Legislatures in all 50 states have passed some form of elder abuse prevention laws. Laws and definitions of terms vary considerably from one state to another, but all states have set up reporting systems. Generally, adult protective services (APS) agencies receive and investigate reports of suspected elder abuse.

Reports to APS agencies of domestic elder abuse increased 150 percent between 1986 and 1996. This increase dramatically exceeded the 10 percent increase in the older population over the same period.

A national incidence study conducted in 1996 found the following:

• 551,011 persons, aged 60 and over, experienced abuse, neglect and/or self-neglect in a one-year period;
• Almost four times as many new incidents of abuse, neglect and/or self-neglect were not reported as those that were reported to and substantiated by adult protective services agencies;
• Persons, aged 80 years and older, suffered abuse and neglect two to three times their proportion of the older population; and
• Among known perpetrators of abuse and neglect, the perpetrator was a family member in 90 percent of cases. Two-thirds of the perpetrators were adult children or spouses.

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

Signs and symptoms of physical abuse include but are not limited to:

• bone fractures, broken bones and skull fractures;
• bruises, black eyes, welts, lacerations and rope marks;
• open wounds, cuts, punctures and untreated injuries in various stages of healing;
• sprains, dislocations and internal injuries/bleeding;
• broken eyeglasses/frames, physical signs of being subjected to punishment and 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; and
• the caregiver's refusal to allow visitors to see an elder alone.

Sexual Abuse

Sexual abuse is defined as non-consensual sexual contact of any kind with an elderly person. 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 and sexually explicit photographing.

Signs and symptoms of sexual abuse include but are not limited to:

• bruises around the breasts or genital area;
• unexplained venereal disease or genital infections;
• unexplained vaginal or anal bleeding;
• torn, stained, or bloody underclothing; and
• an elder's report of being sexually assaulted or raped.

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, humiliation 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.

Signs and symptoms of emotional/psychological abuse include but are not limited to:

• being emotionally upset or agitated;
• being extremely withdrawn and non-communicative or non-responsive;
• unusual behavior usually attributed to dementia (e.g., sucking, biting, rocking); and
• an elder's report of being verbally or emotionally mistreated.

Financial or Material Exploitation

Financial or material exploitation is defined as the illegal or improper use of an elder's funds, property, or assets. Examples include but are not limited to cashing an elderly person's checks without authorization/permission; forging an older person's signature; misusing or stealing an older person's money or possessions; coercing or deceiving an older person into signing any document (e.g., contracts or will); and improperly using conservatorship, guardianship, or power of attorney.

Signs and symptoms of financial or material exploitation include but are not limited to:

• sudden changes in bank account or banking practice, including an unexplained withdrawal of large sums of money by a person accompanying the elder;
• the inclusion of additional names on an elder's bank signature card;
• unauthorized withdrawal of the elder's funds using the elder's ATM card;
• abrupt changes in a will or other financial documents;
• unexplained disappearance of funds or valuable possessions;
• substandard care being provided or bills unpaid despite the availability of adequate financial resources;
• discovery of an elder's signature being forged for financial transactions or for the titles of his/her possessions;
• sudden appearance of previously uninvolved relatives claiming their rights to an elder's affairs and possessions;
• unexplained sudden transfer of assets to a family member or someone outside the family;
• the provision of services that are not necessary; and
• an elder's report of financial exploitation.

Neglect is defined as the refusal or failure to fulfill any part of a person's obligations or duties to an elder. Neglect may also include failure of a person who has fiduciary responsibilities to provide care for an elder (e.g., pay for necessary home care services) or the failure on the part of an in-home service provider to provide necessary care. Neglect typically means the refusal or failure to provide an elderly person with such life necessities as food, water, clothing, shelter, personal hygiene, medicine, comfort, personal safety, and other essentials included in an implied or agreed-upon responsibility to an elder.

Signs and symptoms of neglect include but are not limited to:

• dehydration, malnutrition, untreated bed sores, and poor personal hygiene;
• unattended or untreated health problems;
• hazardous or unsafe living condition/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); and
• an elder's report of being mistreated.

Abandonment

Abandonment is defined as the desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.

Signs and symptoms of abandonment include but are not limited to:

• 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; and
• an elder's own report of being abandoned.

Self-neglect

Self-neglect is characterized as the behavior of an elderly person that threatens his/her own health or safety. Self-neglect generally manifests itself in an older person as a refusal or failure to provide himself/herself with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions. The definition of self-neglect excludes a situation in which a mentally competent older person, who understands the consequences of his/her decisions, makes a conscious and voluntary decision to engage in acts that threaten his/her health or safety as a matter of personal choice.

Signs and symptoms of self-neglect include but are not limited to:

• dehydration, malnutrition, untreated or improperly attended medical conditions, and poor personal hygiene;
• hazardous or unsafe living conditions/arrangements (e.g., improper wiring, no indoor plumbing, no heat, no running water);
• unsanitary or unclean living quarters (e.g., animal/insect infestation, no functioning toilet, fecal/urine smell);
• inappropriate and/or inadequate clothing, lack of the necessary medical aids (e.g., eyeglasses, hearing aids, dentures); and
• grossly inadequate housing or homelessness.

Why Does Elder Abuse Occur and Who are the Perpetrators?

Elder abuse, like other types of domestic violence, is extremely complex. Generally a combination of psychological, social, and economic factors, along with the mental and physical conditions of the victim and the perpetrator, contribute to the occurrence of elder maltreatment. Although the factors listed below cannot explain all types of elder maltreatment because it is likely that different types (as well as each single incident) involve different casual factors, they are some of the causes researchers say are important.

Caregiver Stress

Caring for frail older people is a very difficult and stress-provoking task. This is particularly true when older people are mentally or physically impaired, when the caregiver is ill-prepared for the task, or when the needed resources are lacking. Under these circumstances, the increased stress and frustration of a caregiver may lead to abuse or willful neglect.

Impairment of Dependent Elder

Some researchers have found that elders in poor health are more likely to be abused than those in good health. They have also found that abuse tends to occur when the stress level of the caregiver is heightened as a result of a worsening of the elder's impairment.

Cycle of Violence

Some families are more prone to violence than others because violence is a learned behavior and is transmitted from one generation to another. In these families, abusive behavior is the normal response to tension or conflict because they have not learned any other ways to respond.

Personal Problems of Abusers

Researchers have found that abusers of the elderly (typically adult children) tend to have more personal problems than do non-abusers. Adult children who abuse their parents frequently suffer from such problems as mental and emotional disorders, alcoholism, drug addiction, and financial difficulty. Because of these problems, these adult children are often dependent on the elders for their support. Abuse in these cases may be an inappropriate response by the children to the sense of their own inadequacies.

Who Are the Abusers?

More than two-thirds of elder abuse perpetrators are family members of the victims, typically serving in a caregiving role.

Is Elder Abuse a Crime?

Depending on the statute of a given state, elder abuse may or may not be a crime. However, most physical, sexual and financial/material abuses are considered crimes in all states. In addition, depending on the type of the perpetrator's conduct and its consequences for the victims, certain emotional abuse and neglect cases are subject to criminal prosecution. However, self-neglect is not a crime in all jurisdictions, and, in fact, elder abuse laws of some states do not address self-neglect.

For Help Regarding Elder Abuse

When domestic elder abuse occurs, it can be addressed if it comes to the attention of authorities. Although each state has a different system to address elder abuse, the following are some of the agencies that have been established by federal, state and local governments to help:

Which State and Local Agencies are Helping Victims and Their Families Involved in Elder Abuse?

In most states, the APS (Adult Protective Services) agency, typically located within the human service agency, is the principal public agency responsible for both investigating reported cases of elder abuse and for providing victims and their families with treatment and protective services. In most jurisdictions, the county departments of social services maintain an APS unit that serves the need of local communities.

However, many other public and private agencies and organizations are actively involved in efforts to protect vulnerable older persons from abuse, neglect, and exploitation. Some of these agencies include: the state unit on aging; the law enforcement agency (e.g., the police department, the district attorney's office, the court system, the sheriff's department); the medical examiner/coroner's office; hospitals and medical clinics; the state long-term care ombudsman's office; the public health agency; the area agency on aging; the mental health agency; and the facility licensing/certification agency. Depending on the state law governing elder abuse, the exact roles and functions of these agencies vary widely from one jurisdiction to another.

Although most APS agencies also handle adult abuse cases (where clients are between 18 and 59 years of age), nearly 70 percent of their caseloads involve elder abuse. The APS community is relatively small compared with the groups working for other human service programs, but it is composed of a few thousand professionals, nationwide.

Adult Protective Services

In most jurisdictions, either APS, the Area Agency on Aging, or the county Department of Social Services is designated as the agency to receive and investigate allegations of elder abuse and neglect. If the investigators find abuse or neglect, they make arrangements for services to help protect the victim.

State Elder Abuse Hotlines

Many states have instituted a 24-hour toll-free number for receiving reports of abuse. Calls are confidential.

Law Enforcement

Local police, sheriff's offices, and prosecuting attorneys may investigate and prosecute abuse, particularly in cases involving sexual abuse or assault. In states whose statutes make elder abuse a crime, there may be a requirement to report suspected abuse to a law enforcement agency.

Long Term Care Ombudsman Program

Since passage of the 1975 Older Americans Act, every state has had a long term care ombudsman program to investigate and resolve nursing home complaints. The program has also been working toward extension of services to board and care facilities and, in some areas, to those who receive professional care at home. Check with your State Unit on Aging or Area Agency on Aging to see if the long term care ombudsman program in your area can help in any given instance.

Information and Referral

Every Area Agency on Aging operates an information and referral (I & R) line that can refer people to a wide range of services for people 60 and older. I & R services can be particularly helpful in locating services that can help prevent abuse and neglect.

National and State Information

Often people who want to help older relatives or friends don't live near them. Long-distance caregivers can call a nationwide toll-free Eldercare Locator number (1-800-677-1116) to locate services in the community in which the elder lives. In addition, some states have established a statewide toll-free number to provide centralized aging services information for residents of their states.

Medicaid Fraud Control Units (MFCU)

Every State Attorney General's Office is required by Federal law to have a MFCU to investigate and prosecute Medicaid provider fraud and patient abuse or neglect in health care programs which participate in Medicaid, including home health care services.

The APS agency screens calls for potential seriousness. The agency keeps the information it receives confidential. If the agency decides the situation possibly violates state elder abuse laws, the agency assigns a caseworker to conduct an investigation (in cases of an emergency, usually within 24 hours). If the victim needs crisis intervention, services are available. If elder abuse is not substantiated, most APS agencies will work as necessary with other community agencies to obtain any social and health services that the older person needs.

The older person has the right to refuse services offered by APS. The APS agency provides services only if the older person agrees or has been declared incapacitated by the court and a guardian has been appointed. The APS agency only takes such action as a last resort.