The Problem of Elder Physical and Emotional Abuse

What This Guide Does and Does Not Cover

This guide begins by describing the problem of elder physical and psychological abuse and reviewing factors that increase its risks. It then identifies a series of questions to help you analyze your local elder abuse problem. Finally, it reviews responses to the problem and what is known about these from evaluative research and police practice.

Elder physical and emotional abuse are but two components of the larger set of problems related to maltreatment of vulnerable persons. This guide is limited to addressing the particular harms created by elder physical and emotional abuse. Related problems not directly addressed in this guide, each of which requires separate analysis, include:

• Abuse of developmentally disabled persons
• Child abuse and neglect
• Domestic violence
• Elder neglect
• Elder sexual abuse
• Financial exploitation of the elderly
• Human trafficking
• Patient abuse

Some of these related problems are covered in other guides in this series, all of which are listed at the end of this guide. For the most up-to-date listing of current and future guides, see www.popcenter.org.

General Description of the Problem

Elder physical and emotional abuse are two types of elder maltreatment that frequently occur simultaneously. The National Center on Elder Abuse defines physical abuse as "the use of physical force that may result in bodily injury, physical pain, or impairment."1 Physically abusive acts include hitting, kicking, shaking, and a number of other acts. Emotional abuse (also known as psychological abuse) is defined as "the infliction of anguish, pain, or distress through verbal or nonverbal acts."2 Harassment, making threats, and intimidation are examples of emotional abuse. In some states emotional abuse of persons receiving formal health care is specified as illegal by statute. In Delaware, for example, a statute outlaws emotional abuse under this definition: "ridiculing or demeaning a patient or resident, making derogatory remarks to a patient or resident or cursing directed towards a patient or resident, or threatening to inflict physical or emotional harm to a patient."3

The first National Elder Abuse Incident Study found that approximately 450,000 older persons reported experiencing abuse or neglect in 1996.4 A later national study found that about 565,000 older persons reported experiencing abuse or neglect in 2003, with abuse substantiated in about one-third of those cases.5 Physical abuse made up about 11 percent of the substantiated cases and emotional abuse about 15 percent. Elder neglect, financial exploitation, and self-neglect made up the bulk of the remaining cases.

These figures underestimate the extent of elder physical and emotional abuse. Some older victims are unable to report their victimization because of cognitive impairments, and others are reluctant to report their mistreatment for one or more of the following reasons:

• Fear of retaliation
• Fear of being placed in a nursing home or becoming destitute
• Religious beliefs that dictate honoring one's spouse (in elder domestic violence cases)
• Mistrust of the police
• Self-blame
• Feelings of futility
• Embarrassment6

Less than a third of elder physical abuse victims contact the police about their victimization.7

Even though emotional abuse is the most frequent type of elder maltreatment—estimates suggest that approximately one in twenty older persons are emotionally/psychologically abused each year8—victims are especially unlikely to report emotionally abusive acts, primarily because there are no visible injuries and they may fear the consequences of reporting.9

It is commonly estimated that between one and two million individuals are victims of elder abuse in the United States each year.10 In domestic settings, estimates from the National Elder Mistreatment Study suggest that about one in 62 older persons, or about 575,000 in all, experience physical abuse each year.11 As the number of elderly persons living in the United States continues to grow, these numbers are likely to increase in the future. The percentage of people living in the United States who were elderly increased 15.1 percent between 2000 and 2010. A higher proportion of elderly persons now lives in the United States than at any time in its history.12

Regarding abuses occurring in institutional settings, a survey of nursing assistants from 10 nursing homes participating in an abuse prevention training program found that roughly one in six reported engaging in physically abusive behaviors and about half reported yelling at residents in the previous 30 days.13 There is some evidence that for-profit homes have more abuse complaints than nonprofit homes.14 Larger facilities also have a higher rate of complaints. While some have suggested that living in a nursing home is a risk factor for physical and emotional abuse, an estimated 90 percent of abuse cases reported to adult protective services (APS) occur in domestic settings.15 

In both domestic and institutional settings, females are more likely than males to experience elder abuse.16 Males are more likely to abuse males and females are more likely to abuse females.17 Regardless of gender, among older crime victims, more than half have experienced both physical and emotional abuse.18 Among older women who experienced physical abuse, 95 percent also experienced psychological abuse.19 In addition, these acts do not occur just once; instead, they often re-occur among those victims who experience abuse.

In long-term-care settings, the majority of physical and emotional abuse is committed by nurse's assistants.20 Part of the reason that assistants have higher rates of abusive behavior is simply that they have more contact with residents than other staff. Another reason may be that the licensing and educational requirements for nurse's assistants are much lower than they are for nurses, physicians, directors, and other long-term-care staff.21

Laws Relating to Elder Physical and Emotional Abuse

Laws of various kinds define elder physical and emotional abuse or prescribe the legal interventions available in these cases. These laws include:

• Protective order statutes
• Adult protective services (APS) statutes
• Guardianship laws
• State health care and nursing home licensing laws
• Medicare/Medicaid laws
• Specific elder abuse laws
• Long-term-care ombudsmen laws
• Traditional criminal laws (e.g., assault and battery, domestic violence)
• Penalty enhancement laws
• Mandated reporting laws22

Forty-nine states and the District of Columbia define elder maltreatment laws in their protective services legislation.23 Emotional abuse is prohibited in the APS statutes of 42 states.24 Some states have laws requiring APS workers and the police to share information on certain types of cases.25

Harms Caused by Elder Physical and Emotional Abuse

Both elder physical and emotional abuse can have a devastating impact on victims, their family members, and communities. The consequences of these offenses include:

• Fear of future victimization is a frequent response. This fear may keep victims from reporting the abuse to authorities.26
• Physical abuse may cause serious injuries, and existing health or physical problems may be exacerbated by the abuse. Older persons are more likely than younger persons to be physically harmed by certain types of physical abuse.
• Health problems may result from either physical or emotional abuse. Older women who suffer psychological abuse are more likely to report ailments, such as bone or joint problems, high blood pressure, and digestive problems.27
• Victims often fall into depression as a result of either emotional or physical abuse.28 Depression may place older victims at a high risk for subsequent victimization.
• Loss of independence occurs when the abuse causes physical impairments. In addition, older victims living in domestic settings may be moved to nursing homes as a result of their victimization.
• Victims lose trust in their caregivers, the institutions providing care to them, and/or the system they believe failed them. Victims may lose trust in individuals whom they once trusted (namely, spouses, adult offspring, and formal or paid caregivers).
• Older physical and emotional abuse victims commonly feel guilt and shame. Many blame themselves for their victimization, especially if they see themselves as burdening their caregivers. Others experience shame, particularly when adult offspring are the perpetrators. It's generally believed that the older victim, feeling responsible for their victimization, may be ashamed that they raised a child capable of abusing others.
• Victims incur financial losses from treatment to deal with the physical and emotional consequences of these offenses.
• Secondary victimization occurs when individuals suffer emotional harm from hearing about the victimization of their peers. This dynamic is believed to be especially common among older victims.
• Elder physical abuse may also lead to death, either as the result of one severe incident or repeated mistreatment.

Researchers have only recently begun to explore the ties between mortality and elder abuse. One study found that elder abuse victims are about three times more likely to die prematurely than non-abuse victims.29 It is believed that many elder homicides are misclassified as deaths due to natural causes.

Factors Contributing to Elder Physical and Emotional Abuse

Understanding the factors that contribute to your problem will help you frame your own local analysis questions, determine appropriate effectiveness measures, recognize key intervention points, and select appropriate responses. This guide identifies the most common factors contributing to elder physical and emotional abuse. In some instances, additional factors may lead to abuse. After working with the various stakeholders involved in the collaborative response to elder abuse, law enforcement personnel will be able to identify risk factors that may not be addressed in this guide.

Elder abuse researchers and criminologists have cited various explanations for elder physical and emotional abuse. These explanations are easily understood through an examination of vulnerable targets, offender motivations, the absence of guardianship, and community and cultural factors.

Vulnerable Targets

Not all older persons experience victimization. Certain factors increase an older person's risk. Two commonly cited risk factors are the presence of Alzheimer's/dementia and dependency. Providing care to individuals with Alzheimer's and related forms of dementia is especially challenging and may increase the odds of committing abusive acts. In some situations, caregivers react to violent behaviors initiated by the individual with dementia, while in others the caregiver's aggression is tied to the strain that caregivers experience. Approximately one in ten caregivers of those with dementia reported physically abusing the individual in their care.30 Spouses are more likely to be violent toward care recipients who suffer from dementia, especially if they live in the same residence and if the care recipient sometimes hits the caregiver or is otherwise disruptive.31

Older individuals' dependence on their relatives has also been cited as a factor that makes them more vulnerable. Gerontologists use the phrase "generational inversion" to refer to the process by which older individuals lose their independence and become more dependent on relatives who once depended on them. The dependence can be emotional, logistical, or financial.32 Elders with cognitive impairments are especially dependent on others and this dependence increases the risk of victimization. About one-fourth of those dependent on others have experienced elder emotional abuse.33

The nature of the dependence may influence the victim's decision to contact the police. Being dependent on another person for care may cause victims to think about the consequences of not having the offender present to provide care. Dependence on a spouse for care inhibits older persons from reporting physical or emotional abuse by that person.34 Dependency varies across older persons. As a group, elderly persons are not nearly as dependent on younger persons as some may believe. Older people who report being mistreated are especially able to maintain independence in the criminal justice system and do things that make the system work for their interests.35

Offender Motivations

Offender motivations refer to factors that increase offenders' likelihood that they will be physically or emotionally abusive toward older persons. Offender motivations for committing elder abuse include the following:

• Mental illness: Living with an adult with mental health problems increases the risk of elder abuse. Those with Alzheimer's or related forms of dementia may act aggressively toward their caregiver, who is often an older person with his own health problems.36 It has been estimated that about one-third of caregivers are "pinched, shoved, bit, kicked, or struck" by their care recipients.37 One-fourth of caregivers who experienced abuse reported abusing the care recipient in response to the victimization. Individuals with Alzheimer's are about twice as likely as those without the disease to be physically abused.38
• Substance abuse: Drug and alcohol abuse is a risk factor for elder physical abuse. Some of these cases may involve adult offspring who have substance-abuse problems that result in their living at home with their aging relatives. Combined with the inability to find and keep a job, substance abuse issues increase the likelihood of abuse in these situations.
• Histories of violence: A history of being abused as a child may predict one will commit elder abuse.39 However, child abuse victims are more likely to become child abusers than elder abusers.40 A history of violence in marriage may predict elder domestic violence, given that abusers do not stop abusing simply by reaching a certain age.41
• Dependence: An offender's dependence on aging relatives can also be a motivation for offending. Consider instances where an adult offspring lives at home with aging relatives because of his/her own problems (e.g., unemployment, relationship problems). For perpetrators, dependence on their parents may make them feel worthless and devalued. Offenders may use violence to compensate for their atypical dependence on their aging relatives. Similarly, those who commit emotional abuse are also more likely to be dependent on their victims.42 The emotional abuse may be their way of addressing feelings of worthlessness.
• Burden: Caregivers experience physical and financial stress from caring for their aging relatives, and they sacrifice a great deal of their own time along the way. Stress, by itself, is not necessarily a predictor of elder abuse; rather, adaptations to stress are more likely the precipitating factors. Providing care to an aging relative is stressful for almost anyone, but many people provide such care without becoming abusive. But for those providing long-term care, the risk of burnout, aggression, and patient conflict increase, along with the risk of abuse.43
• Rationalizations: Elder abusers sometimes rationalize their abusive behavior.44 They may deny responsibility by blaming caregiving demands for their abuse, or they may claim the victim's behavior precipitated the abuse. Perpetrators of emotional abuse may claim that the abuse did not harm the victim.

Guardianship and Isolation

The more socially isolated older individuals are, the more at risk they are for physical abuse.45 Socially isolated individuals are less likely to be protected by loved ones, public safety professionals, or other potential guardians. Isolation is so problematic in elder abuse cases that some have argued that when individuals actively isolate older persons to gain power and control over their lives, this amounts to emotional abuse.46 It is also argued that the isolation found in long-term-care settings may place residents at a higher risk for maltreatment.47

Community and Cultural Factors

Community and cultural factors also contribute to elder physical and emotional abuse. In some cities, high poverty rates contribute to unemployment, which leads to adult offspring living at home with their aging parents. As noted, having unemployed adults live at home with aging relatives is a risk factor for elder maltreatment. In addition, residents providing care to Alzheimer's patients in disadvantaged areas are less likely to accept formal services, which may place them at a higher risk for maltreatment.48 Also, services available for older victims vary across rural and urban communities.49 Fewer services not only put individuals in some communities at higher risk for victimization, but the consequences of victimization are more difficult to address when certain services are not available.

Community factors also bear on institutional abuses. Urban areas, for example, have been found to have higher abuse rates in nursing homes.50 This difference potentially stems from the higher crime rates found in urban areas, and the difficulties of finding appropriate staff for these positions in these communities. In addition, nursing homes are distributed unequally across cities, making it more difficult for some loved ones to act as de facto guardians by visiting their aging relatives.

Cultural factors may also promote elder abuse. Cultures with high respect for the elderly have lower elder abuse rates.51 Cultures that devalue the elderly, in turn, promote values and behaviors that place older persons at risk. Ageism refers to attitudes or practices that systemically discriminate against the elderly population. Ageist attitudes foster abusive behaviors. In addition, a culture's level of altruism (willingness to help others) is tied to elder abuse. For example, institutional abuses have been tied to a culture's willingness to devote scarce financial resources to help those in need. The more charitable counties are, the lower their rate of institutional abuses.52 Similarly, putting profit (a cultural value) before high-quality health care places older individuals at risk for patient abuse.