Want to know more

Elder Mistreatment
Geriatric Nursing Protocol: Detection of Elder Mistreatment

Terry Fulmer, PhD, RN, FAAN , Billy A. Caceres, RN, BSN, BA

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC.  These protocols were revised
and tested in NICHE hospitals.
The text is available here.

Evidence-Based Content - Updated August 2012

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:


Identify best practices in identifying and responding to cases of EM



With the projected increase in the population of older adults world-wide and the rise in medical and technological advances, it is anticipated that older adults will be living longer. Therefore, it is expected that cases of EM, although currently underreported, will be on the rise. As patient advocates and providers of care, nurses  serve  an  important  function  in  the  screening  and  treatment  of  cases  of  EM. However, current data shows that nurses and other health care professionals are not reporting all cases of EM they encounter either because of lack of knowledge about manifestations of EM or how reporting and investigation by state agencies functions.

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Background/Statement of Problem

A. Definitions:

1. Elder mistreatment: “Intentional actions that cause harm or create serious risk of harm (whether harm is intended) to a vulnerable elder by a caregiver or other person who is in a trust relationship to the elder,” or “failure by  a  caregiver  to  satisfy  the  elder’s  basic  needs  or  to  protect  himself  or herself from harm (Ref 1).” Conflicting casual theories of EM:
2.   Physical abuse: The use of physical force that may result in bodily injury, physical pain, or impairment (Ref 2).
3.   Sexual  abuse:  Any  form  of  sexual  activity  or  contact  without  consent, including with those unable to provide consent (Ref 2).
4.   Emotional/psychological  abuse:  The  infliction  of  anguish,  pain,  or  distress through verbal or nonverbal acts (Ref 2).
5.   Financial abuse/exploitation: The illegal or improper use of an elder’s funds, property, or assets (Ref 3).
6.   Caregiver  neglect:  The  refusal  or  failure  to  fulfill  any  part  of  a  person’s obligations   or   duties   to   an   older   adult,   including   social   stimulation (Ref 2).
7.   Self-neglect:  The  behavior  of  an  older  adult  that  threatens  his  or  her own  health  or  safety.  Disregard  of  one’s  personal  well-being  and  home environment (Ref 2).
8.   Risk-vulnerability model: Posits that neglect is caused by the interaction of  factors  within  the  older  adult  and  his  or  her  environment.  The  risk and  vulnerability  model  adapted  to  EM  by  Frost  and  Willette  (1994) provides  a  good  lens  through  which  to  examine  EM.  Vulnerability is determined by characteristics within the older adult that may make him or her more likely to be abused by caregivers such as poor health status, impaired  cognition,  history  of  abuse,  and  so  forth.  Risks  refer  to  factors  in  the  external  environment  that  may  contribute  to  EM  (Ref 4; 5).
9.   Psychopathology of the abuser: Abuse is believed to stem from a perpetrator’s own  battle  with  psychological  illness  such  as  substance  use,  depression, and other mental disorders (Ref 6).
10.   Exchange theory: Speculates that the long-established dependencies present in the victim–perpetrator relationship are part of the “tactics and response developed in family life, which continue into adulthood” (Ref 6).
11.   Social  learning  theory:  Attributes  EM  to  learned  behavior  on  the  part  of the perpetrator or victim from either their family life or the environment; abuse is seen as the norm (Ref 6).
12.   Political    economy    theory:    Focuses    on    how    older    adults    are    often disenfranchised  in  society  as  their  prior  responsibilities  and  even  their self-care are shifted on to others.  

B.    Characteristics of Victims


1.   Decreased  ability  to  complete  ADLs  and  more  physically  frail  (Ref 4; 7; 8).
2.   Cognitive  deficits  such  as  dementia  (Ref 5; 9; 3).
3.   History of childhood trauma (Ref 5; 10).
4.   Depression  and  other  mental  disorders,  as  well  as  an  increased  sense  of hopelessness (Ref 5; 8).
5.   Social isolation and lack of support systems (Ref 7; 8; 11).
6.   History of substance abuse (Ref 7; 8).

C. Characteristics of Perpetrators


1.   Family member in 80% or more of cases (Ref 12).
2.   Long history of conflict with the victim (Ref 13).
3.   Live with victim for an extended time (Ref 14).
4.   Higher rates of caregiver strain (Ref 14).
5.   History of mental illness (Ref 14).
6.   Depression and other mental disorders (Ref 14).
7.   Social isolation and lack of support systems (Ref 14).

D. Etiology and/or Epidemiology

1.   Recent data suggests that in the United States, more than 2 million older adults suffer from at least one form of EM each year (Ref 1).
2.   The National Elder Abuse Incidence Study estimates that more than half a million new cases of EM occurred in 1996 (Ref 15).
3.   Even though 44 states and the District of Columbia have legally required mandated reporting, EM is severely underreported. There is a lack in uniformity across the United States on how cases of EM are handled (Ref 15).
4.   NCEA, (1998) estimates that only 16% of cases of abuse are actually reported.
5.   The  National  Council  on  Elder  Abuse  revealed  that  neglect  accounts  for approximately  half  of  all  cases  of  EM  reported  to  APS.  About  39.3%  of these cases were classified as self-neglect and 21.6% attributed to caregiver neglect, including both intentional and unintentional (Ref 1).
6.   Over  70%  of  cases  received  by  APS  are  attributed  to  cases  of  self-neglect with those older than 80 years thought to represent more than half of these cases (Ref 16).

Parameters of Assessment


Assessment  of Elder Mistreatment
Type of Mistreatment Questions to Assess Type of Mistreatment Physical Assessment and Signs and Symptoms
Physical abuse Has anyone ever tried to hurt you in any way?
Have you had any recent injuries?
Are you afraid of anyone?
Has anyone ever touched you or tried to touch you without permission?
Have you ever been tied down?

Suspected evidence of physical abuse (i.e., black eye) ask:
-How did that get there?
-When did it occur?
-Did someone do this to you?
-Are there other areas on your body like this?
-Has this ever occurred before?
Assess for:
Bruises (more commonly bilaterally to suggest grabbing), black eyes, welts, lacerations, rope marks, fractures, untreated injuries, bleeding, broken eyeglasses, use of physical restraints, sudden change in behavior.

Note if a caregiver refuses an assessment of the older adult alone.

Review any laboratory tests. Note any low or high serum prescribed drug levels.

Note any reports of being physically mistreated in any way.
Emotional/Psychological abuse Are you afraid of anyone?
Has anyone ever yelled at you or threatened you?
Has anyone been insulting you and using degrading language?
Do you live in a household where there is stress and/or frustration?
Does anyone care for you or provide regular assistance to you?
Are you cared for by anyone who abuses drugs or alcohol?
Are you cared for by anyone who was abused as a child?
Assess cognition, mood, affect, and behavior.
Assess for:
Agitation, unusual behavior, level of responsiveness, and willingness to communicate.




Note any reports of being verbally or emotionally mistreated.
Sexual abuse Are you afraid of anyone?
Has anyone ever touched you or tried to touch you without permission?
Have you ever been tied down?
Has anyone ever made you do things you didn't want to do?
Do you live in a household where there is stress and/or frustration?
Does anyone care for you or provide regular assistance to you?
Are you cared for by anyone who abuses drugs or alcohol?
Are you cared for by anyone who was abused as a child?
Assess for:
Bruises around breasts or genital area; sexually transmitted diseases; vaginal and/or anal bleeding; or discharge, torn, stained, or bloody clothing/ undergarments.

Note any reports of being sexually assaulted or raped.
Financial abuse/exploitation Who pays your bills? Do you ever go to the bank with him/her? Does this person have access to your account(s)? Does this person have power of attorney?

Have you ever signed documents you didn’t understand?
Are any of your family members exhibiting a great interest in your assets?
Has anyone ever taken anything that was yours without asking? Has anyone ever talked with you before about this?
Assess for:
Changes in money handling or banking practice, unexplained withdrawals or transfers from patient's bank accounts, unauthorized withdrawals using the patient's bank card, addition of names on bank accounts/cards, sudden changes to any financial document/will, unpaid bills, forging of the patient's signature, appearance of previously uninvolved family members.

Note any reports of financial exploitation.
Caregiver neglect Are you alone a lot?
Has anyone ever failed you when you needed help?
Has anyone ever made you do things you didn’t want to do?
Do you live in a household where there is stress and/or frustration?
Does anyone care for you or provide regular assistance to you?
Are you cared for by anyone who abuses drugs or alcohol?
Are you cared for by anyone who was abused as a child?
Assess for: Dehydration, malnutrition, untreated pressure ulcers, poor hygiene, inappropriate or inadequate clothing, unaddressed health problems, non-adherence to medication regimen, unsafe and/or unclean living conditions, animal/insect infestation, presence of lice and/or fecal/urine smell, soiled bedding.

Note any reports of feeling mistreated.
Self-neglect How often to you bathe?
Have you ever refused to take prescribed medications?
Have you ever failed to provide yourself with adequate food, water, or clothing?
Assess for:
Dehydration, malnutrition, poor personal hygiene, unsafe living conditions, animal/insect infestation, fecal/urine smell, inappropriate clothing, non-adherence to medication regimen.
Source: Fulmer, T., & Greenbery, S. (n.d.). Elder mistreatment & abuse. Retrieved from http://consultgerirn.org/resources

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Nursing Care Strategies

A.   Detailed  screening  to  assess  for  risk  factors  for  EM  using  a  combination  of physical assessment, subjective information, and data gathered from screening instruments (Ref 17).
B.    Strive to develop a trusting relationship with the older adult as well as the caregiver. Set aside time to meet with each individually (Ref 17).
C.   The  use  of  interdisciplinary  teams  with  a  diversity  of  experience,  knowledge, and skills can lead to improvements in the detection and management of cases of  EM.  Early  intervention  by  interdisciplinary  teams  can  help  lower  risk  for worsening  abuse  and  further  deficits  in  health  status  (Ref 14; 18).
D.   Institutions  should  develop  guidelines  for  responding  to  cases  of  EM  (Ref 14; 17).
E.    Educate victims about patterns of EM such that EM tends to worsen in severity overtime (Ref 12; 19).
F.    Provide older adults with emergency contact numbers and community resources (Ref 12).
G.   Referral to appropriate regulatory agencies.

Evaluation and Expected Outcomes

A.   Reduction  of  harm  through  referrals,  use  of  interdisciplinary  interventions and/or relocation to a safer situation and environment.
B.    Victims of EM express an understanding how to access appropriate services.
C.   Caregivers take advantage of services such as respite care or treatment for mental illness or substance use.
D.   If possible, evaluate progress in relationships between caregiver and older adult through screening instruments such as The Modified CSI and GDS.
E.    Institutions  establish  clear  and  evidence-based  guidelines  for  management  of EM cases.

Follow-Up Monitoring of Condition

A.   Follow-up  monitoring  in  the  acute  care  setting  is  limited  compared  to  the follow-up that may be performed in the community or long-term care settings.

Relevant Practice Guidelines

A.   American  Medical  Association.  Diagnostic  and  treatment  guidelines  on  elder abuse and neglect. Chicago, IL: Auhtor.
B.    Aravanis,  S.  C.,  Adelman,  R.  D.,  Breckman,  R.,  Fulmer,  T.  T.,  Holder,  E., Lachs, M., . . .     Sanders, A. B. (1993). Diagnostic and treatment guidelines on elder abuse and neglect. Archives of Family Medicine, 2, 371–388.
C.   Jones, J., Dougherty, J., Schelble, D., & Cunningham, W. (1988). Emergency department protocol for the diagnosis and evaluation of geriatric abuse. Annals of Emergency Medicine, 17(10), 1006–1015.
D.   Neale, A., Hwalek, M., Scott, R., Sengstock, M., & Stahl, C. (1991). Validation of the Hwalek-Sengstock elder abuse screening test. Journal of Applied Gerontology, 10, 406–418.
E.    Phillips,  L.  R.,  &  Rempusheski,  V.  F.  (1985).  A  decision-making  model  for diagnosing  and  intervening  in  elder  abuse  and  neglect.  Nursing  Research,  34(3), 134–139.

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1. National Research Council. (2003). Elder mistreatment: Abuse, neglect, and exploitation in an aging America. Panel to Review Risk and Prevalence of Elder Abuse and Neglect. In R.J. Bonnie & R.B. Wallace (Eds.), Committee on National Statistics and Committee on Law and Justice, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academics Press.

2. National Center on Elder Abuse. (2008). Information about laws related to elder abuse. Retrieved from http://www.ncea.aoa.gov/NCEAroot/Main_Site/Library/Laws/InfoAboutLaws_08_08.aspx

3. Naik, A.D., Teal, C.R., Pavlik, V.N., Dyer, C.B., & McCullough, L.B (2008). Conceptual challenges and practical approaches to screening capacity for self-care and protection in vulnerable older adults. Journal of the American Geriatrics Society, 56(Suppl. 2), S266-S270.

4. Frost, M.H., & Willette, K. (1994). Risk for abuse/neglect: Documentation of assessment data and diagnoses. Journal of Gerontological Nursing, 20(8), 37-45.

5. Fulmer, T., Paves, G., VandeWeerd, C., Fairchild, S., Guadagno, L., Bolton-Blatt, M., & Norman, R. (2005). Dyadic vulnerability and risk profiling in elder neglect. The Gerontologist, 45(4), 525-534. Evidence Level IV.

6. Wolf, R. (2003). Elder abuse and neglect: History and concepts. In R.J. Bonnie, & R.B. Wallace (Eds.), Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Panel to Review Risk and Prevalence of Elder Abuse and Neglect (pp. 238-248). Committee on National Statistics and Committee of Law and Justice, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academics Press.

7. Peisah, C., Finkel, S., Shulman, K., Melding, P., Luxenburg, J., Heinik, J.,...Bennett, H. (2009). The wills of older people: Risk factors for undue influence. International Psychogeriatrics/IPA, 21(1), 7-15. Evidence Level V.

8. Dyer, C.B., Pavlik, V.N., Murphy, K.P., & Hyman, D.J. (2000). The high prevalence of depression and dementia in elder abuse or neglect. Journal of the American Geriatrics Society, 48(2), 205-208. Evidence Level IV.

9. Gorbien, M.J., & Eisenstein, A.R. (2005). Elder abuse and neglect: An overview. Clinics in Geriatric Medicine, 21(2), 279-292. Evidence Level V.

10. Lachs, M.S., Williams, C.S., O'Brian, S., Pillemer, K.A., & Charlson, M.E. (1998). The mortality of elder mistreatment. Journal of the American Medical Association, 280(5), 428-432. Evidence Level II.

11. Draper, B., Pfaff, J.J., Pirkis, J., Snowdon, J., Lautenschlager, N.T., Wilson, I., & Almeida, O.P.(2008). Long-term effects of childhood abuse on the quality of life and health of older paople: Results fromt he depression and early prevention of suicide in general practice project. Journal of the American Geriatrics Society, 56(2), 262-271. Evidence Level II.

12. Cowen, H.J., & Cowen, P.S. (2002). Elder mistreatment: Dental assessment and intervention. Special Care in Dentistry, 22(1), 23-32.

13. Krienert, J.L., Walsh, J.A., & Turner, M. (2009). Elderly in America: A descriptive study of elder abuse examining National Incident-Based Reporting System (NIBRS) data, 2000-2005. Journal of Elder Abuse & Neglect, 21(4), 325-345. Evidence Level V.

14. Wiglesworth, A., Mosqueda, L., Mulnard, R., Liao, S., Gibbs, L., & Fitzgerald, W. (2010). Screening for abuse and neglect of people with dementia. Journal of the American Geriatrics Society, 58(3), 493-500. Evidence Level IV.

15. National Center on Elder Abuse. (1998). The national elder abuse incidence study: Final report. Retrieved from http://aoa.gov/AoARoot/AoA_Programs/Elder_Rights/Elder_Abuse/docs/AbuseReport_Full.pdf

16. Lachs, M.S., & Pillemer, K. (1995). Abuse and neglect of elderly persons. The New England Journal of Medicine, 332(7), 437-443.

17. Perel-Levin, S. (2008). Discussing screening for elder abuse at the primary health care level. Retrieved from World Health Organization http://www.who.int/ageing/publications/Discussing_Elder_Abuseweb.pdf

18. Jayawardena, K.M., & Liao, S. (2006). Elder abuse at end of life. Journal of Palliative Medicine, 9(1), 127-136. Evidence Level V.

19. Phillips, L.R. (2008). Abuse of aging caregivers: Test of a nursing intervention. Advances in Nursing Science, 31(2), 164-181. Evidence Level II.


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