Journal of Gerontological Nursing


Mildred O Hogstel, PhD, RN, C; Linda Cox Curry, PhD, RN










Elder abuse has been recognized widely only recently and still is not reported often (Bourland, 1990). It has been identified as a hidden social problem in society (NCEA, 1998a). Elder abuse first was discussed in the literature in 1975 in an article entitled, "Granny Bashing," in the British Medical Journal (Burston, 1975). Because England was the first country to focus on geriatric medicine and nursing as a specialty, elder abuse was recognized, investigated, and reported more often (Burston, 1975). The purpose of this article is to increase awareness of the various types of abuse and intervention strategies.


Definitions of abuse vary. It is very difficult to define elder abuse because different countries, states, people, ethnic groups, and cultures define elder abuse in various ways. A broad definition of elder abuse used in this article is mistreatment of older individuals, either intentional or unintentional, that causes harm or potential harm. Factors contributing to more specific definitions of elder abuse are:

* Commission: the act of willful abuse.

* Omission: failure to provide needed care and support.

* Active/intentional: knowingly and intentionally committing an act of abuse.

* Passive/unintentional: abuse caused by lack of knowledge, ability, effort, or resources.

* Mistreatment: poor treatment.

* Maltreatment: bad treatment.


Physical and financial abuses are the most common types reported. Psychological abuse and neglect often are not identified as abuse because of lack of sensitivity to the feelings and needs of older people and lack of knowledge about the aging process. Elder abuse can be categorized in many ways. Some of the most common types, based on data from the National Center on Elder Abuse (NCEA) (1998a), may be found hi Table 1 with examples.


Elder abuse, like child and spouse abuse, occurs in all socioeconomic groups, cultures, societies, and countries. Because of the lack of consistent definitions and other factors, it has been very difficult to obtain accurate incidence and prevalence statistics on elder abuse (Wolf, 1996). Most of the statistics on incidence have been rough estimates, ranging from 820,000 to 1,860,000 older individuals being abused each year in the United States (NCEA, 1998a). A commonly used estimate is 1 in 20 individuals age 65 and older is abused each year (Wolf, 1996). If the United States population is approximately 270,000,000, and 13% of the population is age 65 and older, then approximately 1,755,000 older individuals are abused each year (Wolf, 1996). Official agency reports from states have increased from 117,000 in 1987 to 293,000 in 1996 (NCEA, 1998a). Estimates of prevalence range from 4% (1,404,000) to 10% (3,510,000) of the population age 65 and older. One study in the Boston area found a prevalence rate of 3.2% when interviewing 2,000 community-dwelling individuals age 65 and older. Spouse abuse was more prevalent than abuse by adult children (Wolf, 1996).


One possible cause of elder abuse is the increasing prevalence of violence in society. Some family caregivers and health care providers have grown up with violence and consider it "an acceptable way to solve problems" (Delong, 1995, p. 8). Parents pull or slap their children, husbands beat their wives and vice versa, neighbors get angry and fight each other, criminals shoot innocent people, and the effects of violence on television and in movies seem to be accepted and even enjoyed. It has been suggested that if parents have physically abused their children, these children as middle-age adults may believe consciously or subconsciously it is time for retribution and, thus, physically abuse their aging parents (Wolf, 1996). However, research does not demonstrate that effect at this time (Wolf, 1996).









Demographic factors include the increasing number of older people, especially the oldest of the old (those individuals age 80 and older). By the year 2000, the fastest growing age group will be those individuals age 95 and older (Atchley, 1997). Resentment of caregivers because of the challenging and demanding caregiving situations, fatigue, exhaustion, and lack of social stimulation also is a possible cause. Another factor is continuing family conflict and personality traits of members that have caused problems for years (Wolf, 1996). Adult children may disagree about the care and support of their parents. This last factor is a very real and common one. An only child caring for parents may have more responsibility but less family disagreements and conflicts.

Economic factors may contribute to elder abuse. Inadequate financial resources is one of the external stresses that increases the risk of abuse by caregivers (Haviland & O'Brien, 1989). Financial burdens increase because older family members have greater needs.

Another factor may be ageism, a negative view of aging caused by lack of knowledge or accurate information. Some people assume erroneously that older people, especially those who are sick, have decreased intellectual, cognitive, and memory abilities and that these individuals probably will not know what is happening or even remember it. In the presence of ageism, the needs and rights of older people can be minimized because older people are not valued as individuals. For example, physicians may refuse to perform needed surgery on a healthy 93-year-old individual simply based on age.


Older individuals most likely to be abused are those who:

* Are White (NCEA, 1998b).

* Are women (older than age 75) (Haviland & O'Brien, 1989).





* Live with a relative (Haviland StO'Brien, 1989).

* Are socially isolated and have low self-esteem (Godkin, Wolf, & Pillemer, 1989).

* Are of lower cognitive functioning (Godkin et al., 1989).

* Are physically disabled or mentally impaired (Haviland & O'Brien, 1989; Godkin et al., 1989).

* Are dependent on their caregivers (Haviland Si O'Brien, 1989).

* Have poor relationships with the perpetrators (Godkin et al., 1989).

* Have been prior victims of abuse and have used alcohol (Kosberg, 1988).


Elder abuse occurs in all settings, including hospitals, nursing facilities, assisted living facilities, retirement centers, hospices, and homes. The most common types and characteristics of abusers are found in Table 2.


Nurses, especially those who work in home health care agencies and hospital emergency departments, need specific assessment skills to detect elder abuse so it can be reported and prevented. Nurses also need to be aware of abuse that may be occurring in their own agencies or facilities by colleagues or other coworkers, remembering that physical neglect, medical neglect, psychological abuse, and psychological neglect may be occurring. The major signs of abuse are found in Table 3.


In the absence of federal policy related to maltreatment of older adults, each state has established its own guidelines. State statutes differ, but all 50 states and Washington, DC have elder abuse laws. All except eight states require reporting by professionals (NCEA, 1998a), but some states have no adult protective services laws to address mistreatment, which puts the burden on the criminal laws (Douglass, 1995). State nursing practice acts include statements that causing or permitting or failing to report physical, emotional, or verbal abuse, or injury to employers, appropriate legal authorities, or licensing boards is unprofessional conduct (Board of Nurse Examiners, 1995). Usually, a report is made to a state agency that refers the case to a protective service worker. However, there are few support systems to guide health care clinicians in reporting cases (Fulmer, 1994).

Unfortunately, health care providers often are unaware of state laws or disregard them (ClarkDaniels, 1990). Physicians are responsible for only 2% of all reports of suspected elder mistreatment (Rosenblatt & Kyung-Hwan, 1996). Barriers that prevent health care providers from reporting suspected abuse are (ClarkDaniels, 1990; Daniels, Baumhover, Si Clark-Daniels, 1989):

* Doubt in confidentiality.

* Concern about angering the abusers.

* Possible court appearances.

* Damage to professional relationships with clients.

* Skepticism about investigative follow up.

* Lack of confidence in support services.

* Doubt in ability to recognize abuse.

* Lack of cooperation by clients or families.

* Fear of involvement.

Another reason for underreporting elder abuse is lack of health care providers* knowledge, information, and sensitivity to the needs of older people. Older people do not report abuse for several reasons:

* Fear of further abuse or retaliation by the abusers (e.g., family caregivers, paid caregivers)

* Feelings of shame for the abusers, especially if the abuser is a family member (e.g., saying, "I don't want anyone to know that my son hits me," denying the abuse or making excuses to themselves and others to protect loved ones) (Delong, 1995).

* Fear of losing what care they do receive from abusive caregivers and being sent to a nursing home or put out on the street.

* Fear of being accused of lying or of being considered mentally incompetent (e.g., being considered an unreliable witness).

* Various cultural perceptions (e.g., value of serf).

Neighbors, friends, or other people who become aware of the abuse may not want to interfere in "family matters" (Delong, 1995, p. 9). In addition, some older people may not know they are being abused (e.g., financial abuse), are so isolated that they have no way to report abuse or to escape (Delong, 1995), or have some type of dementia such as Alzheimer's disease.


Intervention is the area that needs the most research emphasis to reduce the incidence of abuse (Fulmer, 1994). Intervention should be considered in three layers that overlap - primary, secondary, and tertiary. Primary intervention focuses on strategies to prevent maltreatment of older adults. Secondary intervention focuses on identifying and treating the immediate effects of the maltreatment and minimizing trauma. Tertiary interventions are those actions occurring after maltreatment has occurred and facilitate long-term recovery and rehabilitation from the trauma.





Primary Intervention

Education is the major strategy, not only for health care professionals, but also for the public. The media should be encouraged to provide more information on elder abuse to the public. Thirty percent of the victims of criminal material abuse such as confidence games (i.e., theft by trickery or devices), mail fraud, telemarketing fraud, and other types of financial mismanagement are older adults (Wood, 1991). Informed older adults are more likely to avoid these types of scams. An informed public may be more likely to change attitudes toward reporting abuse, to recognize situations in which someone is at risk for abuse, to support and participate in support services, to propose legislation, and to be more personally sensitive to the needs of the older population in general.

The American Association of Reared Persons (AARP) has published a booklet on prevention of elder mistreatment (Douglass, 1995). Providing adequate communitybased support services can reduce the stress and strain often present when older adults live with their families or have problems with independent living. Inadequate support services also are problematic when intervening in abuse situations.

Secondary Interventions

These interventions are directed at limiting the extent of injury or loss so older people can regain their normal functioning or material assets. The effectiveness of secondary intervention depends on reporting accurate physical, mental, and functional assessments. Early intervention may reduce more severe maltreatment. Emergency department personnel and primary care providers are in excellent positions to screen for and recognize abuse. There is a need to establish and use specific protocols to screen those at risk.

Several useful clinical assessment instruments have been identified to recognize abuse in older clients (Ashley & Fulmer, 1988; Weiler & Buckwalter, 1992):

* Elder Assessment Instrument (Fulmer & O'Malley, 1987), which includes demographic information, functional evaluation, risk factors, and types of abuse.

* Qualcare Scale, developed by Phillips, Morrison, and Chae (cited in Fulmer, 1994), which provides a tool for assessing quality of home care and elder mistreatment.

* HALF assessment tool (Ferguson & Beck, 1983). The acronym refers to abuse assessment of health status, attitudes toward aging, living arrangements, and finances. It is practical in length and easy to use.

* Elder Abuse Diagnosis and Intervention Model (Tornita, 1982), an interview format for older adults and caregivers, which includes functional assessment, mental status evaluation, assessment of activities of daily living, and a physical examination.

* REAH tool (Hamilton, 1989). The acronym for risk of elder abuse in the home. A combination of a vulnerability assessment score of older individuals and a stress assessment score of the caregivers.

* Rathbone-McCuan and Voyles (1982) provide guidelines for a less structured observation in home settings, including physical and behavioral indicators of older victims and aggressive behaviors or disinterest of the family caregivers.

Tools such as these are helpful. However, it also is important for health care providers to individualize protocols for their settings, considering the differences among state laws and their reporting and investigative procedures.

After a situation has been identified, there is a need to assess the nature and extent of the abuse or neglect. Health care providers then have the responsibility of selecting an appropriate intervention. The older individuals may need help to make informed and competent decisions.

An intervention model to combat abuse of older adults must be community-based and interdisciplinary. Reis and Nahmiash (1995) described an excellent model that involves:

* A tool package that involves screening and tracking.

* A team approach to execute intervention strategies.

* A volunteer system to assist and monitor.

* A victim empowerment group.

* An abuse committee for community advocacy and education.

This model represents a low-cost action plan that is interdisciplinary, collaborative, and based within the community.

Legislation must focus on penalties or therapy for perpetrators and the provision of adequate support services. Adequate funding must be provided to implement current programs. Most states have inadequate services to intervene. Responsibilities for investigation and services also may be assigned to as many as 15 different types of agencies by various state laws (Brewer & Jones, 1989). Caseloads in some adult protective services are so high that limited time can be spent on each case (Cash & Valentine, 1987). A more effective working relationship between social agencies and the criminal justice system would bring resolution in cases in which criminal law clearly is broken. Lack of federal and state legislation and other actions inhibit professionals from reporting suspected abuse. Most laws emphasize principles of selfdetermination with the use of the least restrictive interventions (HydeRobertson, 1994).

Tertiary Intervention!

Tertiary intervention begins after immediate treatment has been completed and focuses on rehabilitation and recovery of the older individuals. These interventions frequently overlap secondary services. For example, plans for rehabilitation services frequently are made while secondary treatment is being administered. Tertiary treatment must be directed at the perpetrators as well as the victims, although the literature is mixed regarding the effectiveness of therapy for perpetrators. A chart of primary, secondary, and tertiary intervention strategies is provided in Table 4.


Nationally, abuse among older adults has increased and occurs in all socioeconomic groups. Dependent older adults are the most vulnerable population. Contributing factors are complex and include societal trends, family conflicts, and personality traits.

Despite the problems involved in developing an adequate support system when abuse is suspected and reported, nurses have ethical and legal obligations to be aware of state laws and to report abuse. They also have a responsibility to be proactive in improving the quality of life and care of older people. Suggested actions to meet this responsibility include:

* Increase knowledge of needs of the older adult population.

* Learn common signs of aging for comparative assessment.

* Acquire essential physical, mental, and functional assessment skills for detecting signs of elder abuse, especially in settings where older people receive care.

* Know state laws regarding reporting procedures.

* Learn supportive community services and appropriate referral resources.

* Educate peers about elder abuse.

* Promote continuing education on elder abuse.

* Observe for signs of abuse and neglect by others in work settings.

* Inform older people and the public about the increasing problem of all types of elder abuse by speaking to community groups and encouraging emphasis on elder abuse in the media.

* Support, assist, and educate family caregivers.

* Participate in activities that promote prevention and intervention strategies.

* Volunteer with local agencies to enhance services offered to older adults.

* Advocate for legislative changes to protect older adults.

* Develop, participate in, and support research on elder abuse.

* Establish telephone hotlines at work sites.

Nurses need to work actively to direct professional and public attention to the problem of elder abuse. They can make a difference not only in the intervention and treatment of abuse but also in the prevention of abuse. Elder abuse continues to be an escalating problem, and nurses have a responsibility to be strong advocates for this vulnerable population.


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