The Best Exotic Marigold Hotel
Independence Day 2012

Elder Abuse – What is It?

category_bug_journal2.gif You think you know the answer to that, right? Well, not so fast. I did too until I started looking into elder abuse for us. There are a zillion definitions, several kinds of abuse, no useful statistics and differing laws in every U.S. state.

It's amazing how many ways people can find to hurt others and although I feel I've only scratched the surface, I already know more than I want about this shameful problem that should be of concern to everyone. I'll try not to overwhelm you with too much information all at once.

Over time, I'll break down a complex phenomenon into something resembling coherence. Let's begin today with getting the terminology and basic facts straight.

There are many definitions of elder abuse. This one is from the National Center on Elder Abuse (NCEA), a program of the U.S. Administration on Aging. It is particularly simple and clear:

”[A]ny knowing, intended, or careless act that causes harm or serious risk of harm to an older person – physically, mentally, emotionally, or financially.”

Elder abuse generally falls into three categories – domestic, institutional and self-abuse which are self-explanatory. Domestic refers to maltreatment caused by someone with a special relationship with the elder - a spouse, a sibling, a child, a friend or a caregiver.

Institutional abuse refers to that which occurs in residential facilities – nursing homes, group homes and varieties of care facilities where the abuse is usually perpetrated by people who have a contractual obligation to provide for elders.

Here, in no particular order, is a breakdown of types of elder abuse. I had no idea there are so many possibilities:

Physical abuse - inflicting physical pain or injury such as slapping, bruising, restraining by physical or chemical means.

Emotional abuse - inflicting mental pain, anguish or distress through verbal or nonverbal acts such as humiliation, intimidation or threats.

Financial abuse - some call this exploitation but I don't think that makes the point strongly enough. It is the illegal theft, fraud, misuse, concealment or neglect, or use of undue influence to gain control of an elder's money or property for another person's benefit.

Sexual abuse - non-consensual sexual contact of any kind.

Neglect - failure by caregivers to provide food, shelter, health care, physical safety or emotional needs.

Desertion - desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person.

What is horrifying to realize is the detail of this list could not exist if these acts did not regularly occur.

In addition, there is “self-neglect” described as the inability of an elder to understand the consequences of action or inaction to such an extent that it will lead to harm or endangerment. For now, I am assuming this item is included because people who should notice and do something sometimes do not.

There are none. No one knows how many elders are affected. Estimates range from half a million to five million people annually and most experts believe that the majority of elder abuse, maybe as much as 80 percent, goes unreported.

Laws and penalties for elder abuse vary widely across states. There are criminal penalties for some forms of elder abuse and where there are not, a growing number of prosecutors are using other kinds of criminal and civil laws to bring abusers to justice. Perhaps, as this series continues, we can get the TGB elderlaw attorney, Orrin Onken, to address some of this for us.

The U.S. Administration on Aging (AoA), the Centers for Medicare and Medicaid Services (CMS) and the Department of Justice (DoJ) provide information and some funding to state and area agencies in support of their prevention activities and victim assistance programs.

But although federal laws on domestic violence and child abuse provide federal funds and shelters for victims, there is no comparable or direct federal assistance for elder abuse victims.

The Affordable Care Act, just upheld by the U.S. Supreme Court last week, includes the Elder Justice Act which, when enacted, will “help prevent and eliminate elder abuse, neglect, and exploitation.” Or so says the White House [pdf].

”Specifically, the law requires the secretary of HHS, in consultation with the Departments of Justice and Labor, to award grants and carry out activities that provide greater protection to those individuals in facilities that provide long-term services and support, and provides greater incentives for individuals to train and seek employment at those facilities. It also requires the immediate reporting of suspected crimes to law enforcement officials.”

The ACA also establishes uniform reporting standards along with a nationwide program for national and state background checks for employees who have direct contact with patients in long-term care facilities.

I suppose that's a start, but it does not address domestic abuse at all.

Here is a short video I would like you to watch. It is from Alberta, Canada and the government intervention does not necessarily apply in the U.S. states. But it gives a good picture of how elder abuse can develop.

So. That's a general overview of elder abuse in the United States. Future posts will deal with warning signs, prevention, local resources, how to report abuse and whatever else I think we should know.

Elder Abuse Part 2: Institutional Abuse Overview

At The Elder Storytelling Place today, Stroppy: Daintree Country, Ozzie Style


This is really valuable, Ronni. Thank you!!!!!

Thanks for highlighting this important issue. The more attention this gets, the better. I certainly agree with your word "shameful", as so much of the abuse is handed out by a person's own family members.

Of course I say this tongue-in-cheek, but there are "those" days when dealing with my mother I easily run out of patience. Takes lots of will power not to verbally lash out at her (some days sheer will power ain't enough). So, while elder abuse is just as shameful and horrible as child abuse, I can see where an exhausted, overextended, and probably depressed caregiver could fall prey to such behavior - don't get me wrong - I do not condone it, nor defend it.

On most occasions caring for my mother is akin to when I was raising four daughters; the communication is very similar. Repeated instructions, etc.

Not to say my mother is senile or mentally incompetent, but she is stubborn and has either very selective hearing, or just plain doesn't process what she hears correctly anymore.

The best self-correction I have is to stop and mentally put myself at her age and ponder how I would feel were the tables turned.

What probably happens as much or more than "abuse" is when there is one adult child still living with, or near, the elder parent, and the other adult children think their sibling is sponging off or exploiting old mother. Another way to cause big rifts among siblings.

I imagine many of your readers in a caregiving role have shared Cowtown Pattie's experience. My mother was so easy going and concerned with others' needs, and there were still times when I would run out of patience and feel doubly blue because I felt that way and knew she did not deserve my having that attitude. Like Cowtown Pattie, my strategy to deal came from experience rearing children and a mental "walk-a-mile-in-her-shoes" lecture.

Thanks for once again dealing with a complex elder issue.

The elder person is so vulnerable. Often they are dependent on the abuser for their meals and care and are afraid to speak up. The role reversal is hard on both generations. Child abuse and elder abuse have much in common.

Big problem, and growing. A good tactic is to go public—if someone is a problem, share it with other children, spouse, siblings, friends, and priests or pastors. Abuse flourishes in the shadows of secrecy.

It's amazing how big a problem and how much disbelief and denial there is about elder abuse. A while back I posted news of a "genius award" by the MacArthur Foundation to a lawyer working on the issue.

My husbands siblings talked my mother-in-law into signing everything over to them. When she began losing her memory, they placed her in an accredited nursing home. It was difficult for her to get up from her low, dorm style bed. The stool in the bathroom was about 12 inches high and there were no grab bars. My husband was not on the list of people allowed to know about her condition or care. When we came to visit, he had to show all sorts of ID to see her. She finally did not know us but she knew what had been done to her. We were legally allowed no input. I must add the nursing home was in Kansas. The added blow to us was that my husband spent 34 years working for the federal Administration on Aging. If this was not a case of elder abuse, I don't know what is. Of course, being duped by greedy children is not uncommon.

Thanks,Ronni, for bringing up this subject.

It's important that we talk about it and learn from each other what to look for and how to deal with it.

This is such an important subject and so hard for families. One source of seniors abuse that is very difficult to monitor is the married life of unhappy senior couples. Many of today's seniors come from a generation who just didn't talk about marital difficulties including any abuse that was going on. This is particularly difficult when the elderly couple are becoming more isolated in their home and dependent on each other. In this type of scenario the abused may not speak up because they feel they wouldn't be able to live alone without their partner and perhaps can't afford to move to a retirement home without their spouse's financial resources. The more we get this information out to people and defuse the sense of shame many seniors have in speaking up, the better.

Abuse is in the eye of the beholder.

My mother was abusive to all of us girls as we grew up. She quit hitting us once we moved out of the family home, but her tongue was "sharper than a serpent's tooth." She rarely had a nice word to say about any of us, so I was amazed that one of my sisters insisted that Mom come to live with her after my dad's death.

Mom continued to pick on us as she aged. However my sister also got some revenge. She simply would not speak to Mom for days at a time. Once Mom became unable to drive, my sister decided that Mom should quit smoking and drinking (Mom would usually have a beer every day). Mom could no longer go to buy her own cigarettes or beer and so had to quit "cold turkey." My sister would leave the house for hours at a time, leaving Mom alone. This was a daily occurence. Mom was not disabled, but could no longer remember how to cook, so she would scrounge around the kitchen to find something to eat, sometimes finding only some crackers or candy or pieces of bread. Then my sister would come home and bring a pizza. Mom hated pizza.

In short, they drove each other nuts. I lived in another state and offered to move my mom to a place near my home, but she refused to move. I tried to get my sister to get Meals on Wheels or something similar for Mom, but my sister refused to allow strangers to come to her house.

I talked to an attorney in Mom's town who specialized in "elder care." He informed me that Mom's case would not qualify as elder abuse in their state and that I didn't have a leg to stand on to move Mom into a facility or even to my own home.

My Mom is dead now, so I no longer have to worry about her, but the thought that this could be done to someone and that there was little or no recourse has led me to put a lot of thought into how I want to be taken care of myself should my husband die before me... And all y'all should think about your situations, too.

The scenario of the senior couples is one of the saddest, in my experience. Two years ago when my 90 year old in-laws had to go into assisted living following some rapidly escalating health issues, we began getting calls reporting that my mother-in-law had been seen hitting my father-in-law. We had not realized, until moving them out of their house, the extent of my mother-in-law's dementia. They were always very proper, very self-contained people and my father-in-law had not even told us that she was being treated for Alzheimer's. After his death,we removed my mother-in-law from assisted living, after four months of steady decline. We moved her back to her house and I have been her 24/7 caregiver for the past 16 months. We had a very rough summer last year when she became physically aggressive towards me and the respite caregivers who were here on occasion. Twice I had to call the sheriff to help me get her back to the house after a walk down the block during which she insisted in walking off towards the highway and would only kick and hit me when I tried to redirect her back toward the house. Fortunately, they were very helpful and supportive, staying and chatting with us for several minutes after getting us home safely. The past ten months have gone much better, but I wasn't sure for awhile that this arrangement was going to work. We were very fortunate that her behavior responded pretty well to a minor change in medication, and that we were able to use private pay respite care services to help us through that time. We can no longer afford the private pay services, but now get 10 hours a week of state paid respite care. I'm thankful for this, but would love to see more support provided for the thousands of families who are trying to keep their loved ones comfortable and cared for at home.

My recent musical drama, still in performance is exactly about this topic, elder abuse and the hidden subtle nature of it. Deprivation particularly. Phone lines and cables and even pets being removed.
My research broke my heart, it is so prevalent and the number of people who have talked to me as the result of the play is stunning.
Thanks for writing about it, the more who know the more awareness there will be.

Excellent topic and well-covered here. Have encountered instances of abuse (fortunately few) in my work. In one case the professional should have known better and another professional present failed to report it or intervene. A stroke patient roommate of the abused young individual (who was not physically touched in any manner) witnessed, but was uncertain if it was a matter of concern, so confided the matter to me. I confirmed the behavior had been totally inappropriate and reported it! The abused young person should never have been in that particular facility in the first place -- mostly thirty and older adults.

Another situation with aged patient and companion had to do with the latter deciding to cease following specified safe eating/drinking precautions. This became complicated because of companion's choice about end-of-life choices and decisions changed which absent family may or may not have been fully involved in, but not communicated to physician, staff.

There are instances when husbands and wives must occupy separate rooms at one or the others request due to any of the various abuse issues you've described.

Sometimes dementia, adverse residual effects due to a variety of medical/neurological reasons can alter individuals behaviors resulting in abuses of all kinds.

I recall one man who was convinced his wife was going to divorce him, badgering her so that she had to be aided to limit her time with him.

A family history of relationships impinges on behaviors as control switches from parent to child sometimes adversely affecting patients when family members visit -- or siblings/relatives have conflicts.

Then there are the patient to patient situations, sometimes romantic complications.

There are as many stories as there are people and I'm describing situations in various types and qualities of facilities.

Obtaining trusted help for a loved one living in their own residence can be a real challenge as I learned with my own mother years ago.

These complications are just some of the reasons why well-meaning laypeople desiring to volunteer to enter facilities to be patient advocates need lots of training. I saw first hand one such sincere volunteer totally disrupt a patient's life due to erroneous conclusions because the volunteer didn't understand the patient's communication issues and limitations. Finally, in court, a judge was able to correct the situation. The patient and her lawyer friend should never have been subjected to that process.

My experience with those who cope with loved ones having hearing loss that is described as "selective hearing," or "they can hear when they want to" is usually not the hard-of-hearing person deliberately doing so. There can be a variety of reasons why they seem to hear at some times and not at others which I won't try to explain here.

The bottom line is in all these instances whether as a patient, a loved one and/or caregiver -- PATIENCE IS THE NAME OF THE GAME!

Expectations the patient/elder must adjust their life to yours may be unrealistic. Some adjustment may be possible, but the caregiver may have to make more adjustment than they might think they should. I'm hearing now the failure of a dear colleague friend to realize and accept this while logically coping with 80+ and 90+ parents -- control, control, control -- give and take -- probably with an underlying fear of obvious declining function on the parents side.

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