RECOGNIZING ELDER ABUSE AND DEPENDENT ADULT ABUSE

Healthcare professionals should be aware of possible indicators of abuse when caring for adults who may be victims of elder abuse or dependent adult abuse. This abuse can be recognized by many indicators, both among those adults who are victims of such abuse as well as among their abusers. It is important to be aware, however, that signs and symptoms of adult abuse vary according to the type of abuse and that the indicators described below do not always indicate abuse.

The complexity of cases of abuse makes it difficult to establish assessment criteria to meet profiles of signs and symptoms of victims. There have been a succession of tools—such as the EASI (Elder Abuse Suspicion Index)—introduced and used with some success (McGill University, 2020). (See “Resources” at the end of this course.)

Common recommendations described within the literature for abuse assessment with dependent adults include:

• Separate the dependent adult from the caregiver when carrying out an assessment.
• Pay special attention to the physical and psychological aspects of the assessment.
• Be aware that physically abused older adults may have large bruises and will, if able to communicate, identify the cause of injury.
  • Bruises will most likely occur on the face, lateral aspects of the right arm, and the posterior torso (i.e., back, chest, lumbar, and gluteal regions).
  • Bruises may be in various stages of healing from frequent falls, fractures, dislocations, burns, and human bite marks.
  (Boltz et al., 2020)

Victim Indicators

A detailed summary of possible victim indicators of dependent adult or elder abuse are described below, grouped into the categories of physical, behavioral/psychological, environmental, and financial. This list is not all-inclusive and expands on indicators mentioned above (Boltz et al., 2020; CDC, 2020; NHAC, 2020b).

Substance use and abuse affect the older population as well as younger adults. Older adults should also be assessed for substance use issues.

POSSIBLE PHYSICAL INDICATORS

• Lack of medical care
• Lack of personal cleanliness and grooming, body odors
• Swollen eyes or ankles
• Decayed teeth or no teeth
• Bites, fleas, sores, lesions, lacerations
• Injuries in various stages of healing and incompatible with explanation
• Bruises, broken bones, or burns
• Untreated pressure injuries
• Signs of confinement (i.e., tied to furniture, locked in a room, etc.)
• Obesity, malnourishment, or dehydration
• Broken glasses (frames or lenses)
• Drunk, overly medicated, or under-medicated
• Lying in urine, feces, old food
• Petechiae (small, purplish, hemorrhagic spots on the skin) from strangling, which can be found anywhere along the path of injury, such as on the eyelids, in the lower eyelid, on the scalp, and over the ear canals, nose, face, and/or mouth
• Dislocated joints (especially the shoulder from being grabbed)

POSSIBLE BEHAVIORAL AND PSYCHOLOGICAL INDICATORS

• Not dressing appropriately for the weather conditions
• Wearing all of one’s clothing at once
• Living on the street (homeless)
• Intentional physical self-abuse, suicidal statements
• Refusing needed medical attention
• Refusing to take medications
• Not following medication directions
• Threatening or attacking others physically or verbally
• Refusing to open the door to a visitor
• Spending the day in total darkness
• Denying obvious problems (i.e., medical condition, etc.)
• Exhibiting increased depression, anxiety, or hostility
• Being withdrawn, reclusive, suspicious, timid, unresponsive
• Refusing to discuss the situation
• Expressing unjustified pride in self-sufficiency
• Disoriented as to place and time
• Exhibiting diminished mental capacity (i.e., dementia)
• Longing for death, with vague health complaints

POSSIBLE ENVIRONMENTAL INDICATORS

• No food in the house or rotten/infested food
• Lack of proper food storage
• Clothes extremely dirty or uncared for
• Utilities cut off or lack of heat in winter
• Lack of water or contaminated water
• Doors or windows made out of cardboard
• Unvented gas heaters, chimney in poor repair
• Gross accumulation of garbage, papers, and clutter
• Large number of pets with no apparent means of care

POSSIBLE FINANCIAL INDICATORS

• Sudden changes in bank account practices
• Unexplained withdrawal of a large sum of money
• Adding names on a bank signature card
• Unapproved withdrawal of funds using an ATM
• Sudden changes in a will or other financial documents
• Unexplained missing funds or valuables
• Unpaid bills despite having enough money
• Forged signature for financial transactions or for the titles of property
• Sudden appearance of previously uninvolved relatives claiming rights to a person’s affairs and possessions
• Unexplained sudden transfer of assets
• No knowledge of one’s own finances
• Caretaker overly interested in finances of the dependent adult
• Isolation of the dependent adult
• Caregiver refusing to allow visitors (socialization) to see the dependent adult alone
• Loss of personal belongings such as art, silverware, jewelry, or other valuables

Perpetrator Characteristics

Characteristics of the perpetrators of older adult abuse include:

• History of, or current existence of, depression or other mental health disorders
• Stress of providing care to the older adult
• Lack of support from other possible caregivers
• Perception that taking care of the older adult is too much of a burden
• Abusing alcohol or other drugs
• Being socially isolated due to the demands of caregiving
• History of domestic violence in the home
• Being abused by the older adult in the past
• Financial difficulties because of having to care for the elder
  (Help Guide, 2019; Meiner & Yeager, 2019)

Caregivers may exhibit abusive behaviors with dependent adults and/or participate in neglectful behaviors toward the victim. The following table summarizes the types of dependent adult abuse, including examples of abusive actions and warning signs and symptoms of abuse.

SUMMARY OF ABUSE TYPES AND INDICATORS

Type of Abuse	Abusive Act	Signs and Symptoms
(Meiner & Yeager, 2019; NHAC, 2020a, b, c)
Physical	Violent behaviors including hitting, pushing, kicking, shaking, pinching, or burning Deliberately giving medication for the purpose of causing illness or inappropriate sedation Physical restraint use Force-feeding Physical punishment	Dependent/older adult’s report of physical abuse or mistreatment Multiple and/or untreated injuries in various healing stages Bruises, cuts, black eyes, open wounds or other marks on the skin Bruises in various stages of healing Bruises in specific patterns and shapes (e.g., a handprint or a belt buckle) Broken bones (especially spiral fractures), sprains, or dislocations Broken personal care items (e.g., eyeglasses, dentures, hearing or ambulatory aids) Lab findings of inappropriate medicine use Changes in elder or caregiver behavior
Psychological or Emotional	Verbal assaults, insults, or harassment Intimidation or threats Humiliation Social isolation from friends, family, or activities “Silent treatment” Treating dependent person as a baby or belittling Deliberately embarrassing the dependent/older person	Dependent/older adult’s report of verbal or emotional abuse Changes in the victim’s behavior or emotional responses Tearfulness and/or agitation Withdrawn behavior Reluctance to communicate Caregiver answering for the dependent/older adult Depression
Sexual Abuse	Unwanted touching Coerced nudity Sexually explicit photography or video recording Sexual assault or rape Forcing dependent/older adult to watch sexually explicit videos, social media postings, or pornographic pictures	Dependent/older adult’s report of sexual abuse Bruises or bleeding around breasts, genitals, or anus Torn, bloody, or stained underwear Sexually transmitted disease or unexplained genitourinary infection Difficulty sitting Pain in the genitals or anus
Financial Abuse	Stealing or misusing money or possessions Unauthorized check cashing, bank withdrawal, or credit card use Signature forgery on legal documents Forcing the elder to give away valuable possessions Improper use of power of attorney or trusteeship	Dependent/older adult’s report of exploitation Unexplained money withdrawal or change in banking practices Changes in legal documents such as a will or guardianship Missing money or possessions Provision of unneeded goods or services Unexplained withdrawals from bank accounts
Neglect	Lack of basic necessities including food, water, clothing, shelter, medicine, or utilities Personal hygiene and discomfort not attended to Unsanitary living conditions Failure to give medication	Dependent/older adult’s report of neglect Dehydration, malnutrition, weight loss Untreated pain, falls, or medical conditions Bedsores, lice, or other infections and injuries Soiled or inadequate clothing or bedding Spoiled food, fecal, or urine odors
Self-Neglect	Refusing basic necessities, including food, water, clothing, shelter, medicine, or utilities Not attending to personal hygiene and discomfort not attended Deliberately living in unsafe or unsanitary conditions Refusing to seek necessary medical care	Poor personal hygiene Dehydration, weight loss, malnutrition Untreated medical conditions, infections, or injuries Spoiled food, fecal or urine odors, animal or pest infestations