Signs, Risk Factors, Ageism, and Impacts 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.¹ Manifestations of abuse may also be impacted by the older adult’s physical and cognitive condition, social connectedness, and emotional state.

• 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 worthlessness²

• 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 changes³ ⁴ ⁵

• 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

• Malnutrition⁶

• Dehydration or malnutrition

• Untreated bed sores

• Poor personal hygiene

• Unattended or untreated health problems

• Unsafe and/or unsanitary living conditions⁷

• 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 restlessness⁸

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.⁹ 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.

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.¹⁰ 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.¹¹ Knowledge of the discrete and interrelated factors may inform efforts to mitigate the risk of elder abuse, manage environmental threats, and prevent recurrent abuse.¹²

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.¹³ 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.¹⁴

• 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 perpetrator¹⁵ ¹⁶

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 age¹⁷ ¹⁸

• 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.¹⁹

• Older people with dementia are particularly susceptible to abuse. Nearly one in two older adults with cognitive impairment experiences abuse.²⁰ 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.²¹

• 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 abuse²²
• Mistreatment by 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.²³

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.²⁴

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.²⁵

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.²⁶

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.²⁷ ²⁸

There is scant evidentiary support for protective factors that may safeguard older adults from mistreatment.²⁹ 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.³⁰ ³¹ Limited research has pointed to physical activity as a protective factor against negative emotional well-being outcomes for victims.³² For additional information on interventions, please see the section on Interventions.

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.³³ Through an ageist lens, older people are perceived as an undifferentiated group with negative traits, among them forgetful, inept, ailing, and irritable.³⁴ 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.³⁵ 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.³⁶ Another study demonstrated that exposure to a brief framing intervention was able to reduce implicit bias against older adults.³⁷

Additional research is needed to understand the theoretical and empirical relationships between ageism and elder abuse.³⁸ The World Health Organization recommends combating ageism as the top priority for addressing elder abuse globally.³⁹

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.⁴⁰ Below is a partial, representative list of abuse-related consequences by type of mistreatment experienced.

• 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 outcomes⁴¹

• Physical trauma

• Psychosocial consequences

• Increased hospitalization and mortality

• Depression and anxiety⁴²

• Cognitive decline⁴³

• 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 mortality⁴⁴

• Compromised physical wellness

• Diminished independence in later life

• Monetary loss, financial dependence

• Psychological decline

• Loneliness⁴⁵

• Depression, anxiety, and sleep disorders⁴⁶ ⁴⁷

• 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 guilt⁴⁸