Research, Statistics, & Data

The study of elder mistreatment is a fairly recent area of scholarship in the United States. First discussed in the 1970’s, abuse of older adults was for many years a largely hidden, private matter rather than an issue of social, health, or criminal concern. Research efforts began slowly as state laws recognizing the offense were enacted and public awareness rose. While a research base has been steadily growing, the subject matter is still largely understudied and there remains a critical deficit in the development of robust studies. Notably, elder abuse research and funding lag behind efforts in the comparable and related disciplines of child abuse and intimate partner violence. Further studies are vital to identify the scope of the problem, explore areas of need, and to validate evidence-informed, best practice strategies to address elder abuse prevention, detection, treatment, and response.

Theory and Research-informed Practice
Definitions, Types of Elder Mistreatment, and Prevalence
Signs, Risk Factors, Ageism, and Impacts of Mistreatment
Perpetrator Identity and Poly-victimization
Guardianship and Elder Mistreatment
Intersectionality and Interdisciplinarity of Elder Mistreatment
Elder Mistreatment and the International Response
Elder Mistreatment Detection and Screening Instruments
Interventions

Theory-informed Research and Practice

Theories are essential to explain the complex causes, risk factors, inter-relational dynamics, and consequences of elder mistreatment. They frame the way research is conducted, collected, and analyzed and inform identification of patterns, themes, and tendencies that influence appropriate strategies for intervention. In addition to improving practice measures to prevent and detect abuse, theory is critical to the development of policies that advance the education of practitioners and knowledge in the field. Early theoretical models have been critiqued for several reasons, including their limited scope, discipline-specific focus, and failure to consider cultural implications. While there is no current theoretical consensus, a number of approaches have emerged that lend insight to the area, including the ecological model, the abuse intervention/prevention model, contextual framework, trauma-based theories, and stress process theory.

Research and Data

The statistics and data below provide information about the growing older adult population, definitions of abuse, the prevalence of mistreatment, and risk and protective factors for mistreatment, among other key topic areas. The research-based findings are sourced to peer-reviewed publications, articles, and relevant government agency data. Please note that the information referenced is based upon a variety of studies, each reflecting the author’s respective orientation, the type of research conducted, methods employed, measures evaluated, study-specific operational definitions, and contextually related data sets.

The Growing Older Population

As of 2018 there were 52.4 million adults 65 and over in the United States. By 2040, that number is expected to climb to 80 million, comprising nearly 21% of the total population. People aged 85 and older are predicted to almost triple from their current 6.7 million to 19 million by 2060. For the first time, in 2034, it is anticipated that older Americans will outnumber children. Declining rates of fertility and the aging of the baby boom generation are believed to contribute to the increasing ranks of older adults nationwide.

Demographic Snapshot of Older Adults in the United States

• Life expectancy has risen from 68 years in the mid-20th century to the current average of about 81 years for women and 76 years for men.
• In 2018, there were 29.1 million older women in the United States, compared with 23.3 million older men.
• Overall, approximately 28% of older people live alone. More than 25% of those who live by themselves are older women aged 65-74. For women between the ages of 75-84, the proportionate share jumps to 39%, and for women over 85, 55% live by themselves.
• In 2022, 5.9 million people 65+ lived below the poverty level. Another 2.7 million had incomes at or just above the poverty level (near-poor).
• In 2022, 1.3 million adults aged 65 and older lived in nursing homes. The CDC estimates that approximately 82% of nursing home residents are 65 and older.
• It is expected that by 2030, there will be a 50% increase in the number of elders over the age of 65 who require nursing home care.
• The number of older Americans living with Alzheimer’s disease will likely more than double from 5.8 million to 13.8 million in 2050.
• Nearly 10% of U.S. adults ages 65 and older have dementia. Another 22% have mild cognitive impairment.
• With an aging population, there will be an increased need for caregiving. In 2021-2022, 37.1 million family caregivers provided unpaid care to a family or non-family member 65 and older. Family caregivers ages 55 to 64 (21%) were the most likely to provide care to someone 65 or older, followed by those ages 45 to 54 (20%) and 65 and older (15%).

Definitions

Though there is increasing consensus on the core components of elder mistreatment, the field has not adopted a universally accepted definition of abuse. Several reasons have been suggested for the lack of uniformity. Different professional disciplines, each with their own objectives, interests, and perspectives may use distinct approaches to classify elder abuse.

Conceptual understandings may also vary based on differing cultural and social norms among communities. Perceptions may derive from numerous factors including faith, family, circumstances, context, and community, resulting in diverse descriptions of, and responses to, mistreatment. Notably, in the United States legal definitions of abuse vary by state statute. Internationally, definitional variability is observed both between and within countries. A lack of consistency in definitions and data elements on elder mistreatment across jurisdictions makes it challenging for researchers to measure elder mistreatment and identify trends.

Notwithstanding deficits in classification, the following definitions are commonly cited by researchers in their studies on elder mistreatment.

• According to the Centers for Disease Control and Prevention, “Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. An older adult is someone age 60 or older. The abuse often occurs at the hands of a caregiver or a person the elder trusts.”
• The World Health Organization states that “Elder abuse can be defined as “a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.” Elder abuse can take various forms such as financial, physical, psychological, and sexual. It can also be the result of intentional or unintentional neglect.”
• The National Research Council describes elder abuse as “(a) intentional actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, or (b) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.”
  Types of Elder Mistreatment

Elder mistreatment typically takes one of five forms: physical abuse, psychological or emotional abuse, sexual abuse, financial abuse, and neglect. As with the broader definition of elder mistreatment, understandings of specific types of mistreatment may vary. They are often impacted and informed by socio-cultural orientations and may be differently construed by different constituencies and individuals.

Physical Abuse: the intentional use of physical force or physical coercion that may result in bodily injury, physical pain, or impairment. Acts of physical violence include, but are not limited to, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. Physical abuse also embraces any unlawful, excessive, or unnecessary use of physical or chemical means to restrain or confine an elder, such as force-feeding and physical punishment.

Sexual Abuse: non-consensual sexual contact of any kind with an older adult, perpetrated through force, threats, or the exploitation of authority. Sexual abuse includes, but is not limited to, unwanted touching, sexual assault or battery, sexual harassment, and sexual interaction with elders who lack the capacity to give consent.

Emotional or Psychological Abuse: the infliction of anguish, pain, or distress through verbal or nonverbal acts including, but not limited to verbal assaults, insults, threats, intimidation, humiliation, isolation, and harassment.

Financial Abuse: the illegal or improper use of an elder’s funds, property, or assets including, but not limited to 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 the improper use of conservatorship, guardianship, or power of attorney.

Neglect: the refusal or failure to fulfill any part of a person’s obligations or duties of care to an elder which include, but are not limited to, life necessities such as food, water, clothing, shelter, personal hygiene, medicine, comfort, and personal safety.

Related Concepts

Self-neglect is a phenomenon related to but distinct from elder neglect. Self-neglect is a form of self-harm that may co-occur with, provoke, or be triggered by elder mistreatment. It is characterized as the behavior of an older person that threatens their own health or safety, including but not limited to the refusal or failure to provide themselves with life necessities. Self-neglect is the most frequently reported form of mistreatment referred to Adult Protective Services, with the highest rate of recurrence. The estimated prevalence of self-neglect among community-dwelling older adults ranges from 18.4% to 29.1%, though it is believed to be underrecognized and underreported.

Abandonment is oftentimes considered a subtype of neglect and other times believed to constitute a separate category of mistreatment. By definition, it is the desertion of an older adult by an individual who has physical custody of an elder, or who has assumed responsibility for providing care for that elder.

Elder Financial Frauds and Scams

Elder frauds and scams are typically perpetrated by strangers, compared with elder financial abuse committed by trusted others. Monetary losses can be significant, resulting in medical and mental health impairments, eviction, poverty, and homelessness. Economic costs may also be accompanied by emotional and psychological injury, including. a loss of independence, stability, and social connection in elderhood.

Financial crimes are frequently unreported, unrecognized, and unaddressed. It is estimated that only 1 in 44 cases of exploitation receives formal supportive services. Older victims may be reluctant to reveal harms because of shame and embarrassment, concerns that a complaint will result in loss of independence and autonomy, fears of retaliation by the offender, or the cognitive inability to recognize, discover, and communicate abuse to authorities.

Research shows that older adults with cognitive decline or impairments are at a higher risk of being financially exploited. A study on financial decision making found that nearly two-thirds of older adults who were involved in a scam and were investigated by Adult Protective Services were rated as having decision-making deficits. New evidence also suggests certain neuropsychological factors may indicate vulnerability to financial exploitation. A study on older adults without dementia found that individuals at higher risk for financial exploitation demonstrated worse verbal memory, confrontation naming, phonemic fluency, and set shifting.
Studies indicate the possibility that vulnerability to financial exploitation could be an early behavioral manifestation of preclinical Alzheimer’s Disease. Longitudinal cohort studies with measures of both vulnerability to financial exploitation and Alzheimer’s Disease pathology are needed to enhance understanding of the temporal relationship between neuropathology and financial exploitation vulnerability.
Prevalence of Abuse

Incidence and prevalence rates of mistreatment are informed by the core definitions, inclusion criteria, theoretical basis, and methodology utilized by respective researchers to guide the collection of data. As a result, prevalence estimates of abuse, as reflected in recent studies, are variable.

• Abuse in the Community: Studies have found that at least one in 10 community-dwelling older adults experienced some form of abuse in the prior year. Global estimates from a recent meta-analysis reflect that one in six elders, or 15.7%, in the community experienced past year abuse.
  Prevalence rates by type of abuse differ across studies. One study, relying on self-reports of abuse, assigned the following percentages by type of abuse: psychological (11.6%), physical (2.6%), financial (6.8%), neglect (4.2%), and sexual (0.9%) abuse. Another recent study found the following: emotional (4.6%), physical (1.6%), financial (family:5.2%), financial (stranger:6.5%), neglect (5.1%), and sexual (.6%).

A recent meta-analysis assessing the global prevalence rates of the abuse of older women found that one in six experienced abuse in the prior year. By type, the pooled prevalence rates reflected the following percentages: psychological abuse (11.8%), physical abuse (1.9%), financial abuse (3.8%), neglect (4.1%), and sexual abuse (2.2%).

A systematic review and meta-analysis of the prevalence of elder abuse and neglect in rural areas around the globe found that at least three out of ten older persons in rural areas have experienced abuse and neglect, which is higher than current global estimates of elder abuse. Neglect was the most common (26%), followed by psychological or emotional abuse (17%), physical abuse (7%), and financial abuse (5%), while sexual abuse was rarely reported.

Findings from the 2016/2017 National Intimate Partner and Sexual Violence Survey (NISVS) revealed an estimated 1.4 million adults in the U.S. aged 60 years or older experienced at least one incident of psychological aggression by an intimate partner in the past 12 months and over half a million experienced past-year intimate partner physical violence. An estimated 1.1 million older adults experienced sexual violence by any perpetrator in the past year.

• Abuse in Institutions: Few studies have investigated the prevalence of mistreatment within institutions, in particular residents’ experiences of abuse in residential care settings. Studies that have been conducted have provided wide-ranging, sometimes disparate estimates. A recent systematic review that collected staff self-reports of abuse of residents found high levels of institutional abuse. By type, prevalence estimates reported: psychological abuse (33.4%), physical (14.1%), financial (13.8%), neglect (11.6%), and sexual abuse (1.9%).
  Note: A study of 100 nursing homes in 30 states found that approximately 240 residents experienced fear of retaliation when voicing care concerns and making complaints related to rights violations and mistreatment. In some cases, residents’ cognitive disability due to dementia prevented them from reporting their concerns. Many issues were not reported, delaying or inhibiting investigation.
• NCEA Technical Assistance Data
  In a study examining the types of elder abuse reported to the National Center on Elder Abuse’s resource line, researchers found that financial abuse was the most commonly reported form of mistreatment. Allegations of physical abuse were most likely to co-occur with another type of abuse. Family members were the most often identified offenders.

Note: Studies have recognized that projections of abuse likely underestimate the actual population prevalence. For every incident of abuse reported to authorities, nearly 24 additional cases remain undetected. Underreports may be caused by a number of factors including an older person’s fear of retaliation by the offender, reluctance to disclose the incident because of shame or embarrassment, concern they will be institutionalized, dependency on the offender, and an inability to report because of physical limitations or cognitive impairments.

Signs of Mistreatment

The most frequently observed signs of mistreatment are referenced below. Please note that indicia of abuse may present differently based upon multiple factors, including the type, degree, duration, and context of abuse experienced. Manifestations of abuse may also be impacted by the older adult’s physical and cognitive condition, social connectedness, and emotional state.

Psychological Abuse

• Emotional distress or agitation
• Withdrawal from activities of daily life
• Uncommunicative or non-responsive
• Unusual behaviors commonly attributed to dementia (e.g., sucking, biting, rocking)
• Lack of self-care
• Poor self-esteem, feelings of despair, or a sense of worthlessness
• Physical Abuse
• Bruises, abrasions, welts, lacerations, or rope marks

• Head trauma and/or bone fractures
• Open wounds, cuts, punctures, untreated injuries in various stages of healing
• Sprains, dislocations, and internal injuries/bleeding
• Bite, strangulation, burn marks, or patterns of injury
• Falls, including broken eyeglasses or frames
• Physical indicia of punishment, including evidence of physical restraints
• Medication overdose or chemical restraints
• Sudden behavioral changes
• Financial Abuse

• Sudden changes in bank account or banking practices, including unexplained withdrawals or the addition of signatories to an older person’s bank signature card
• Abrupt changes to a will or other financial documents
• The unexplained disappearance of funds or valuable possessions, or sudden transfer of assets
• Substandard care provision, unpaid bills, or eviction proceedings
• The provision of unnecessary services
• Depression or anxiety
• Evidence of poor financial decision making
• Malnutrition
• Neglect

• Dehydration or malnutrition
• Untreated bed sores
• Poor personal hygiene
• Unattended or untreated health problems
• Unsafe and/or unsanitary living conditions
  Sexual Abuse

• Bruises, abrasions, or lacerations around the breasts or genital area
• Unexplained sexually transmitted disease or genital infection
• Unexplained vaginal or anal bleeding or incontinence
• Increased anxiety or depressive symptoms
•  

Sleep disturbances, agitation, or restlessness

Abuse in Institutional Settings

Older residents of long-term care facilities who have disabilities or otherwise experience frailties may be at heightened risk of mistreatment and less able to safeguard themselves from environmental harm or extricate themselves from danger. Abuse within institutions may be observed in the forms outlined above but may also be discerned in other ways. For example, physical abuse may appear as hygiene neglect, which results in skin abrasions and breakdown such as pressure ulcers. Other means of institutional abuse are medication withholding, food deprivation, treatment neglect, and chemical restraints. Psychological mistreatment may be also employed and expressed as threats of death or harm.

Risk Factors and Protective Factors of Mistreatment

Risk Factors

Recognizing the factors associated with the increased risk of elder mistreatment is critical to help understand the sources and causes of abuse, neglect, and exploitation. It is important to note at the outset that elder abuse is a complicated phenomenon, often rooted in the respective characteristics of the older person and the perpetrator within the context of their interconnected relationship. Each situation is unique and the particular risk factors may vary.

Research studies have discerned both victim and perpetrator characteristics that offer insight as to why certain older people may be susceptible to and targeted for mistreatment, and the reasons offenders may be more likely to commit acts of mistreatment. One study reported that offender traits may be a stronger predictor of abuse than victim features. Knowledge of the discrete and interrelated factors may inform efforts to mitigate the risk of elder abuse, manage environmental threats, and prevent recurrent abuse.

Risk factors can be characterized as “static” or “dynamic.” Static variables are those elements in an individual’s world that are fixed and unlikely to change, such as historical violence or criminality. Dynamic variables, on the other hand, are those factors which may be modified through risk management strategies and tailored interventions. This could include perpetrator substance abuse which may be controlled through treatment, medication, and/or court ordered protections.

Below are examples of risk factors commonly observed among victims and perpetrators. Because of the significance and interrelationship of abuse within the larger societal framework, the impact of socio-cultural risk factors will be addressed below as well.

Victim Risk Factors

• Chronic medical conditions and poor physical health
• Functional disability and dependence
• Mental health problems
• Cognitive deficits
• Financial dependence
• Lower socioeconomic status
•  Substance misuse
•  High levels of stress and poor coping mechanisms
• Prior exposure to trauma
• Limited social support
• Poor relationship between the victim and the perpetrator
  Other victim-centric variables that have been correlated with a potential increased risk of abuse include the following:

• Health care insecurity
• Gender (women)
•  Younger older age
• Unmarried/single. One study reported that older adults who were unmarried or not in a relationship had 2.5 times the odds of experiencing sexual violence than those who were married or partnered.

Dementia and Elder Mistreatment

Older people with dementia are particularly susceptible to abuse. Nearly one in two older adults with cognitive impairment experiences abuse. In addition to being dependent upon others for assistance, elders with dementia are more likely to experience deficits in memory, communication, and judgment that make it harder for them to identify, prevent, and report mistreatment. Many may also be reluctant to report abuse by caregivers and others upon whom they rely. Older people with dementia are often at an increased risk of mistreatment because of pre-existing medical and mental health weaknesses.

Perpetrator Risk Factors

• Chronic medical conditions and poor physical health
• Mental health problems
  Cognitive deficits
• Financial dependence
• Substance misuse
• High levels of stress and poor coping mechanisms
•  Negative attitudes towards the older adult
• Early childhood abuse
• Mistreatment by Caregivers

Caregivers

Grounded in the abuse intervention/prevention model developed by Mosqueda and colleagues, Rosen and colleagues developed a conceptual model addressing risk factors related to caregiver neglect. The approach identifies risk factors across three domains: the vulnerable older adult, trusted other (caregiver), and context. Predisposing factors may be associated with an increased risk of caregiver abuse.
Separately, a study on family caregivers found that communication neglect can be a warning sign of potential abuse. The study reported that when the person they were caring for displayed problematic behaviors or had cognitive-related issues, the caregiver was more likely to intentionally avoid engaging in meaningful interactions with the care recipient, causing communication neglect, which contributed to caregiver anger, frustration, and abuse.
A positive past relationship between the caregiver and the care recipient was found to be a potential protective factor against elder abuse, depending on other variables.
Note: In health care settings, staffing shortages, stress, and a lack of training may be key factors that may lead to elder mistreatment. A study that explored healthcare professionals’ perceptions of elder mistreatment revealed that private and work stress may impact the occurrence of elder maltreatment. Increasing staff and/or shorter shifts, workplace wellness programs, additional training, and support to manage stress could help alleviate this risk.

Risk of Revictimization

Causal factors that forecast the initial onset of abuse are relevant to revictimization. Additional considerations have been identified that create or contribute to an increased risk of recurrence. These perpetuating factors include an older adult’s perception of the mistreatment, the degree to which they protect or defend the offender, the receptiveness to help, barriers to accessing supportive services, and the extent of influence imposed by the perpetrator to suppress an older adult’s help-seeking behavior.

Potential Community and Socio-cultural Risk Factors

Community contexts and societal perceptions have been cited as possible predictors of elder abuse. Some studies have reported that living in urban centers may increase the likelihood of mistreatment. Others have noted that age bias and stereotypes about older people contribute to elder mistreatment. As public discourse and depictions portray elders as inept, fragile, or burdensome, audiences may begin to accept ageist misconceptions as fact and tolerate, even perpetuate, the adverse treatment of older adults.

Protective Factors

There is scant evidentiary support for protective factors that may safeguard older adults from mistreatment. Two factors, however, have been cited as effective means to shield elders from harm. High levels of social support and embedded community networks have been found to offer protection to ward off abuse. The other suggested supportive measure relates to the elder’s living environment. Empirical studies have found that shared living situations may accelerate the risk of abuse. Separation from conflict may serve to mitigate environmental stress which can foster mistreatment. Limited research has pointed to physical activity as a protective factor against negative emotional well-being outcomes for victims. For additional information on interventions, please see the section on Interventions, below.
Ageism and Elder Mistreatment
Ageism is the systematic stereotyping and discrimination of people based upon their age. Often overlooked and significantly understudied, ageism is observed on a societal and personal level. Through an ageist lens, older people are perceived as an undifferentiated group with negative traits, among them forgetful, inept, ailing, and irritable. These blanket misperceptions tend to devalue individual aptitudes and disregard the heterogeneity within the older cohort. They also contribute to adverse physical and mental health correlates. One systematic review and meta-analysis of the literature found that interventions such as education and intergenerational contact may reduce stereotyping and the effects of ageism. Another study demonstrated that exposure to a brief framing intervention was able to reduce implicit bias against older adults.
Additional research is needed to understand the theoretical and empirical relationships between ageism and elder abuse. The World Health Organization recommends combating ageism as the top priority for addressing elder abuse globally.
Impact of Mistreatment

Like the signs of abuse, the impact of elder mistreatment may be experienced differently by older adults. The effects of maltreatment are often related to the scope, nature, type, and severity of abuse. An older person’s response may also be influenced by the many multifactorial, intersecting medical, mental health, and socio-cultural facets of their life. Contextual factors, including a prior history of trauma, may also play a role in determining the impacts perceived and manifested by the individual who was abused. For older people who live with several types of abuse, the reactions may be overlapping and complex.

Among the devastating effects of abuse, older adults may sustain physical injuries, psychological harms, and financial losses. Traumas may lead to compromised health, hospitalization, and mortality. Elders may also experience deteriorated family relationships, decreased autonomy, and institutionalization, which may result in a diminished quality of life.

Below is a partial, representative list of abuse-related consequences by type of mistreatment experienced.

Psychological Abuse

•  Feelings of shame and guilt
• Loss of self-esteem and compromised sense of self-worth
• Physical decline
• Loss of attachment to the perpetrator, who may be a family member caregiver
• Increased morbidity and mortality
• Emotional distress, loneliness, and isolation
•  Depression, anxiety, post-traumatic stress disorder, and other adverse psychological health outcomes

Physical Abuse

• Physical trauma
• Psychosocial consequences
• Increased hospitalization and mortality
• Depression and anxiety
• Cognitive decline

Neglect

• Malnutrition and dehydration
• Unmet basic physiological needs, including hygienic conditions and living quarters
• Functional impairment
• Lower quality of life
• Psychological distress and depression
• Poor physical health
• Increased disability and mortality

Financial Abuse

• Compromised physical wellness
• Diminished independence in later life
• Monetary loss, financial dependence
• Psychological decline
• Loneliness
• Depression, anxiety, and sleep disorders

Sexual Abuse

• Physical injury
• Post-traumatic stress syndrome
• Depression, anxiety, and/or sleep disturbances
• Dissociative symptoms
• Changes in self-image
• Poor health and hospitalization
• Feelings of shame and guilt

Perpetrator Identity

Perpetrators of elder mistreatment share some common characteristics but are largely heterogeneous with significant variability across types of abuse. Greater insight into these differences in typology may serve to inform appropriate interventions and response. Below are general offender patterns extrapolated from research. An Abuser Risk Measure has been developed to measure the risk of abuse by perpetrators.

Offender Characteristics

• Age: The average age is 45. The majority of cases reported to APS or law enforcement involve a known who is, on average, a generation younger, than the older adult.
•  Gender: Much of the data indicates a lack of gender differences among offenders, but one study found that 62% of perpetrators were men.
• Race: 77% of perpetrators were found to be Caucasian.
•  Education: 38% of perpetrators did not graduate from high school, although 44% received a high school diploma.
•  Employment: Between one third and two thirds of offenders were unemployed at the time of the incident.
•  Marital Status: 70% of elder abuse perpetrators were unmarried at the time of the offense.
•  Health: Most perpetrators appeared to be relatively healthy.
• Family History: Almost half of the perpetrators reported a history of early childhood violence.
•  Substance Abuse: 20% to 50% of perpetrators reported substance misuse.
•  Mental Health: Approximately 25% to 35% of perpetrators reported having a serious mental illness.
•  Criminal Record: Between 25% and 46% of perpetrators had a criminal record at the time of the offense.
•  Relationship Problems: One study found that 68% of perpetrators experienced interpersonal relationship problems, while another reported only 21%.
•  Living Arrangements: Between 53% and 64% of elder abuse victims and perpetrators cohabitated at the time of the offense.
•  Financial Problems: 30% of financial exploitation perpetrators compared with less than 1% of interpersonal perpetrators had financial problems.
•  Financial Dependence: Approximately one third of perpetrators were financially dependent upon the victim at the time of the offense.
•  Social isolation: 35% of offenders reported lack of an individual they could contact to take them to the doctor or speak with if needed.

Offender Identity by Type of Mistreatment

• Psychological Abuse: The most frequent offender is a partner/spouse.
•  Physical: The most frequent offender is a partner/spouse.
•  Neglect: Adult children are the most frequent perpetrators.
•  Financial: Family members (54%) and care workers (31%), compared with partners (13%), were the more frequent perpetrators.
•  Sexual abuse: There is little evidence to support a conclusion, but of the studies conducted it appears that sexual abuse was most often perpetrated by partner/spouses (40%) and acquaintances (40%).

Offender Classifications

One study differentiated perpetrators by personality and behavioral attributes. Four discrete profiles were identified: “Caregiver,” “Temperamental,” “Dependent Caregiver,” and “Dangerous.” Given the heterogeneity among offenders, researchers suggested that interventions be tailored by typology to effectively address the mistreatment and mitigate harm.

Poly-victimization

Poly-victimization is the intersection of multiple co-occurring or sequential forms of abuse that can result in cumulative and compounding harms for older adults. The concept of poly-victimization recognizes that past traumas over the life course can heighten the negative impact of mistreatment in older age. Early childhood adversity, both experiencing and witnessing mistreatment, can also exacerbate later life abuse. One study reported that approximately 1.7% of older people experienced prior year poly-victimization.

Guardianship and Elder Mistreatment

Guardianship is a relationship created by state law in which a court gives one person or entity (the guardian) the duty and power to make personal and/or property decisions for another whom the court has found unable to make such decisions. Terms vary by state, but frequently a “guardian” makes personal and health care decisions, and a “conservator” makes financial decisions. In this summary, the generic term “guardianship” refers to both, unless otherwise indicated.

Guardians are appointed by the court to protect an at-risk individual, and often to prevent or address abuse. While many guardians act in the individual’s best interest, some take advantage of those they were named to protect — making guardianship both a solution to and a source of elder abuse.
Despite tragic media exposes, the extent of guardianship abuse is unknown, as data is scant to nonexistent. Courts need data to monitor guardianship practice, and policymakers need data to target necessary improvements.

Most states lack even basic information on the number of adults subject to guardianship. Given insufficient state data, national figures have been estimates at best. In 1987, the Associated Press referenced “300,000 to 400,000 elderly people” under guardianship. In 2011, researcher from the National Center for State Courts (NCSC) calculated there may be 1.5 million adults subject to guardianship across the country, and in 2016, estimated 1.3 million open cases.

There are significant challenges in collecting consistent court data, for example:

•  State and local courts have different technology, databases, and definitions
• Many courts lack funding for technology to track guardianship cases
• There may not be a distinct field for adult guardianship data, separate from probate data or from minors
•  Data may be collected going forward, but older open cases are not included
•  Data may be collected on the number of filings, but not on the number of open cases, demographics, the number of limited orders and restorations of rights, or key monitoring events
•  There may be no data indicating abuse or exploitation, such as the number of removals of guardians for cause
•  It is difficult to track use of less restrictive options used instead of guardianship

Research on key guardianship data includes:

• A 2010 NCSC court survey finding that “quality data on adult guardianship filings and caseloads is generally lacking. The absence of accurate caseload measures is widespread”
•  A 2010 Government Accountability Office (GAO) report concluding that GAO “could not determine whether allegations of abuse by guardians are widespread,’ but identified hundreds of allegations in 45 states and DC between 1990 and 2010
•  A 2016 Government Accountability Office report concluding that “the extent of abuse by guardians nationally is unknown due to limited data on key factors related to elder abuse by a guardian.” The study profiled eight closed cases of guardianship abuse
•  A 2018 brief on conservatorship data quality by NCSC and research partners summarizing the status of guardianship data
•  A 2018 U.S. Senate Special Committee on Aging hearing and report that found “few states are able to report accurate or detailed guardianship data”

Recent recommendations and resources have recognized and begun to address the compelling need for adult guardianship data:

•  The 2013 National Probate Court Standards recommend that courts “collect and review meaningful caseload statistics including . . . the number of guardianships and conservatorships being monitored”
•  In 2012, the Minnesota Judicial Branch launched a Conservator Account Auditing Program (CAAP) to improve statewide oversight of court-appointed conservators and protect assets. Conservators file electronically, and CAAP auditors review accounts and present the results to the parties and district judges. The Minnesota model has been refined and expanded, and other states have sought to adapt it
• In 2020 NCSC released a report on Guardianship/Conservatorship Monitoring: Recommended Data Elements, to provide guidance on consistent collection of data
• The U.S. Administration for Community Living developed a National Adult Maltreatment Reporting System (NAMRS) as a national reporting system for Adult Protective Services that includes elements on abuse by surrogate decision-makers including guardians
• The Fourth National Guardianship Summit, convened by the National Guardianship Network in 2021, made a number of recommendations to improve guardianship practices nationwide. Recommendations included statewide data collection systems, standardized forms for financial management plans and personal care plans, regular reviews and verification of guardians’ reports, periodic visits of the ward to assess their well-being, annual in-person court review, and the establishment of a complaint process supported by an independent statewide investigative body to investigate alleged malfeasance by guardians.

Elder abuse can precipitate, result from, or co-exist with other forms of violence. The following are topic areas that address the intersectionality of elder mistreatment and related phenomena

• Elder abuse and opioid misuse.
• Elder abuse and substance abuse.
• Elder abuse and alcohol misuse.
• Elder abuse and animal cruelty.
• Elder abuse and bullying.
• Elder abuse and homelessness.
• Elder abuse and sibling violence.
• Elder abuse and family violence.
• Elder abuse and child abuse.
• Elder abuse and domestic violence.
• Elder Abuse and COVID-19.

At its core, elder mistreatment is a multidimensional issue that invokes many different disciplines and practice areas. These include medicine, psychology, social work, law, and gerontology to name a few. Various professions address elder abuse identification, reporting, and intervention through the lens of their respective domains. Below is a list of some practice areas and their responses to elder abuse, with articles cited for reference.

• Elder abuse and social work.
• Elder abuse and psychology.
• Elder abuse and psychiatry.
• Elder abuse and the law.
• Elder abuse and criminal justice.
• Elder abuse and dentistry.
• Elder abuse and dermatology.
• Elder abuse and orthopedics.
• Elder abuse and the emergency department.
• Elder abuse and health care.
• Elder abuse and primary care.
• Elder abuse and the hospital.
• Elder abuse and care managers
• Elder abuse and radiology.
• Elder abuse and caregiving
• Elder abuse and veterans

Elder abuse is recognized globally as a significant public health problem impacting older adults worldwide. International bodies from the World Health Organization to the United Nations and the International Network for the Prevention of Elder Abuse, among other agencies, have noted the individual and societal harms caused by elder mistreatment. Each year, the United States and countries around the world commemorate World Elder Abuse Awareness Day (WEAAD) to promote understanding and awareness of the abuse and neglect of older persons.

Research studies have been undertaken to describe, evaluate, and address elder mistreatment across the globe. Below are a sampling of recent articles discussing abuse in various countries.

• Australia
• Brazil
• Belgium
• Canada
• Chile
• China
• Greece
• Hungary
• India
• Iran
• Israel
• Italy
• Jamaica
• Japan
• Kenya
• Mexico
• Nepal
• New Zealand
• Norway
• Poland
• Serbia
• Singapore
• Spain
• South Korea
• Switzerland
• Turkey
• Uganda
• United Kingdom

Several screening tools have been developed to aid providers in the detection of abuse. These instruments are typically comprised of questions intended to assess for potential or presenting mistreatment. In a preliminary screening, positive responses can be followed up with further screenings, examinations, or referrals to facilitate comprehensive assessment and appropriate intervention. These detection aids vary by profession and often require training prior to implementation.

While there are a number of screening instruments available to assist practitioners, currently there is no gold standard. Tools vary in their format, length, and focus. Although some have shown promise, they may not be sufficiently broad to offer comprehensive detection of multiple forms of abuse. Additional research is needed to assess mistreatment and validate tools in different contexts, over different cultures and risk groups, and across professional disciplines.

General discussions and systematic reviews of elder abuse screening instruments are available.

The following are among the tools identified for use in healthcare settings:

• Brief Abuse Screen for the Elderly (BASE)
• Caregiver Abuse Screen (CASE)
• Detection of Elder abuse Through Emergency Care Technicians (DETECT)
• ED Senior Abuse Identification (ED Senior AID) tool
• Elder Abuse Suspicion Index (EASI) – also for LE
• Elder Assessment Instrument (EAI)
• Elder Mistreatment Screening and Response Tool (EM-SART)
• Emergency Department Elder Mistreatment Assessment Tool for Social Workers (ED-EMATS)
• Expanded Indicators of Abuse (E-IOA)
• Geriatrics Mistreatment Scale (GMS)
• Hwalek–Sengstock Elder Abuse Screening Test (H-S/EAST)
• Indicators of Abuse (IOA)
• Lichtenberg Financial Decision Rating Scale (LFDRS-SF)
• Older Adult Financial Exploitation Measure (OAFEM)
• Responding to Elder Abuse in GERiAtric care-Self-administered (REAGERA-S).
• Vulnerability to Abuse Screening Scale (VASS)

The following tools have been identified for use by Adult Protective Services and other caseworkers in the field of aging:

• California Undue Influence Screening Tool (CUIST)
• Elder Abuse Risk Assessment and Evaluation tool (EARAE)
• Elder Abuse Decision Support System (EADSS)
• Weinberg Center Risk and Abuse Prevention Screen (WC-RAPS)

A number of strategies have been identified to aid in the prevention of and response to elder mistreatment. They range from interpersonal and community-based supports to restorative and criminal justice remedies. Multidisciplinary teams represent another model of intervention developed to address complex cases of abuse. Professional provider education and public awareness, as well, are established and growing efforts to bolster primary prevention. These models are addressed in greater detail below.

Studies have recommended implementation of harm reduction interventions that align with the older adult’s preferred case resolution. Goal attainment scaling has been proposed as an approach tailored to meet the older adult’s individual needs. Using this model, individuals define and determine their own desired outcomes or goals. Another model suggests a severity framework to guide individualized outcome measures. This construct shifts the focus from binary remedies to nuanced interventions that consider the complexity, variability, types, and spectrum of mistreatment. This person-centric approach is tailored to the victim’s circumstances, needs, presenting harm, risk of recurrence, and contextual considerations.

Other models have contemplated comprehensive approaches to intervention that go beyond victim-directed responses to holistically embrace the victim’s relationship with the offender, the context of abuse, and the home environment.
Leading researchers in the field agree that high quality research is a requisite to evaluate and affirm best practice strategies to address elder mistreatment.

Social Support

Low social support is one of the most common risk factors for abuse across types. Conversely, the presence of a social network may act as a protective influence to help prevent abuse. Available social resources may also mitigate adverse outcomes such as poor health and diminished mental health in the aftermath of mistreatment.

The degree and quality of social interactions have been found to impact an older adult’s perceived social support and susceptibility to abuse. Negative exchanges may lower the level of apparent support or contribute to an environment more conducive to perpetrator misconduct.

Social reserves may be drawn from informal family, friend, and faith networks. Formal supports include institutional response systems such as law enforcement, Adult Protective Services, and the Long-term Care Ombudsman, addressed below. They also embrace formal health services such as homecare and community-based programs.

Several community-based response models have been advanced to prevent and respond to elder mistreatment. Among them, Age-friendly Health Systems (AFHS) suggests a construct for screening older adults for abuse across health care settings. AFHS uses the 4M framework, namely, What Matters, Medication, Mentation, and Mobility in primary care, emergency departments, and long-term care facilities to detect and respond to suspected abuse.

Adult Protective Services

Adult Protective Services (APS) is the most widely used intervention to address elder mistreatment and neglect. This social services agency is charged with investigating allegations of abuse and neglect and facilitating appropriate responses. Interventions may include assessment and service coordination. Referrals may be made to law enforcement and result in criminal prosecution. APS may make recommendations for protective elder abuse retraining orders or guardianships. Caseworkers may also suggest and help implement restorative resolutions.

APS arose out of Title XX of the Social Security Act of 1974, which provided federal funding to states to develop APS programs. In response, each state developed its own APS organization and infrastructure. Current APS systems are separately funded and administered by state and local governments.

Programs differ among states and between counties as to client eligibility and available resources. A California study evaluating APS investigations across county jurisdictions reported significant variability in findings. To better ensure consistent APS policies and practices nationwide, a working group of experts developed the Voluntary Consensus Guidelines for State APS Systems to provide a framework for state APS rules and laws. The guidelines address domains of program administration, response times, reports, investigations, interventions, training, and program evaluation. The National Adult Maltreatment Reporting System (NAMRS) collects quantitative and qualitative data on APS practices and policies and the outcomes of investigations, as reported to APS agencies.
All states require statutorily specified professionals and/or agencies or facilities to report incidents of suspected elder abuse to reporting agencies, including APS. Mandatory reporters may include healthcare professionals, social service providers, caregivers, clergy, financial institutions, among others. The list of mandated reporters as defined by state statute.

Generally, individuals who have experienced abuse must consent to APS services and interventions. Older people with decisional capacity may decline APS assistance. Under certain circumstances, APS may render involuntary protective assistance to individuals who lack capacity or when the exigencies of the situation require intervention. A screening tool has been developed to assess the decisional capacity of abused and neglected older adults.

Studies have been conducted to evaluate older adults’ utilization of APS services, examine barriers to victim self-reports, and measure older adults’ satisfaction with APS services and investigations. Researchers have explored the effectiveness of APS outcomes and means to measure individualized case resolutions.

Some issues facing APS workers are compassion fatigue and stress, largely attributed to large caseloads of complex of cases. Misconceptions about APS can also negatively impact their work and often has negative consequences for how their clients engage with them and their willingness to accept support from APS. In particular, many older adult clients may fear that the involvement of APS means that they will lose their autonomy. Some potential solutions to these challenges are promoting self-care strategies, integrating compassion fatigue resiliency programs, reframing the public’s perception of APS, and complementary programs that work alongside APS.
Mandated reporters are a crucial part of reporting and responding to elder abuse because they often work closely with older adults who may be exposed to abuse. A recent study examining obstacles to communication between APS and reporters of elder abuse found that feedback may have a significant role in supporting victims of elder abuse. Mandated reporters are essential abuse prevention and intervention partners and improvements need to be made in the communication between APS and reporters.

The RISE program (Repair harm, Inspire change, Support connection, Empower choice) was implemented in Maine as a component of a larger community-based elder abuse and self-neglect intervention that complements APS. A teaming approach provides opportunities for members of the older adult’s social network to strengthen relationships that, in turn, provide a resilient social network for the older adult experiencing mistreatment. The presence of social support can provide important opportunities for monitoring the mistreatment and holding alleged harmers accountable for their actions.

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Long-term Care Ombudsman

Like APS community-based responses, long-term care ombudsmen investigate allegations of abuse in facilities. Ombudsmen serve as advocates who act at the behest of residents to help resolve complaints, protect their rights, and improve systemic problems in long-term care.

The Long-term Care Ombudsman Program was authorized in 1978 under the Older Americans Act to establish a consumer advocacy program intended to maintain or improve the quality of life for long-term care residents. Administered at the state level, programs employ both paid and volunteer ombudsmen to investigate complaints.

Data regarding program activities, including facility visits, complaints, information and assistance provided, and community education are reported in the National Ombudsman Reporting System (NORS).

Forensic Centers and Multidisciplinary Teams

Cases of elder abuse are often complex and multifactorial, invoking several different and disparate domains of practice. A single case may intersect social service, health care, law enforcement, and civil legal disciplines. Multidisciplinary teams (MDT) provide regular, coordinated elder mistreatment case review across practice areas. Integrated case review is associated with greater interagency collaboration, intended to enhance the efficient delivery of remedial assistance to older victims of abuse.

Team characteristics, program structures, resources, constituent members, and processes differ by team. MDT’s typically have a geriatric health, social service, mental health, law enforcement, victim advocate, and prosecutorial presence. More recently, some MDTs have added forensic accountants to their teams. One type of MDT, the elder abuse forensic center (FC), applies forensic science to address complicated cases of abuse. FC’s often support the efforts of frontline workers and include conducting home visits to assess older adult’s medical and mental health capacities.
Two elder mistreatment MDTs based out of the emergency department are the Vulnerable Elder Protection Team (VEPT) at Weill Cornell Medicine/NewYork-Presbyterian Hospital and the Vulnerable Elder Services, Protection, and Advocacy (VESPA) team at the University of Colorado and Denver Health. Using trauma-informed and trust building strategies to screen and respond to elder mistreatment, these interdisciplinary response teams are a promising model to improve detection and intervention where older adult patients with socio-medical issues are commonly present.
MDTs continue to replicate across urban and rural areas across the country. MDTs have demonstrated promise as an effective intervention. As teams grow, researchers have suggested that the field develop a coordinated, uniform data collection strategy to advance best practices.

Awareness, Education, and Training

Community awareness campaigns continue to be an important approach to enhance understanding of aging and elder abuse. World Elder Abuse Awareness Day (WEAAD), celebrated across the United States and internationally since 2006, continues to be an annual platform for global awareness, recognition, and engagement.
The Reframing Aging and Reframing Elder Abuse initiatives have developed evidence-based communication strategies to increase public awareness and promulgate systemic solutions to prevent ageism and address elder abuse. In collaboration with the Frameworks Institute, the NCEA created a public communications strategy to increase recognition of aging and elder abuse, recasting public perceptions of older people and mistreatment.

Educational programs have also been identified as an intervention. Older people can receive instruction in understanding the risks factors associated with mistreatment and the availability of helping agencies and resources. For example, the Keep Control campaign in Dublin, Ireland is a strengths-based intervention which empowers older adults to protect themselves from financial abuse.
Middle school students to undergraduates have been found to benefit from classroom education on aging and ageism. Intergenerational programs have also been identified to increase awareness and reduce ageism and discrimination. Studies have reported on the efficacy of intergenerational service learning, pen pal projects, and art activities.
Professional provider instruction and training in the signs and symptoms of elder mistreatment is an essential intervention. Healthcare providers are often best positioned to detect mistreatment, report abuse, and identify helping resources. In addition to medical and mental health clinicians, educating other mandatory reporters, as designated by state statute, is a key component to prevention and early identification of abuse.
Many research endeavors related to educational approaches to elder abuse prevention focus on healthcare professionals and the general public, but few focus on community gatekeepers. There is a need for evidence-based programs that educate gatekeepers on preventing elder abuse from occurring in the first place. Researchers recommend that certain areas of study such as social work and nursing incorporate education on elder abuse into their curricula.

Financial Management

Diminished financial management abilities and reduced cognitive function have been identified among the risk factors that predispose older adults to financial exploitation. Evidence-based approaches such as the Success After Financial Exploitation (SAFE) program, developed by the Lifespan Fraud and Scams Prevention program in Rochester, New York, educate and coach older adults on finances and money management. A recent study found that most SAFE participants were very satisfied or satisfied (91%) with the services they received. Participants also reported significantly less stress at the six-month follow-up. They also provide information on fraud and scams to professionals who work with older people. In addition to providing education, elder financial programs may help older adults respond to consequential financial hardships in the wake of exploitation.

Restorative Justice

As noted above, cases of elder abuse are often complex and multilayered. Traditional interventions, such as criminal justice and social service remedies, may not be the preferred resolution for older adults at the center of conflict. More recently, as individualized goals and outcomes have risen to the fore, restorative justice approaches have gained increased currency.
Researchers have found that restorative processes have the potential to prevent social isolation, a predictor of abuse, and serve as an alternative remedy for abuse. Specifically, researchers have drawn attention to restorative processes to educate offenders on harmful behaviors, mitigate social isolation, heal relationship rifts, and support overwhelmed caregivers.

Harm Reduction

Studies have explored the use of harm reduction approaches to inform work with older people who have experienced abuse in later life and across the lifespan. This holistic, conceptual framework recognizes the collective neurological, biological, psychological, and socio-cultural impacts of trauma and the weight that burden places on individuals, families, and communities. A trauma-informed approach incorporates the six principles of safety, trust, peer support and self-help, collaboration, empowerment, voice, and choice. With these principles in mind, trauma-informed services integrate individualized care and tailored services to empower elders, improve the community response, and reduce the risk of revictimization.
Person-centric interventions that focus on older adults have been identified as particularly important in interventions addressing elder sexual abuse. One approach applies a holistic life course lens, assessing an older adult’s life history of abuse when developing a treatment plan. An intervention study targeting older adults who experienced elder abuse, who were also experiencing depression, found that 20% endorsed suicidal ideation. A 10-week treatment called PROTECT (Providing Options to Elderly Clients Together) was successful in reducing suicidal ideation over time as well as significantly decreasing depressive symptoms in non-suicidal patients. Recent research has highlighted the importance of involving older adults in developing policies that could affect their rights.

Service Advocate

Another client-centered, restorative practice that has emerged is the service advocate model. This approach developed as an extension of forensic center services. Working within the forensic center, a service advocate provides case management, crisis intervention, and supportive services to forensic center clients. The advocate promotes client wellbeing and self-efficacy, while balancing their preferences and protective interests. The service advocate may also offer resources and services to the offender to promote safety and wellbeing within the caregiver/client dyad.

Elder Mediation

Elder mediation is a community-based, voluntary intervention that has been utilized to help older adults and their family members resolve conflict. It is a specialized form of dispute resolution that addresses conflicts arising within the context of aging and elder issues. Typically, a neutral, impartial mediator assists parties to collaboratively arrive at mutual agreement using an interests-based, solutions-oriented approach. The focus is generally client-centered, with an emphasis on preserving elder rights, preferences, and needs. Education, care planning, and resource dissemination may be part of the recommended resolution. Studies have found that mediation may be an effective strategy to prevent or end financial abuse.

Elder Shelters

Elder shelters, such as the prototype Weinberg Center for Elder Justice in New York, provide a safe haven and wraparound resources to older adults who have been abused. Beyond providing a home, medical care, and provisions, shelters can be a hub for a coordinated, interdisciplinary community response to abuse. Advocates help residents access their legal rights and available remedies in the aftermath of trauma.

Caregiver Support

KINDER (Knowledge and Interpersonal Skills to Develop Enhanced Relationships), is an 8-week psychoeducational intervention to prevent psychological mistreatment among family caregivers to persons living with dementia by building healthy caregiving relationships. A pilot study of the intervention demonstrated a statistically significant decrease in psychological mistreatment and relationship strain, increased quality of care, and increased caregiver resourcefulness.
COACH (Comprehensive Older Adult and Caregiver Help), a strengths-based, individualized caregiver support intervention, successfully reduced elder mistreatment of persons living with chronic illness. Mistreatment dropped from 22.5% at baseline to 0% following the completion of the intervention, compared with a control group, who did not report a significant change.

Research and Policy

Since the passage of the Elder Justice Act in 2010, the elder justice movement has gained traction, but federal recognition and funding have only begun to address the prevailing and mounting need to prevent elder mistreatment and address consequential harms. Several articles discuss the present and future of elder justice.