Is self-neglect a form of abuse

Abuse of the Elderly

Abuse of older people manifests itself in physical or emotional abuse, neglect or financial exploitation.

Common types of abuse among the elderly include physical abuse, emotional abuse, neglect, and financial exploitation. Each form can be intentional or unintentional. The perpetrators are often adult children, but also other relatives or paid or informal carers. The abuse usually increases in frequency and severity over time. Less than 20% of abuse cases are reported; therefore, doctors must be vigilant in identifying elderly patients at risk for abuse.

Physical abuse is the exercise of coercion, which manifests itself in physical or psychological injuries or complaints. These include hitting, shoving, shaking, immobilizing, force feeding, and unjustified administration of medication. It can also include sexual assault (any form of sexual intimacy without consent or with the use or threat of violence).

Mental abuse is the use of words, actions, or other means that cause emotional stress or anxiety. It includes threats (e.g. admission to home), insults and harsh orders, as well as silence and ignoring the person. This includes infantilization (a condescending form of age discrimination in which the perpetrator treats the elderly as a child), which drives the elderly into dependence on the perpetrator.

neglect means failure or refusal to provide food, medicine, personal care or other necessities; it includes rejection. Neglect that causes physical or psychological damage is considered abuse.

Financial abuse means exploiting or caring for a person's property or funds. These include fraud, pressure on a person to distribute their assets, and irresponsible management of a person's money.

Although the actual incidence is unclear, elderly abuse appears to be an increasing public health issue in the United States. According to reports from the National Center on Elder Abuse, one in ten older adults is a victim of physical, mental, sexual, financial, exploitation or neglect. In Canadian and Western European studies, the incidence of abuse was comparable to that in the United States.

Risk factors

For the victim, risk factors for previous abuse are illness (chronic illness, dysfunction, cognitive impairment) and social isolation. For the perpetrators, risk factors are substance abuse, mental disorders, a history of violence, stress and dependency on the victim (including shared housing - see table Risk factors for the abuse of older people).

Elderly Abuse Risk Factors

Abuse of isolated people is less likely to be recognized and stopped. Social isolation can intensify stress.

A chronic illness, functional impairment, or both

The ability to escape, seek help, and defend oneself is diminished.

People with a chronic disorder or impaired function may require more care, which increases the stress on caregivers.

Cognitive impairment

The risk of financial abuse and neglect is particularly high.

People with dementia can be difficult to care for, frustrating caregivers, and can be aggressive and counterproductive, provoking abuse by overworked caregivers.

Alcohol or drug abuse, intoxication or substance withdrawal can lead to abusive behavior. Substance-dependent caregivers may attempt to use or sell drugs that have been prescribed for the elderly person, thereby depriving the elderly of their treatment.

Mental disorders

Mental disorders (e.g. schizophrenia, other psychoses) can lead to abusive behavior.

Adult children released from an inpatient mental health facility can return home to their elderly parents for care. Even if these patients were not violent in the facility, they can be at home.

History of violence

A history of violence in a relationship (especially between spouses) and outside the family can predict abuse in the elderly. One theory suggests that violence is a learned response to difficult life experiences and a learned method of expressing anger and frustration. Since reliable information on past violence in the family is difficult to come by, this theory is unfounded.

Dependence of the perpetrator on the older person

Dependence on the elderly for financial support, housing, emotional support, and other needs can create resentments that contribute to abuse. If the elderly person refuses to provide resources to a loved one (especially an adult child), abuse is more likely.

Stressful life events (e.g. chronic financial problems, death in the family) and care responsibilities increase the likelihood of abuse.

For victims and perpetrators

Elderly people living alone are much less likely to be abused. When housing is shared, there are more opportunities for tension and conflict that usually precede abuse.


Previous abuse is difficult to detect because many signs are barely recognizable and the victim is often unwilling or unable to talk about the abuse. Victims can hide the abuse out of shame, fear of retaliation, or a desire to protect the perpetrator. Sometimes when victims of abuse seek help, they encounter age-discriminatory responses from health care professionals, e.g. For example, dismiss reports of abuse as confusion, paranoia, or dementia.

The social isolation of the victim often makes it difficult to detect abuse by the elderly. Abuse tends to increase isolation because the perpetrator often limits the victim's access to the outside world (e.g. the victim is denied visits and phone calls).

Symptoms and signs of previous abuse may be mistakenly attributed to a chronic condition (e.g., a hip fracture due to osteoporosis). However, the following clinical situations are particularly indicative of abuse:

  • Time interval between an injury or illness and seeking medical help

  • Discrepancies between the description of the patient and the caregiver

  • Severity of injury that cannot be reconciled with the caregiver's explanation

  • Implausible or vague explanation of the injury by the patient or caregiver

  • Frequent visits to the emergency room for exacerbations of chronic illness, despite the fact that an appropriate treatment plan and adequate resources are in place

  • Absence of the caregiver when a functionally impaired patient presents to the doctor

  • Laboratory results that do not match the previous history

  • Refusal of the caregiver to accept home care (e.g. visits from a nurse) or leaving the elderly patient alone with a healthcare professional


If previous abuse is suspected, the patient should be interviewed alone, at least intermittently. Other people involved can also be interviewed separately. The patient interview can begin with general questions about safety assessment, but should also include direct questions about possible abuse (e.g. physical violence, restraint, neglect). If abuse is confirmed, the nature, frequency and severity of the events should be determined. The circumstances causing the abuse (e.g. alcohol intoxication) should also be investigated.

The patient's social and financial resources should be assessed as they influence management decisions (e.g. housing, hiring a professional caregiver). The examiner should inquire whether the patient has relatives or friends who are able and willing to care, listen, and provide support. If the financial resources are sufficient but basic needs are not being met, the investigator should determine why. Assessing these resources can also help identify risk factors for abuse (e.g., financial distress, financial exploitation of the patient).

Confrontation should be avoided when talking to the family caregiver. The interviewer should find out whether the care responsibility for the relatives is a burden and, if necessary, acknowledge their difficult role. The caregiver is asked about the most recent stressful events (e.g. grief, financial burdens), the patient's illness (e.g. need for care, prognosis) and the documented causes of each recent injury.

Physical examination

The patient should be carefully examined for signs of previous abuse, preferably at the first visit to the doctor (see table, Signs of Abuse in the Elderly). The doctor may require the help of a trusted family member or friend of the patient, government services for the protection of the elderly, or occasionally law enforcement agencies to encourage the caregiver or patient to allow the evaluation. If abuse is found or suspected, reporting to Adult Protective Services is mandatory in most states.

Signs of elder abuse

Withdrawal of the patient

Infantilization of the patient by the caregiver

Caregiver insistence on providing the history

General appearance

Poor hygiene (e.g. unkempt appearance, uncleanliness)

Skin and mucous membranes

Poor skin turgor or other signs of dehydration

Bruises, especially multiple bruises at different stages of development

Inadequate care of existing skin lesions

Traumatic alopecia (distinguishable from male or female alopecia patterns)

Welts (the shape can indicate the infliction - e.g. utensils, stick, belt)

Wrist or ankle lesions suggestive of restraint or immersion burns (i.e., in the form of a stocking-glove distribution)

Previously undiagnosed fracture

Unexplained pain

Unexplained gait disorders

Mental and emotional health

Cognitive status should be assessed, e.g. B. using the Mini-Mental-State-Test ({blank} examination of the mental status). Cognitive impairment is a risk factor for abuse of the elderly and can affect the reliability of the history and the ability of the patient to make management decisions.

The mood and emotional status should be assessed. If the patient is feeling depressed, ashamed, guilty, anxious, scared, or angry, the beliefs underlying the emotions should be explored. If the patient downplays or rationalizes family tensions or conflicts, or is reluctant to talk about abuse, the investigator should determine whether these attitudes interfere with the confirmation or admission of abuse.