Journal of Gerontological Nursing

AGED ABUSE

Cornelia M Beck, RN, PhD; Doris Ferguson, RNP,MNSc

Abstract

Introduction

Although abuse of the aged by family members has received little attention in the nursing literature, there is a growing recognition among health care providers of the extent of this phenomenon. It may well be that the 1980s will bring to public awareness the prevalence of battered aged - elderly parents who reside with, are dependent upon, and battered by their adult, caretaking children.1

Neither at the national nor the state level are consistent data available on the incidence of aged abuse. In addition, most available information does not include the type of abuse observed. However, four specific areas of abuse have been identified in the literature. These are violation of rights, material abuse, physical abuse, and psychological abuse.

Specific Areas of Abuse

Violation of Rights

Violation of rights is a broad category that encompasses denial of the basic rights of the aged person as enumerated by the 1961 and 1971 White House Conferences on Aging. These rights are:

1. Having basic necessities met, such as food and decent housing

2. Feeling useful and respected

3. Having adequate medical care

4. Obtaining employment based on merit

5. Sharing in the community's recreational and educational resources

6. Having moral and financial support from the family and community

7. Having access to knowledge on how to improve later life and the resources that enable improvement, and

8. Living and dying with dignity3

Violation of these rights is observed frequently among theelderly, particularly those on low fixed incomes. Being forced from one's dwelling is a quite common example. The elderly person who lives alone may be »forced into a nursing home because his family no longer considers him able to live alone, while in actuality he may be very capable of independent living with support services.2

The elderly's access to basic necessities, adequate medical care, and other community resources has been affected greatly by the flight of the young and affluent to the suburbs, leaving the elderly in the deteriorating urban areas. The location and design of facilities that provide needed resources also place many obstacles in the elderly's path of access to these services to which they have a right.

Material Abuse

Material abuse includes theft or misuse of money or property. Children may visit their elderly parents once a month primarily to steal their Social Security checks. The older person who objects may be subject to further abuse physically or psychologically. Families may rely on a Social Security check or other subsidies received for the older person's care. Therefore, money may serve as a motive for keeping the older person in the home, even when institutionalization is advisible.

The older person who is no longer capable of managing financial affairs may be disadvantaged by those caring for him. Money saved to provide for retirement needs may be used by the family for other purposes, sometimes with the result of depriving the aged person of basic needs.

Physical Abuse

Physical abuse includes withholding personal care, medical care, or food. A sort of benign neglect is most prevalent. This occurs in families in which children are frustrated by their own inability to give proper care to aged relatives, particularly in households in which both husband and wife must work.

In a study by Stever and Austin of twelve cases of family abuse of disabled elderly persons, neglect was the most common form of physical abuse.4 Examples included leaving nonambulatory patients unattended for long periods, resulting in vermin infestation and decubitus ulcers. Other areas of physical abuse found in this study were the misuse of medical therapy and nutrition. The aged persons were…

Introduction

Although abuse of the aged by family members has received little attention in the nursing literature, there is a growing recognition among health care providers of the extent of this phenomenon. It may well be that the 1980s will bring to public awareness the prevalence of battered aged - elderly parents who reside with, are dependent upon, and battered by their adult, caretaking children.1

Neither at the national nor the state level are consistent data available on the incidence of aged abuse. In addition, most available information does not include the type of abuse observed. However, four specific areas of abuse have been identified in the literature. These are violation of rights, material abuse, physical abuse, and psychological abuse.

Specific Areas of Abuse

Violation of Rights

Violation of rights is a broad category that encompasses denial of the basic rights of the aged person as enumerated by the 1961 and 1971 White House Conferences on Aging. These rights are:

1. Having basic necessities met, such as food and decent housing

2. Feeling useful and respected

3. Having adequate medical care

4. Obtaining employment based on merit

5. Sharing in the community's recreational and educational resources

6. Having moral and financial support from the family and community

7. Having access to knowledge on how to improve later life and the resources that enable improvement, and

8. Living and dying with dignity3

Violation of these rights is observed frequently among theelderly, particularly those on low fixed incomes. Being forced from one's dwelling is a quite common example. The elderly person who lives alone may be »forced into a nursing home because his family no longer considers him able to live alone, while in actuality he may be very capable of independent living with support services.2

The elderly's access to basic necessities, adequate medical care, and other community resources has been affected greatly by the flight of the young and affluent to the suburbs, leaving the elderly in the deteriorating urban areas. The location and design of facilities that provide needed resources also place many obstacles in the elderly's path of access to these services to which they have a right.

Material Abuse

Material abuse includes theft or misuse of money or property. Children may visit their elderly parents once a month primarily to steal their Social Security checks. The older person who objects may be subject to further abuse physically or psychologically. Families may rely on a Social Security check or other subsidies received for the older person's care. Therefore, money may serve as a motive for keeping the older person in the home, even when institutionalization is advisible.

The older person who is no longer capable of managing financial affairs may be disadvantaged by those caring for him. Money saved to provide for retirement needs may be used by the family for other purposes, sometimes with the result of depriving the aged person of basic needs.

Physical Abuse

Physical abuse includes withholding personal care, medical care, or food. A sort of benign neglect is most prevalent. This occurs in families in which children are frustrated by their own inability to give proper care to aged relatives, particularly in households in which both husband and wife must work.

In a study by Stever and Austin of twelve cases of family abuse of disabled elderly persons, neglect was the most common form of physical abuse.4 Examples included leaving nonambulatory patients unattended for long periods, resulting in vermin infestation and decubitus ulcers. Other areas of physical abuse found in this study were the misuse of medical therapy and nutrition. The aged persons were oversedated, prescribed drugs were not administered, and they were not fed regularly or were given diets of "junk" food.

In many cases reported to the House Select Committee on Aging, aged parents or relatives have been given excessive doses of tranquilizers to make them more manageable, or have been tied while their children go shopping or do housework.5 Multiple unexplained bruises and fractures also are common. Worst of all are the instances of actual beatings. Aged parents may be battered to "control their behavior or merely to vent unchecked frustration."6 Simple greed also may be the motive behind physical abuse. This occurs often during visits to nursing homes when children are trying to exact a change in the will or other property arrangement.5

Psychological Abuse

Psychological abuse includes verbal assaults and threats, provocation of fear, and isolation of the older person either physically or emotionally.2 In their frustration with providing care for the aged, caregivers may exhibit overt or covert hostility toward the older persons. Fear may be provoked when family members, who are aware of their power over the aged, use subtle or obvious pressures and threats to force theelderly to conform. Because elderly people are aware of their dependency, they may conform because they are afraid that their basic needs will not be met.7

Several factors that affect the relationship between the aged person and the caregiver may be precursors to psychological abuse or may, in themselves, be a subtle form of abuse. These factors are: 1 ) not understanding the significance of losses to the aged; (2) not acknowledging the social needs of the aged; and (3) treating the aged like children, including denying their sexuality.

Because the dynamics of loss are understood inadequately in our society, parental mourning often is recognized only when the loss has to do with a significant other. Very few people realize that seemingly insignificant losses may precipitate strong grief reactions in elderly persons. For example, the elderly person might grieve over the death of a pet, the loss of the right to drive an automobile, or the decline of sensory acuity. Thus, older persons reactions' to loss frequently are unnoticed or misunderstood. Depression, repeated physical complaints, stubbomess, and becoming hypercritical are among the common reactions of the aged to loss. What is seen as stubbomess may be a desperate attempt to hold remaining possessions or lifestyles. Isolation and denial, as defenses against the pain of loss, may be seen by adult children as demonstrating lack of feeling on the part of the aged parent. The aged's feelings of helplessness and despair, normal reactions to loss, may be experienced as burdensome parental traits. When this happens, elderly persons are subjected to additional stress - the inability to handle grief experiences appropriately at a time in life when losses are multiple and cumulative. The older person's feelings maybe degraded by caretakers who do not understand the significance of the losses. In addition, caregivers are faced with bothersome behaviors by their parents that they cannot understand. These behaviors may then become triggers for physical or psychological abuse.8

Although children often can accept the occurrence of physical and psychological changes in their parents with age, they may not be as able to grasp that the social needs of the elderly also may change. The lack of understanding may result in the adult offspring's placing aged parents into inappropriate social molds. In a study of 50 adult offspring and their aged parents, it was the elderly parents' distress over their social life that angered the offspring more than any other problem presented. The children felt that their parents would be happier if they were socially involved and active, even if the parents did not express a need to be so. This lack of understanding of the aged person's social needs also is evidenced among children who are uncomfortable about visiting their parents and complain, "There is nothing todo; we just sit there." It is often incomprehensible to them that they might be supporting their parents emotionally, merely by their presence and interest. Again, this lack of understanding of the aged person's social needs may lead to conflict and eventual abuse.8

Treating the aged person like a small dependent child also is a source of psychological abuse. The aged person who is treated like a child will tend to respond in the same way that an infant responds to his mother. Indeed, this attitude toward the aged person tends to "promote the regressive traits themselves, makes for increased dependency, destroys self-reliance, intensifies false feelings of helplessness, and mars as well as undermines any remaining sense of strength, power, and adult dignity."8

It has been suggested that the aged regress to childlike patterns because they realize that only by such responses will they get what they need. This regression is a form of adaptation necessitated by the resocialization process instituted by the caregivers. The demanding, undisciplined, and selfish behavior seen in the elderly may be a result of such socialization, just as it is in infantilized children. When the aged person becomes frustrated and angry because he is treated like a child, his behavior becomes unacceptable to others. This unacceptable behavior may provoke punishment by adult offspring and may lead to eventual abuse.7

An extension of this infantilization of the elderly is the repression of sexual expression among the elderly, much in the same way that sexuality is stifled in young children. Butler and Lewis reported data that indicated clearly that the level of sexual activity in the elderly has been underestimated totally except in cases of illness.10 Nonetheless, children continue to deny the sexuality of their aged parents, sometimes to the extent of depriving them of their rights in this area.

Causes of Aged Abuse

What is the cause of aged abuse? Why does it occur? One framework within which this phenomenon may be understood is that of role theory. A change in the role of the elderly in relation to their adult offspring affects the way the aged parents are treated.7 A role reversal occurs when aged parents cast adult offspring into parental roles, expecting them to supply needs, guard status, or make decisions. This role reversal can be threatening psychologically to both generations and can intensify role conflicts. At the same time that the aged parent is casting adult offspring into the parental role and depends on the offspring for financial support, the elderly person may still be reluctant to relinquish authority over the offspring.1 This is an additional source of role conflict. When these role conflicts are present, the potential for abuse is heightened.

The elderly parent is presumed to be protected by virtue of the love, gentleness, and caring we assume that the family provides. However, the sense of duty in offspring varies with their sex, birth order, experience during childhood, and current life situation. Care of the sick elderly parent is more difficult in today's society in which women often work, leaving no unemployed caretaker at home. In addition, the financial burden of caring for the aged person causes a downward adjustment in living standards. The offspring may resent this obligation and manifest long suppressed hostilities toward the parents. As Steinmetz1 has stated: "Furthermore, the timing of this responsibility is likely to coincide with the launching stage of their own children. The middleage offspring are helping their adolescent and young adult children to become emancipated from home while simultaneously caring for the increasingly dependent elderly parent. This is often a period of college and wedding expenses as well as a time when many women are looking forward to fulfilling their own educational and occupational plans. Since the major caretaking responsibility will most likely be assumed by the wife, this further interruption of her personal goals may breed resentment towards the parent. The normative responsibility of caring for one family of orientation (theelderly parent) versus the desire to maximize the family of procreation's resources results in additional frustration and stress and produces an environment conducive to battering."

Concepts from family systems theory also can be helpful in understanding the psychodynamics underlying the phenomenon of aged abuse. It has been demonstrated that families will adopt a defense mechanism of denial of the elderly parent's illness in order to maintain the family system. Families may claim that the parent's disabilities are so painful that they cannot bear it. Their own survival may depend on maintaining the myth of the elderly parent's invincibility and immortality.11 This distorted belief system serves as a family defense mechanism to ward off the anxiety of possible separation or annihilation. In addition, it contributes to the family's neglecting the needs of an elderly ill parent or to their refusing to place the parent in a nursing home where needs could be met.12

A great deal of actual violence is also tolerated because of this denial. All family members attempt to minimize the seriousness of the violent behavior. Even when the aged parents who are victims of abuse understand what is happening, they may prefer the familiar torments from their adult children to the unknown evils of an unfamiliar life situation.6 Through this denial of abuse, the aged parents are protecting their adult children as well as protecting their self-images. Confronting the aberrant abusive behavior of their adult children would give recognition to their own failure in effective parenting13 and expose them to the shame and humiliation of admitting they raised such odious sons and daughters.6

The denial of abuse by the aged parents and the adult children also is seen in the avoidance of confrontation or open discussion of the violent action and the refusal to request outside help. Thus families tolerate a great deal of violence without taking any action, even when someone is injured physically.

Summary

It is obvious that the abuse of the aged is a fertile ground for developing research questions. Basic to this area is a study of the characteristics of relationships between adult offspring and their elderly parents. Knowledge about these relationships and the qualities that influence them would "facilitate the development of intervention strategies for use where improvement in intergenerational relationships is desirable."14

Other questions that need to be answered are:

What are the dynamics in the families of the neglected, abused elderly?

What are the characteristics of the neglecting-abusing adult offspring?

Is theelderly ill person analogous to the child who is seen as "different"?

What are the characteristics of the neglected-abused older parent?

Is there a relationship between the attitude of adult offspring toward aging and the potential for abuse?

What are the interventions that will be most effective in preventing aged abuse?

While there are many questions still to be answered, it is possible to identify areas of assessment in working with families of theelderly that will alert us to potential or actual abuse. It is also possible to identify intervention strategies for both preventing and managingaged abuse. Those who work with the elderly must make themselves aware of the possibility of abuse so that we can try to prevent it.

References

  • 1. Steinmetz S. Battered parents. Society 1978; 15(5):54.
  • 2. Lau EE, Kosberg JI. Abuse of the elderly by informal care providers. Aging 1979: 299:10-15.
  • 3. Murray RB, Huelskoetter MMW, O'Driscoll DL. The Nursing Process in Later Maturity. New Jersey, PrenticeHall, 1980:138.
  • 4. Steur J, Austin E. Family abuse of the elderly. J Am Geriatr Soc 1980;28(8): 372-6.
  • 5. Anderson J. Gram slamming. 50 Plus 1978;18(9):20.
  • 6. ------------ . Granny bashing. Human Behavior 1979;8(4):48.
  • 7. Gresham ML. The infantilization of theelderly. Nurs Forum 1976; 1 5(2) :204.
  • 8. Simos B. Adult children and their aging parents. Social Work 1973;I8(3):79-8I.
  • 9. Jaeger D, Simmons LW. The Aged 111. New York, Appleton-Century-Crofts, 1970:48.
  • 10. Butler RN, Lewis MI. Aging and Mental Health. St. Louis, CV. Mosby, 1973:100.
  • 11. Miller MB, Bernstein H. Sharkey H. Denial of parental illness and maintenance of family homeastasis. J Am Geriatr Soc 1973;21(6):278-85.
  • 12. Johnson DG. Abuse and neglect-not for children only! J Gerontolog Nurs 1979; 5(4):12.
  • 13. Harbin HT, Madden DJ. Battered parents: A new syndrome. Am J Psychiatr 1979; 136(10): 1 290.
  • 14. Johnson ES. Relationships between the elderly and their adult children. Gerontologist 1 977; 17:90.

10.3928/0098-9134-19810601-04

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