Geriatrics/long-term care

Study finds many seniors are abused

Here’s how you can identify and handle abuse

As many as 2 million elderly people are abused each year, and case managers are in an excellent position to identify and help them. Recent research, The National Elder Abuse Incidence Study, concludes that only 16% of abuse cases involving people over age 60 are reported to local Adult Protective Services (APS) agencies. The exact number of abused seniors is difficult to determine because health care professionals and others often miss the signs of abuse.

The study, which ran from October 1994 to December 1997, was conducted by the National Center on Elder Abuse at the American Public Human Services Association in Washington, DC, and Baltimore-based Westat, a social science and survey research firm.1 The study showed that the greatest percentage of cases of elder abuse occurred among people age 80 or older. More than half of the cases of neglect involved people in the 80-plus age group, and about 44% of physical abuse involved people in that age group.

Every state has laws on elder abuse. In fact, most require health care professionals to report suspected or known abuse. "Every time we hire a new case manager, we include information on abuse, neglect, and exploitation in the orientation packet," says Betsy Pegelow, RN, MSN, director of special projects and the Channeling program at Miami Jewish Home and Hospital for the Aged. "In Florida, any professional who observes abuse must report it. The orientation packet includes the state’s definitions of abuse, neglect, and exploitation. Case managers are on the front lines. They observe the patient and the caregiver interactions."

Channeling, a caregiver support program, trains case managers on the programs, policies, and procedures for reporting suspected elder abuse. "We tell case managers to discuss their concerns with their immediate supervisor and then bring the case to the attention of the clinical supervisor," Pegelow explains. "If we are not sure whether abuse is taking place, we may call in the home health agency to be our additional eyes and ears. The home care aide may observe behaviors that the case manager isn’t aware of."

Connecticut Community Care (CCCI) in Bristol, TN, also provides a thorough orientation on elder abuse for new case managers. "We go over signs and symptoms of abuse. Most of our case managers come from a home health background and are already somewhat familiar with issues of abuse," says Sherry Ostrout, MSW, social service regional supervisor for CCCI.

Make yourself the good guy’

Of course, it isn’t always easy for a case manager to continue working with a client after reporting suspected abuse to APS. "In Florida, when Adult Protective Services goes out, they don’t tell the abuser who made the report. Many times the family suspects it is the case manager. It’s one of those situations you have to be prepared to handle," says Pegelow. "It helps for case managers to focus on their client. Your ultimate goal is to protect the client."

CCCI case managers work in teams. "If it became very difficult for a case manager to continue working a case, it might be better for the client to have another case manager on the same team take over," Ostrout suggests. "Fortunately, we’ve developed an excellent relationship with Adult Protective Services. Often , they take the role of the bad guys’ and let us be the good guys’ who are there to help the client and the abuser through the situation."

The five types of abuse involving the elderly typically are described as neglect, emotional, physical, financial, and abandonment. The National Elder Abuse Incidence Study found that the greatest percentage of elderly who suffered from any one of those five types of abuse had household incomes of less than $10,000. Also, while more elderly women than men are victims, there is a higher percentage of men who are abandoned. About 62% of the victims of abandonment were men, according to the national study, compared with about 38% women. On the other hand, women (76%) were more likely to be victims of emotional abuse than were men (24%).

Elder abuse doesn’t follow the same pattern as domestic violence. Whereas domestic violence cases of adults under age 60 typically involve a male abuser and a female victim, elder abuse perpetrators may as likely be women. The study showed that 52.5% of the incidents involved male abusers, and 47.5% involved female abusers. If the abuse is neglect, which is the most frequent type of maltreatment committed, it’s more likely to involve a female abuser. The other forms of abuse are more likely to be caused by men.

Training helps fight abuse

The National Elder Abuse Incidence Study recommends that health care professionals be trained to detect instances of abuse and neglect. Elderly abuse victims often are more isolated than other abuse victims, so case managers may be their first line of defense.

"One area of elder abuse which is grossly underreported and poorly understood is spousal abuse in the elderly," says Ostrout. "Oftentimes, it’s incorrectly labeled under caregiver stress or general elder abuse."

Ostrout recently developed a case manager training program on spousal abuse in the elderly. She since has presented the same training program to local agencies on aging and protective services employees. "How you intervene in cases of spousal abuse in the elderly depends greatly on whether the abuse is part of a long-term pattern of abuse or a new behavior. The first step in these cases is to determine whether the abuse is short-term or long-term," she explains.

If the behavior is short-term, case managers must determine what is causing it, she says. "These reasons can range from serious changes in the victim to cognitive changes." She suggests case managers ask the following questions:

• Has the victim developed an increased physical dependency on the abuser?

• Has a new onset of health problems occurred in the victim or abuser?

• Have there been cognitive changes in the victim or abuser?

• Is the abuser under increased stress?

"If this is short-term or recent-onset abuse, there is a reason. Something has caused the abuse," Ostrout says. "The case manager may observe or suspect that medications are being withheld or the patient is being neglected."

Case managers should request a full physical work-up of both the victim and the abuser, she says. "Once the cause of the abuse is identified, an appropriate management strategy can be planned. If the problem is caregiver stress, the solution may be as simple as working on relieving that stress through respite care."

Long-term spousal abuse is much harder for case managers to address. "Your client may have been in an abusive relationship for 50 years," she says. "In this case, the best person to help you understand how to manage the situation is the victim. What we may view as denial on the victim’s part may be a coping mechanism that has worked effectively for 50 years."

Signs of long-term spousal abuse case managers may observe in victims include low self-esteem, anxiety disorders, depression, delusional behavior, preoccupation with abusers’ comforts and needs, and denial of violence.

"Case managers must realize that if a client says they are being abused, they are probably minimizing the actual level of abuse," Ostrout says. "This is a difficult situation for case managers to remedy. Unlike short-term abuse, there may not be a true solution. The best thing we may be able to do is to tell the victim in advance that a report is being filed so that the victim can take steps to protect their own safety. Listen to the victim. The victim is the expert on how to handle the abuser."

Case managers also can help victims of abuse rebuild their self-esteem. "Case managers can help victims separate themselves from the abuser by developing the victim’s sense of self." (For other suggestions and a list of resources, see stories on pp. 23-24.)

Pegelow adds one note of caution: "Sometimes adults with dementia report they are being abused by their caregiver when it’s not really true. Of more concern is a client who denies abuse due to fear of nursing home placement."


1. National Center on Elder Abuse of the American Public Human Services Association, Westat. The National Elder Abuse Incidence Study. Washington, DC; 1998.