Title VII, Chapter 2, Sections 711/712 of the Older Americans Act, as well as other federal, state, and local sources (Administration for Community Living, n.d.). Each state has an Office of the State Long-Term Care Ombudsman headed by a full-time state ombudsman. Local ombudsman staff and volunteers work in communities throughout the country as part of statewide ombudsman programs, assisting residents and their families and providing a voice for those unable to speak for themselves. The Administration for Community Living funds the National Long-Term Care Ombudsman Resource Center, which is operated by the National Consumers’ Voice for Quality Long-Term Care (or Consumer Voice), in conjunction with the National Association of States Agencies on Aging United for Aging and Disabilities (NASUAD), and which provides training and technical assistance to state and local ombudsmen. Program data for FY 2013 provide a flavor of the activities by LTCO: services to residents were provided by 1,233 full-time equivalent staff and 8,290 volunteers, trained and certified to investigate and resolve complaints who helped resolve 190, 592 complaints, initiated by residents, their families, and other concerned individuals, provided 335,088 consultations to individuals, visited 70 % of all nursing homes and 29 % of all board and care, assisted living and similar homes at least quarterly, and conducted 5,417 training sessions in facilities on such topics as residents’ rights. In addition the LTCO provided 129,718 consultations to long-term care facility managers and staff and participated in 21,812 resident council and 2,371 family council meetings (Administration for Community Living, n.d.). Ombudsmen help residents and their families and friends understand and exercise rights guaranteed by law, both at the Federal level for nursing homes and for States that provide rights and protections in board and care, assisted living and similar homes. Table 16.2 lists the responsibilities of the long-term care ombudsman.
Table 16.2
Responsibilities of the Long-Term care Ombudsman
Educate and inform | Provision of education and information on long-term care related issues and concerns Facilitation of public comment on laws, regulations, policies, and actions Provision of information to residents about long-term care services |
|---|---|
Represent and protect | Representation of residents’ interests before governmental agencies Protection of residents by seeking administrative, legal, and other remedies as appropriate Identification, investigation, and resolution of complaints made by or on behalf of residents Promotion of development of citizen organizations to participate in the program |
Advocate and support | Advocating for changes to improve quality of life and care for residents Provision of analysis, commentary, and recommendations on which affect residents’ rights, health, safety and welfare Provision of technical support and assistance to develop resident and family councils to protect the well-being and rights of residents |
Other Federal Legislation to Address Elder Mistreatment
In addition to the Older Americans Act mentioned above, there are two other important pieces of federal legislation that address elder mistreatment. These are the Social Security Block Grants and the Elder Justice Act (EJA).
Social Security Block Grants
Language in Title XX of the Social Security Act of 1974 gave permission for states to use Social Services Block Grant (SSBG) funds for the protection of adults as well as children (Mixson 1995). By the early 1980s, all states had created an office with the responsibility for providing protective services to some segment of the population, including services to the needy despite the absence of authorizing legislation (NAPSA 2014; U.S. Congress 1981). SSBG funds proved helpful in the establishment of programs to address elder mistreatment , especially Adult Protective Services (discussed below), but the funds are inadequate and diminishing even though reports of elder mistreatment are increasing.
The Elder Justice Act
The Elder Justice Act (EJA) was passed in 2010 as part of the Patient Protection and Affordable Care Act. Although passage of the EJA was truly a victory for the field of elder mistreatment , as of yet, the victory has been somewhat pyrrhic, as the EJA never received funding for its many outstanding provisions and it is set for reauthorization in 2015. Importantly, components of the Act have been undertaken, most notably the formation of the Elder Justice Coordinating Committee, composed of representatives from such agencies as the Administration for Community Living (ACL), the National Institute of Justice (DOJ), and the Social Security Administration. The EJA requires that the Department of Health and Human Services oversee the development and management of federal resources for protecting older adults from elder abuse , including establishing, enhancing, or funding:
The Elder Justice Coordinating CouncilRelated posts:
African-American and Black LGBT Elders
The Intersection of Identities of LGBT Elders: Race, Age, Sexuality, and Care Network
Understanding Transgender Elders
End-of-Life Issues for LGBT Elders
Disabilities and Chronic Illness Among LGBT Elders: Responses of Medicine, Public Health, Rehabilitation, and Social Work
LGBT Elders in Nursing Homes, Long-Term Care Facilities, and Residential Communities
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