Ms. Dee is an 82-year-old woman with mild Alzheimer’s dementia who lives with her son and daughter-in-law. During a routine follow-up visit, Ms. Dee appears uncharacteristically withdrawn and avoids making eye contact. Her son answers most of the questions, stating that she has become more forgetful and clumsier. He mentions that she frequently falls and has difficulty managing her medications.

Elder abuse is a violation of the basic human and civil rights of vulnerable older adults (Cooper C and Livingston G, Clin Geriatr Med 2014;30(4):839–850). It is a global public health issue, impacting about 10% of older adults annually (Lachs MS and Pillemer KA, N Engl J Med 2015;373(20):1947–1956). Recent estimates suggest it may have become more pervasive since the COVID-19 pandemic, with one in five older adults now experiencing some form of abuse (Chang ES and Levy BR, Am J Geriatr Psychiatry 2021;29(11):1152–1159). Elder abuse often presents alongside psychiatric conditions like depression, anxiety, and cognitive impairment, making it important for clinicians to stay attentive to its signs. 

Recognizing elder abuse

Elder abuse takes various forms, including physical, emotional, sexual, and financial abuse, as well as neglect. Recognizing the signs of abuse is critical in initiating timely interventions. 

Physical abuse

This involves the intentional use of force that results in physical harm, pain, assault, or impairment. Physical abuse includes hitting, slapping, pushing, kicking, or restraining an older adult. Look for unexplained injuries or a pattern of repeated trauma, especially in uncommon areas like the jaw or cheekbone. Multiple injuries in various stages of healing should also raise suspicion. 

Sexual abuse

Sexual abuse occurs when an individual is subjected to nonconsensual sexual activity, such as rape, inappropriate touching, forced nudity, or when they are unable to provide informed consent (Patel K et al, Cureus 2021;13(4):e14375). Red flags are unexplained sexually transmitted diseases (STDs) or genital injuries (Lachs and Pillemer, 2015).

Emotional/verbal abuse

Emotional abuse refers to verbal or nonverbal behaviors that cause fear, mental or emotional distress (eg, yelling, threats, humiliation, intimidation, isolation, or controlling behaviors). Patients may appear withdrawn, depressed, or anxious. They often avoid eye contact or defer to their caregiver.

Financial abuse

This includes the unauthorized use of a victim’s finances, often by a trusted person (eg, a family member). Financial exploitation is a distinct and increasingly recognized form of elder abuse, particularly in patients with cognitive decline. Unlike other forms of abuse, financial exploitation may have fewer overt risk factors, requiring a higher degree of vigilance (Fraga Dominguez S et al, J Appl Gerontol 2022;41(4):928–939).

Neglect

This occurs when a caregiver fails to provide for an older adult’s basic needs, including food, water, medication, shelter, or hygiene. It can be intentional or due to the caregiver’s inability to provide care. Signs of neglect are malnourishment or dehydration, poor hygiene or unsuitable clothing (eg, not wearing a coat on a cold winter’s day), or evidence of inadequate or delayed medical care.

Elder abuse during COVID-19 

One study found an 83.6% increase in elder abuse prevalence during the pandemic, with financial strain and isolation being major contributing factors. When using telehealth in detecting abuse, pay close attention to nonverbal cues (eg, subtle body language, concerning comments made by patients or caregivers, living conditions) (Chang and Levy, 2021).

Risk factors for elder abuse

Victim characteristics

The risk of abuse is higher in older women and those with impaired cognition. Elder abuse happens most commonly in people with dementia, especially those with substantial neuropsychiatric symptoms. Cognitive impairment is also a risk factor for financial abuse, as patients with dementia are more susceptible to exploitation. In many cases, financial abusers are family members who have gained access to resources through legal means, such as a power of attorney (Cooper and Livingston, 2014). Those in shared living arrangements have a higher risk of mistreatment, since most abusers are family members, often adult children or partners. Older adults who experience abuse are more likely to have had previous victimization or to be dependent on the perpetrators financially or for care (Fraga Dominguez et al, 2022).

Perpetrator characteristics

Perpetrators often struggle with issues like substance use (especially alcohol), depression, and anxiety. Those with substance use disorders can also have problematic attitudes like ageist beliefs, hostility, and unrealistic expectations of the victim (Fraga Dominguez et al, 2022).

While observing Ms. Dee, you notice that she has multiple bruises in different stages of healing on her arms and legs. When questioned privately, she hesitates but eventually discloses that her son sometimes gets angry with her, especially when she asks for help with daily tasks. She mentions that she often feels afraid to ask for assistance. Her financial situation also seems to have changed—she can no longer pay for her medications, although she has a steady retirement income.

Elder abuse assessment

When assessing for elder abuse, ask open-ended questions about the patient’s daily life, their relationships with caregivers, and any recent changes in their social or financial circumstances. Pay particular attention to their relationships with adult children or partners. In patients with dementia, ask about their finances. If you suspect abuse, interview the older adult privately to allow them to express concerns without feeling threatened.

Consider asking these questions:

• Do you feel safe at home?
• Has anyone stopped you from getting things you need, like food, clothes, medications, or medical care? How about from seeing friends or family?
• Do you get help when needed?
• Does anyone ever yell or curse at you? 
• Has anyone tried to force you to sign papers or use your money when you didn’t want to?
• Has anyone touched you inappropriately or physically hurt you? Source: (Yaffe MJ et al, J Elder Abuse Negl 2008;20(3):276–300.)

Managing elder abuse

The first priority is the older adult’s safety. If they are in imminent danger, involve your institution’s social worker to guide next steps. Hospitalization is not needed unless there are severe medical concerns. Contact Adult Protective Services (APS) to initiate an investigation, which focuses on the older adult’s vulnerabilities and home environment.

Steps to take

1. Involve your social worker to assess and guide actions.
2. File a report with APS—even a low level of suspicion is sufficient to initiate an investigation.
3. For financial abuse, contact local law enforcement (use non emergency lines unless there is immediate danger).
4. Consider alternative housing if the environment is unsafe.

All states have mandatory reporting laws for elder abuse, so ensure you follow local procedures. For more on management visit: www.thecarlatreport.com/InterventionsforElderAbuse. 

To assist Ms. Dee, you start by prioritizing her safety. Given the signs of physical and financial abuse, you contact Adult Protective Services. You consider hospitalization or securing alternative living arrangements. You also involve legal representatives or law enforcement to safeguard her financial assets, including possibly revoking her son’s financial authority.

Carlat Verdict 

Elder abuse is often hidden and worsened by financial strain and isolation. Clinicians are mandated reporters, and early intervention with Adult Protective Services and law enforcement can make a significant difference in protecting vulnerable older adults.