CATEGORIES OF ABUSE

Dependent adult and elder abuse fall into several categories, all resulting from the willful, negligent acts or omissions, including misconduct, gross negligence, or reckless acts, of a caretaker:

  • Physical abuse
  • Sexual abuse
  • Emotional/psychological abuse
  • Financial abuse
  • Neglect (also referred to as deprivation or denial of critical care)
  • Self-neglect
  • Abandonment

Following are general descriptions of these categories. Individual states provide specific descriptions for what constitutes dependent adult abuse and elder abuse in their jurisdictions, and healthcare professionals should familiarize themselves with the laws in their state.

What Constitutes Physical Abuse?

Physical abuse is described as the use of physical force that may result in bodily injury, physical pain, functional impairment, or death. Physical abuse may include, but is not limited to, acts of violence such as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. In addition, inappropriate use of drugs and physical restraints, force-feeding, locking the older adult in a room, and physical punishment of any kind are also examples of physical abuse (CDC, 2020; NIH, 2020).

It is important to differentiate between injuries due to accidents and physical abuse. The following injury patterns can help to differentiate between the two:

  • Persons who are abused often have head or neck injuries without visible harm to other parts of the body. Neck injuries are suspicious because the neck is often protected by the head or face during an accidental fall.
  • Injuries such as scrapes or injuries below the waist are more likely to be due to accidents.
  • Spiral fractures in adults may indicate abuse. Such fractures may be due to violent twisting of the arm.
  • Injuries that cause specific patterns are often indicative of abuse. Examples of such patterns include round burns that may be due to a cigarette or bruises in the shape of a belt buckle or handprint.
    (JEMS, 2020)

What Constitutes Sexual Abuse?

Sexual abuse is defined as nonconsensual sexual contact of any kind with an elderly or dependent adult. 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; sexually explicit photographing; and forced viewing of sexually explicit images (NHAC, 2020b).

Sexual abuse is the least common type of abuse, but it is also the least reported type of abuse compared to all other types of abuse. In nursing homes, there have been over 20,000 complaints of sexual abuse over the past 20 years. Female residents and residents with dementia are at a higher risk of sexual abuse compared to other residents (NHAJ, 2020).

Signs of sexual abuse include:

  • Bleeding from the anus or genitals
  • Bruising on the inner thighs or genitals
  • New sexually transmitted disease
  • Pain of the anus or genitals
  • Panic attacks
  • Pelvic injuries
  • Problems walking or sitting
  • Social or emotional withdrawal
  • Torn, bloody, or stained underwear
    (NHAC, 2020b)

What Constitutes Emotional/Psychological Abuse?

Emotional or psychological abuse is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts. Emotional/psychological abuse includes but is not limited to verbal assaults, insults, threats, intimidation, isolation, humiliation, name calling, terrorizing, and harassment. In addition, treating an older person like an infant; isolating an elderly person from his/her family, friends, or regular activities; giving an older person the “silent treatment”; and enforced social isolation are examples of emotional/psychological abuse (NHAC, 2020b).

Signs of emotional and psychological abuse include:

  • Appearing depressed or withdrawn
  • Appearing frightened
  • Attempting to hurt others
  • Avoiding eye contact
  • Changes in sleeping or eating patterns
  • Isolation from friends and family
  • Low self-esteem
  • Mood swings
    (NHAC, 2020b)

What Constitutes Material/Financial Exploitation?

Financial abuse of the older adult is the illegal, unauthorized, or improper use of the older adult’s resources by someone the adult trusts. Some warning signs of material/financial abuse include:

  • A pattern of missing belongings
  • Older adults who do not know about or understand their finances
  • Someone other than the older adult showing unusual interest in their finances
  • Unexplained withdrawals from bank accounts
  • Evidence of unpaid bills
    (NHAC, 2020b)

What Constitutes Neglect?

Neglect is failure of a caregiver to protect an older adult from harm or failure to provide items of basic necessity, such as:

  • Food
  • Shelter
  • Clothing
  • Supervision
  • Medicine
  • Physical or mental healthcare
  • Other care necessary to maintain that individual’s life or health

Neglect is the most common type of older adult abuse. Evidence of neglect includes:

  • Malnutrition
  • Dehydration
  • Evidence that medicine is not being taken (e.g., blood pressure is too high even though the individual is supposed to be taking antihypertensive medication)
  • Clothing that is inadequate for the weather
  • Dirty clothing
  • Lack of hygiene evidenced by body odor, overt soiling, smell of urine or feces, etc.
    (NHAC, 2020b)

What Constitutes Self-Neglect?

Self-neglect means situations in which the neglect is the result of the acts or omissions of the older or dependent adult themself. This may take the form of the individual refusing care or being unable to provide for their own care, resulting in a threat to their health or safety.

Evidence of self-neglect includes an individual’s refusal or inability to properly:

  • Maintain adequate nutrition or hydration
  • Dress themself
  • Maintain basic hygiene
  • Take medicine
  • Manage finances

Signs of self-neglect include:

  • Poor hygiene
  • Malnutrition
  • Dehydration
  • Unpaid bills
  • Unclean or unsafe home
    (NHAC, 2020b)

What Constitutes Abandonment?

Abandonment occurs when someone who is responsible for the care and welfare of an older adult deliberately deserts them. Persons who are abandoned may be left at such places as a hospital, nursing home, or shopping center. The older adult is frightened and may be confused, lost, or depressed. There may be evidence of malnourishment or poor hygiene (NHAC, 2020b).

Circumstances Not Constituting Abuse

There are certain situations encountered by caregivers that are typically not considered to constitute abuse of the dependent adult or vulnerable elder. Examples of such circumstances include:

  • Circumstances in which the individual declines medical treatment if their religious beliefs call for reliance on spiritual means in place of reliance on medical treatment
  • Circumstances in which the individual’s caretaker, acting in accordance with the individual’s stated or implied consent, declines medical treatment or care
  • Withholding or withdrawing of healthcare from an individual who is terminally ill in the opinion of a licensed physician, when the withholding or withdrawing of healthcare is done at the request of the dependent adult or at the request of the individual’s next of kin and in accordance with applicable laws
  • Good-faith assistance by a family or household member or other person in managing the financial affairs of an individual at the request of the individual or at the request of a family member, guardian, or conservator of the individual
  • Touching that is part of a necessary physical examination, treatment, or care by a caretaker acting within the scope of practice or employment of the caretaker
  • Exchange of a brief touch or hug between the individual and a caretaker for the purpose of reassurance, comfort, or casual friendship
  • Touching between spouses or domestic partners in an intimate relationship
    (IAC, 2020b)
CASE
Neglect

Ellen is 85 years old and lives with her 50-year-old son, Jack. Since Ellen’s health is deteriorating, she needs assistance with activities of daily living, especially using the toilet and dressing. Jack has agreed to serve as his mother’s caretaker, but he does not have much knowledge about the needs of older adults or how to take care of them. Jack works in the construction business, and he is very stressed because business has been slow.

Jack is not consistent with assisting his mother when she indicates her need for help. Therefore, she sometimes remains lying in a urine-soaked bed for hours without clothing or blankets for warmth. Ellen has developed a urinary tract infection as well as pressure injuries on her back due to Jack not responding to her elimination needs and not repositioning her in the bed.

Finally, Jack takes his mother to the local hospital’s emergency room when she becomes too sick to get out of bed. Ellen is admitted with a high temperature. The attending physician immediately suspects abuse, and she immediately acts to make a report. Investigators determine that Jack’s actions constitute neglect because he has not provided his dependent mother with the minimum care she requires.

CASE
Self-Neglect

Lester is 76 years old and lives in a dilapidated cabin along the river and about five miles from town. He is a chronic alcoholic, spending the majority of his monthly income on alcohol instead of groceries. Lester has type 2 diabetes, and he no longer remembers to take his insulin on time.

Lester’s water and electricity were cut off last week since he had not paid his bills for several months. He now uses only river water for cleansing and eats whatever old, canned foods he can find in the kitchen. Due to his poorly controlled diabetes, he has developed ulcers on his feet that have become infected.

When visiting from out of town, Lester’s adult son Charlie discovers his father’s poor living conditions, deteriorating personal hygiene, and ill health. He also notices that his father has become more mentally confused. Charlie tells his dad that he is worried about his health and safety, but Lester angrily insists that he is free to live his life the way he wants.

When Charlie leaves his father’s cabin, he immediately contacts the local county sheriff’s office for assistance and to make a “welfare check” to evaluate his father’s condition. Law enforcement visits Lester’s home. Suspecting self-neglect, they report the case to the state’s Adult Protective Services, which investigates further and assists Lester to address his physical and mental health, hygiene, and safety issues.

CASE
Physical Abuse

Darlene is 85 years old. She has limited mobility and is suffering from dementia. Darlene has been living for three years in a long-term care facility that has a reputation for excellence. Her only living relative is a niece, Chantal, who lives about an hour’s drive away. Chantal visits several times a month and calls the nursing station every week to inquire about her aunt’s status.

Recently, Chantal has been ill and has not visited in nearly four weeks. When she resumes her visits, she finds Darlene in a state of obvious emotional distress. At first, Chantal believes the distress is part of the pattern of dementia. However, as she helps her aunt to sit up in bed in preparation for lunch, Chantal finds a bruise that resembles a handprint on Darlene’s cheek. Alarmed, Chantal examines her aunt further and finds several more bruises in different stages of healing on her buttocks and left breast. The niece immediately goes to the facility administrator with her suspicions of physical abuse.