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June 10, 2024

Detecting Abuse of the Elderly

Part 2 in a series of articles to support World Elder Abuse Awareness   

Warning Signs of Elder Physical, Sexual, Psychological Abuse, Abandonment and Neglect   

Written by Joanne Byron, BS, LPN, CCA, CHA, CHCO, CHBS, CHCM, CIFHA, CMDP, OHCC, ICDCT-CM/PCS of the American Institute of Healthcare Compliance (AIHC), a non-profit healthcare education organization.   

Elder Abuse Awareness for the Healthcare Workforce

The Department of Justice lists the following information that can be used by nurses, physicians and healthcare workforce members.  AIHC is sharing this information in support of World Elder Abuse Awareness Day.  The information below is not all-inclusive or comprehensive, but it is a good start to increase awareness to educate your workforce.

Please feel free to repost, print and make available to your workforce members.  This information can be useful when completing a Social Determinants of Health (SDOH) risk assessment and any time a health care professional determines it is necessary to gain a deeper understanding of presenting problems which are warning signs of elder physical, sexual, psychological abuse, abandonment, neglect and financial extortion.

Detecting Physical Abuse

Warning Signs can present as:

  • Bruises, black eyes, welts, lacerations, or rope marks
  • Bone fractures, broken bones, or skull fractures
  • Open wounds, cuts, punctures, untreated injuries in various stages of healing
  • Sprains, dislocations, or internal injuries/bleeding
  • Broken eyeglasses/frames, physical signs of being subjected to punishment, or signs of being restrained
  • Laboratory findings of medication overdose or under-utilization of prescribed drugs
  • An elder's report of being hit, slapped, kicked, or mistreated
  • An elder's sudden change in behavior
  • The caregiver's refusal to allow visitors to see an elder alone

Consider Asking –

  1. Has anyone hit, kicked, bit, slapped, or thrown things at you?
  2. Has anyone held or tied you down, or locked you in a room or building?
  3. Has anyone shaken, pinched, or burned you?
  4. Has anyone physically hurt you so that you suffered some injury, such as cuts, bruises, or other marks?
  5. Has anyone pushed, shoved, or grabbed you?
  6. Has anyone used a knife or gun on you?
  7. Has anyone not allowed you to go to the bathroom?     
  8. Has anyone given you too much or too little medication?

EXAMPLES: Stories as told by the DOJ regarding physical abuse cases of the elderly

  • Abuse by Guardian/Conservator
    • Blair, 65, had no close relatives. Because of early-onset dementia, he was placed in a nursing home and required guardianship. Chris, Blair’s guardian, came to Blair’s nursing home every few months to see how Blair was doing.
    • During the last visit, Chris began slapping Blair to wake him up. Joan, a care attendant rushed to the room when Blair began crying out for Chris to stop. Joan noticed marks on Blair’s face and asked what had happened. Blair was unable to tell Joan what had happened but Chris quickly left the room.
    • Joan reported the incident to her supervisors who helped her make a report to Adult Protective Services (APS). The report triggered involvement by the state ombudsman and local law enforcement.
  • Abuse by Long-Term Care Aide
    • Monica, 79, was placed in a long-term care facility when her ALS became severe and her family could no longer care for her. Her family became concerned when they saw bruising on her arms and back. Monica was not able to speak and could not tell her family how she got the bruises.
    • Monica’s family asked the staff about the bruising but was not satisfied with the explanation. The family also noticed that when a certain aide helped bathe her, Monica became upset and agitated. They suspected that the aide was hitting Monica and called local law enforcement.
  • Abuse by Disabled Adult Son
    • When George, 79, lost his wife of 50 years to cancer, his son, Lawrence, came to live with him. Lawrence was on disability due to a traumatic brain injury. The brain injury caused behavior changes, including difficulty with self-control and verbal and physical outbursts. The injury also caused violent mood swings.
    • Occasionally, Lawrence went to a neighbor's apartment and got drunk. One night when Lawrence returned home, George asked him if he was drunk. Lawrence yelled "NO" and punched his father in the face. Because George was afraid of further violence, he called 911 to get help from the police.
  • Abuse by Adult Grandsons
    • Katherine, 82, raised two grandsons, Joel and Kent. They had physically abused her since they were teenagers. After 12 years in prison, Joel returned to his grandmother's home because he had nowhere to go. One night Joel came home and was drunk. He banged on the door but Katherine told Joel to go away.
    • After he entered the house through a back window, Joel beat his grandmother. Katherine went to a neighbor’s house and called 911. Joel was arrested and Katherine was taken to the hospital. The police contacted Adult Protective Services (APS).
  • Abuse by Spouse
    • After 58 years of marriage, Virgil and Ella, both 83, knew each other's habits well. Sometimes, when they argued they became physically violent. Nevertheless, they said they loved each other and had never considered divorce. Violence was unfortunately a part of their relationship. As Ella aged, she developed osteoporosis. She began to worry that if she fell down when they were fighting each other she might end up with a broken bone. She confided this to a friend, and her friend suggested calling the local domestic violence hotline to speak with a counselor.

Detecting Abandonment/Neglect

Warning Signs can present as:

  • Dehydration, malnutrition, untreated bed sores, and poor personal hygiene
  • Unattended or untreated health problems
  • Hazardous or unsafe living conditions/arrangements (e.g., improper wiring, no heat, or no running water)
  • Unsanitary and unclean living conditions (e.g., dirt, fleas, lice on person, soiled bedding, fecal/urine smell, inadequate clothing)
  • An elder's report of being neglected
  • The desertion of an elder at a hospital, a nursing facility, or other similar institution
  • The desertion of an elder at a shopping center or other public location
  • An elder's report of being abandoned

Consider Asking – 

  1. Has the person who is supposed to take you to the grocery store, shopping, or to a place of worship stopped taking you there?
  2. Has the person who is supposed to help with household chores or cooking or eating stopped helping you?
  3. Has the person who is supposed to help get you to the doctor, or take medicines at the right times or amounts, or get glasses or dentures stopped helping you?
  4. Has the person who is supposed to help you bathe or shower, or get in and out of bed, or get dressed, or go to the toilet stopped helping you?
  5. Has the person who is supposed to help you pay bills or manage your money stopped helping you?
  6. Has anyone left you alone or deserted you at home or elsewhere for a long period of time?

EXAMPLES: Stories as told by the DOJ regarding abandonment & neglect of the elderly.

  • Neglect by Daughter and Son-in-Law
    • Kofi, 84, was diagnosed with Alzheimer’s disease and moved in with his daughter's family. Sometimes Kofi had trouble sleeping, had physical and verbal outbursts, and began wandering. His daughter and son-in-law were afraid that Kofi might wander out of the house if they left him alone.
    • They locked the doors to the house so that Kofi could not get out and wander around when they left for work. A neighbor noticed Kofi trying to get out of the house. She contacted the local police and Adult Protective Services (APS).
  • Neglect by Son and Daughter-in-Law
    • Tamara, 76, lived alone but had trouble getting around. Her son and his wife asked Tamara to move in with them. Tamara had her own bedroom on the second floor and stayed there most of the time. She could not use the stairs easily.
    • Her son and daughter-in-law both traveled frequently for work and sometimes neglected to give her adequate food and water. They also failed to groom her or to clean her room consistently.
    • One day Tamara became dizzy, weak and disoriented so her daughter took her to the hospital. The hospital staff discovered that she was dehydrated, disheveled and obviously unwashed. They asked about her care, but Tamara said she was well cared for. 
    • Nevertheless, as required by law, the hospital staff reported suspected neglect to Adult Protective Services (APS).
  • Neglect by Sons
    • Clarence, 79, invited his two adult sons to move in with him so he would not be alone after his wife died.
    • The sons soon sent Clarence out to live in the shed and locked him out of the house. Sometimes his sons put food out for him. Occasionally they gave him a basin of cold water with a washcloth.
    • When one of Clarence’s neighbors noticed that Clarence seemed to be living in the shed, she called Adult Protective Services (APS) anonymously and reported what she had seen. She then decided Clarence may need immediate help so she called the police to do a welfare check.
  • Abandonment by Adult Daughter
    • Juliette, 87, lived with her daughter, Nanette, for the past three years. Nanette helped Juliette with daily activities, such as getting her meals, bathing, and cleaning the house.
    • Nanette decided to move in with her boyfriend in another state and left her mother alone in the home.
    • About a week later, Juliette’s niece happened to be in town and stopped by to visit her aunt. She saw that the inside of the house was in very bad condition and found Juliette in poor health. Juliette’s niece contacted Adult Protective Services (APS) and the State Area Agency on Aging.
  • Abandonment by Guardian/Conservator
    • Henrietta, 88, required a court appointed guardian due to combined physical and mental disabilities that left her partially incapacitated. Her niece, Roberta, was appointed as Henrietta’s guardian.
    • Roberta visited Henrietta in her home a few times but then never came back and made no further arrangements for her care.
    • A neighbor noticed the lack of activity at Henrietta’s house. The neighbor knocked but couldn’t get Henrietta to answer door, so she called law enforcement for a welfare check and Adult Protective Services (APS).
  • Another Abandonment by Guardian/Conservator
    • June, 73, suffered a severe brain injury. At first, she was able to care for herself but as she got worse, a court appointed Sam as her legal guardian to assist her. He saw June two times in the first six months but did not return to see June and did not arrange for her care.
    • He falsified reports to the court stating that he saw June every three months. As a result, no one knew that June was living on her own without Sam’s help.
    • June was unable to remember to clean her house and the trash had not been taken out in many months. Due to the deterioration of her house, June received a visit from a county health officer who discovered that June was very frail.
    • The county health officer was a mandatory reporter and called Adult Protective Services (APS). APS petitioned the court for a new guardian.

Detecting Signs of Psychological Abuse

Warning Signs can present as: 

  • Being emotionally upset or agitated
  • Being extremely withdrawn, non-communicative or non-responsive
  • Unusual behavior, such as sucking, biting, rocking
  • An elder's report of being verbally or emotionally mistreated
  • Witnessing a caregiver controlling an older adult or isolating an older adult
  • Exhibiting a change in sleeping patterns or eating habits
  • Personality changes, such as apologizing excessively, or depression or anxiety

Consider Asking –

  1. Has anyone verbally attacked, scolded, or yelled at you so that you felt threatened or intimidated, or afraid for your safety?
  2. Has anyone made you feel embarrassed by calling you names such as “stupid,” telling you that you or your opinion was worthless or blaming you for things that you did not do?
  3. Has anyone talked to you so that you felt that they were talking to a child?
  4. Has anyone forcefully or repeatedly asked you to do something so that you felt forced into doing something against your will?
  5. Has anyone close to you completely refused to talk to you or ignored you for days at a time, even when you wanted to talk to them?
  6. Has anyone kept you away from family, friends, or regular activities against your will?
  7. Has anyone close to you looked at you in such a way that you felt afraid that they were going to hurt you?
  8. Have you felt that someone was watching your every move to try to control you or that that person was stalking you?
  9. Has anyone you know made unwanted phone calls to you or left messages or sent unwanted emails, texts, or instant messages to you?

EXAMPLES: Stories as Told by the DOJ regarding psychological abuse of the elderly

  • Psychological Abuse by Stranger
    • Rosie, 75, lived alone in an independent senior housing community. Her next-door neighbor, a disabled retiree, repeatedly emailed her rude messages and sent vulgar and threatening messages to her cell phone.
    • Fearing her neighbor might harm her if she told him to stop, Rosie contacted local law enforcement and filed criminal charges as well as a petition for a civil restraining order. She also notified housing management.
  • Psychological Abuse by Son
    • Jane had not seen her friend Harry, 87, at Mass for weeks. This was not like her friend since Harry went to Mass almost every Sunday. Jane stopped by Harry’s house. Harry answered the door and Jane was shocked.
    • Her friend had lost weight, looked terrible, and had obviously been crying. Harry told Jane in a hushed voice that since his son had moved in, he would not let him go to church, the senior center, or even out of the house.
    • Harry said that his son was now controlling everything including his money. Before Jane could say anything, Harry’s son started yelling and Harry quickly closed the door. Jane decided to make an anonymous report to Adult Protective Services (APS).
  • Psychological Abuse by Spouse
    • Sarah, 75, had been married for over 50 years to Saul who was abusive. The abuse had a pattern. Her husband would start following her around watching her every move. Then he would make comments under his breath. Finally, he would start pointing his finger in her face and pushing her around.
    • Since Saul’s retirement, this pattern seemed to be getting worse and happening more often. Sarah picked up a pamphlet on Domestic Violence at her synagogue and decided to make her first call for help.
    • From her conversation with the domestic violence advocate, she learned about resources in her area and steps she could take to be safe.
  • Psychological Abuse by Daughter
    • Zoe, 79, was healthy, independent and lived with her unmarried daughter, Trish, to share expenses. Zoe believed they had a good relationship. Nevertheless, Trish sometimes yelled at Zoe, calling her horrible names and telling her she was worthless.
    • Trish began threatening to put Zoe in a nursing home. Zoe tried to ignore these rants because she was grateful to live with her daughter.  However, she thought she deserved to be safe from such comments.
    • Zoe eventually told a close friend about Trish’s yelling and threats. The friend suggested that Trish and Zoe seek counseling and that Trish get respite help from a local Agency on Aging.
  • Psychological Abuse by Guardian/Conservator
    • Mark, 75, had Alzheimer’s disease and was beginning to have severe memory loss and trouble walking around the house.  Mark’s paid caregiver, Yolanda, asked the court to appoint a guardian.
    • Each time the guardian, Mrs. McKee, visited with Mark, she made fun of his memory problems and inability to remember where he was or even who Yolanda was. Yolanda became worried about Mark and the fact that Mrs. McKee, the court appointed guardian, did not seem to take Mark’s condition seriously.
    • Yolanda called Adult Protective Services (APS) and the probate court to review Mark’s guardianship.

Detect Warning Signs of Sexual Abuse

Warning Signs can present as:

  • Bruises around the breasts or genital area
  • Unexplained venereal disease or genital infections
  • Unexplained vaginal or anal bleeding
  • Changes in an older adult's demeanor, such as showing fear or becoming withdrawn when a specific person is around
  • Evidence of pornographic material being shown to a older adult with diminished capacity
  • Blood found on sheets, linens or an older adult’s clothing
  • An elder's report of being sexually assaulted or raped

Consider Asking –

  1. Has anyone forced you to have sexual intercourse or oral sex if you did not want to?
  2. Has anyone touched you in a sexual way or forced you to touch them in a sexual way against your will?
  3. Has anyone made you undress or expose yourself when you didn’t want to?
  4. Has anyone taken pictures of you with your clothes partially or completely off when you didn’t want them to?
  5. Has anyone talked to you in a sexual way that made you feel uncomfortable?
  6. Has anyone made you watch pornography against your will?

EXAMPLES: Stories as told by the DOJ regarding sexual abuse cases of the elderly.

  • Sexual Abuse by Nursing Home Aide
    • Margaret, 77, lived in a nursing home that was known for good residential care. One day, a nursing aide noticed that Margaret appeared anxious, but Margaret would not explain why.
    • While preparing her for a bath, the nursing aide saw multiple bruises on Margaret's arms, neck and back and asked what happened. Initially, Margaret did not say anything. Subsequently, the director of nursing learned from another resident that a new aide had sexually assaulted Margaret.
    • As required by law, the director of nursing reported the sexual assault to Adult Protective Services (APS), and APS initiated an investigation, involving the Ombudsman and local law enforcement.
  • Sexual Abuse by In-Home Caregiver
    • Eduardo, 80, had a stroke. His family hired an in-home caregiver to assist with his daily needs such as bathing and going to the toilet. One day his daughter stopped by to help see her dad.
    • As she helped him get dressed, he winced, and she noticed that his genital area was red and irritated. Her father started to cry and mumbled something about the caregiver hurting him there.
    • The daughter immediately called Adult Protective Services (APS) to make a report. She also called the agency where the caregiver worked, made a complaint, and ended services. APS alerted the law enforcement.
  • Sexual Abuse by Family Member
    • Pearl, 70, took her nephew in when his mother could not handle his behavior problems. The nephew began viewing pornography on the TV that he shared with his aunt. Pearl was uncomfortable about this and told her nephew to stop.
    • One day, the nephew came home and was high on drugs. He forced himself sexually upon his aunt. Pearl called 911 for local law enforcement and went to the hospital where she met with a sexual assault victim specialist.
  • Sexual Abuse by Guardian/Conservator
    • Angela, 71, required guardianship because of her continued alcohol and drug abuse. The court appointed Richard as her guardian.
    • Soon after his appointment, he gave Angela more drugs, sexually assaulted her, and threatened her with prison for her drug use if she reported him.
    • Angela summoned the courage to go to the local police and contacted a lawyer to obtain a new guardian.

Don’t Turn a Blind Eye – Be Part of the Solution

If you see something, say something to your Compliance Officer, Manager or someone in authority.  Ignoring a potentially harmful situation is to neglect our duty of care to our patients. 

Duty of care is a requirement that a person act toward others and the public with the watchfulness, attention, caution and prudence that a reasonable person in the circumstances would use. If a person's actions do not meet this standard of care, then the acts are considered negligent, and any damages resulting may be claimed in a lawsuit for negligence.

This article is sponsored by the American Institute of Healthcare Compliance (AIHC), a non-profit healthcare compliance training organization. Please re-post this article or print and distribute to your workforce for educational purposes.  Locate more information from your State, local law enforcement, medical society and use this link for additional information from the U.S. Department of Justice.  For more information to obtain online training in corporate compliance, click here.

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