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Elder Abuse and Child Abuse: Know the Signs and Your Role

Elder Abuse and Child Abuse: Know the Signs and Your Role
Kathleen Weissberg, OTD, OTR/L
October 10, 2019

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Elder Abuse

Today, we are going to talk about elder abuse and child abuse, and sadly this is more common than you might think. Our goal for today is to learn to spot those warning signs and then to know what your responsibilities are or could possibly be with regard to reporting.

Some Statistics

  • According to the U.S. Government Accountability Office (GAO), elder abuse is a widespread and growing problem
  • Data reporting is a challenge
  • Recent studies indicate that elder abuse incidence rates are far higher than once thought

I thought we would start by going over some stories. According to a study by the United States Government Accountability Office, the GAO, elder abuse is really a widespread and growing problem. The data reporting in this area is a challenge, but despite that, recent studies indicate that elder abuse incident rates are far higher than we probably thought. This slide show includes a few different stories that have come up in the public sector.

  • In NYS, incidence rates nearly 24X greater than the number of cases referred to authorities who can help (Lifespan of Greater Rochester et al., 2011)
  • One in five Americans older than age 65 had been defrauded (Kiplinger’s Personal Finance, 2011)
  • In most cases, the adult children of abused elders were unaware that their mother or father had received solicitations for money (Olson, 2011)

A collaborative public-private report on elder abuse in New York State, for example, found an incident rate of elder abuse nearly 24 times greater than the number of cases referred to social service, law enforcement, or legal authorities who have the capacity and the responsibility to assist adult older victims. And, as a nation, our response is disjointed. The minimal federal investment is only about 12 million dollars, give or take, and it is spread sparsely across eight agencies and two departments with very little coordination. I am going to digress for a second and say that recently the Office of Inspector General came out with a report related to elder abuse. I am not going to go through a lot of the details, but basically they found that a lot of individuals were coming into the emergency room and had diagnosis codes or situations indicative of abuse that was never reported to state authorities. I think we are going to see a little more oversight in the near future on this topic and probably some additional training from some of these government agencies. An Investors Protection Trust Survey found that one in five Americans older than the age of 65 had been defrauded. This is something that we are hearing about quite a bit about in the news. The conservative estimates of the personal cost to victims of financial abuse are easily three billion dollars annually. These reported cases only hint at the extent of the problem. We are not hearing a lot of the other stories that are probably out there. And, in a New York Times article, they talked about financial exploitation and the knowledge of adult children. Many are unaware that their mother or father had even received solicitations for money. Even attentive children, as involved as you can be with your parents, sometimes miss the warning signs. In that particular article, they highlighted the story of Dr. Robert Parker. He is the chief of community geriatrics at the University of Texas Health Medical Center in San Antonio. He failed to notice that his own mother was a victim of financial abuse. So, no matter how involved you are, sometimes you still miss some of these things.

A Chilling Example of Neglect

Before we get into some of the definitions, I wanted to share this story. It was a widely publicized case in Michigan. An elderly female nursing home resident began coughing one night. Her caretakers were busy, and she continued to just cough throughout the night. A couple of staff observed "white things" in her sputum and near her trach collar. It was not until the next morning that somebody actually checked into her mouth, and they found maggots. The maggots had created a partial airway obstruction causing her to suffer abnormal blood oxygen levels and labored breathing. The emergency medical services staff said that they could not even suction because of the very active maggots in the airway. This is just a terrible example and there is no evidence that that staff was disciplined for clearly neglecting this woman so severely. 


“Acts of omission or commission by a person who stands in a trust relationship that result in harm or threatened harm to the health and/or welfare of an older adult.”

Abuse Defined

  • Willful infliction of injury
  • Unreasonable confinement/Involuntary seclusion
  • Intimidation with resulting physical harm, or pain, or mental anguish
  • Punishment with resulting physical harm, or pain, or mental anguish
  • Deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being
  • Corporal punishment & any physical or chemical restraint not required
  • Abuse that includes that which is facilitated or enabled through the use of technology

I think the biggest piece here is that it is willful infliction. It can also include things like unreasonable confinement or involuntary seclusion, and that could happen in the home environment or in an institution. It might be where we are separating an individual from other individuals, from their room, or from another area where they want to go. This can be against their will or even against the will of that person's legal representative. It also could include intimidation or punishment with resulting physical harm, pain, or mental anguish. It could include things like deprivation by an individual, including a caretaker, of goods or services that are necessary to attain physical, mental, or psychosocial well-being. These are all the things that that person needs to be well. It can include corporal punishment or physical or chemical restraints that are not really required to treat that individual's symptoms or their issues. Again, it is anything that would cause pain or an issue, and it can also include things that are enabled through the use of technology. The individual acts deliberately.

  • Elder abuse includes physical, emotional, or sexual harm inflicted upon an older adult, their financial exploitation, or neglect of their welfare by people who are directly responsible for their care
  • Elder abuse tends to take place where the senior lives: where their abusers are often adult children, other family members such as grandchildren, or a spouse or partner. Elder abuse can also occur in institutional settings.

Now elder abuse includes, as we just said, physical, emotional, sexual harm potentially inflicted upon an older adult. It can also include financial exploitation and neglect of their welfare. It is done by somebody who is directly responsible for their care. And in the United States alone, more than half a million reports of elder abuse reach authorities every year, and many more go unreported. Now as older adults become more physically frail, they are less able to take care of themselves. They cannot stand up to bullying, and they cannot fight back a lot of times if they are attacked in some way.

The mental or physical ailment that they have can make them more trying to companions for those who live with them. They may not see, hear, or think as clearly as they used to. This leaves them open, unfortunately, for unscrupulous people to take advantage of them, and we definitely see that. The other thing to keep in mind is that elder abuse tends to take place where that individual lives. We hear stories of elder abuse that occurs somewhere out in the community, but typically, the senior lives with their abusers. The abusers can be adult children, other family members like grandchildren, a spouse, a partner, or a very good friend. The sad reality is that elder abuse can also occur in institutional settings especially long-term care facilities, that is where we hear about it most.

Forms of Abuse

  • Verbal
  • Physical
  • Sexual
  • Mental/Emotional
  • Neglect
  • Abandonment
  • Financial exploitation
  • Self-neglect

What are the different forms? Abuse of elders takes a lot of different forms. Some involve intimidation or threats against the elderly, some involve neglect and other financial trickery. The most common types are listed above. We will go through each one of these in a little more detail and look at some of the warning signs.

Verbal Abuse

  • Oral, written or gestured language that includes disparaging and derogatory terms to the residents or their families to describe the resident within their hearing distance, regardless of their age &/or ability to comprehend or disability

This is almost like bullying. It is talking about that person in such a negative way so that they overhear it. The person feels, based upon this blame, diminished self-worth, or diminished ego, et cetera. This is, obviously, not something that we would want to do.

Physical Abuse

  • The non-accidental use of force against an elderly person that results in physical pain, injury, or impairment. Such abuse includes not only physical assaults such as hitting or shoving but the inappropriate use of drugs, restraints, or confinement.

Physical abuse is pretty straightforward. This does not just include physical assault such as hitting or shoving, but it can also include things like the inappropriate use of drugs or medications, restraints, or even confinement. This can be in an institutional or home setting. The more common types of physical abuse that we see are things like hitting, slapping, pinching, scratching, spitting, holding that person roughly, holding them in their chair, or forcing them into their wheelchair. It also includes controlling behavior through corporal punishment. Unfortunately, we continue to see this in some of our settings. This a corporal type punishment of influence.

Sexual Abuse

  • Contact with an elderly person without their consent. Includes but is not limited to humiliation, harassment, coercion, or sexual assault. Activities such as showing an elderly person pornographic material, forcing the person to watch sex acts, or forcing the elder to undress are also considered sexual elder abuse.

Again, you hear these outrageous stories on the news, and it makes you scratch your head. Sexual abuse includes but is not limited to things like humiliation, harassment, coercion, or even sexual assault. It is non-consensual sexual contact of any type with an individual. It is contact with that elderly person without their consent. It can involve physical sexual acts, but it can also involve other things like showing an elderly person pornographic materials and making them watch it or forcing the person to watch other sex acts or something else occurring in the environment. It can even include forcing the elder to undress in front of you. This would not be part of an ADL or helping them to use the restroom. This is forcing them to undress outside of those normal scenarios.

Emotional/Mental Abuse

  • The treatment of an older adult in ways that cause emotional or psychological pain or distress, including:
    • Intimidation through yelling or threats
    • Humiliation and ridicule
    • Habitual blaming or scapegoating
    • Ignoring the elderly person
    • Isolating an elder from friends or activities
    • Terrorizing or menacing the elderly person
    • Harassment
    • Threats of punishment or deprivation.

This is the treatment of an older adult in ways that cause emotional or psychological pain or distress. It can be intimidation through yelling or threats, humiliation or ridicule, habitual blaming, or scapegoating. It can also be ignoring that elderly person or ignoring their requests, isolating an elder from their friends or their activities, and terrorizing or menacing the elderly person. You may not think that some of these things are necessarily emotional elder abuse, but they could be under the right set of circumstances. For example, if you take a photograph, and that person does not want to be photographed, that could constitute mental, physical, or some sort of abuse. Again, we should not be doing that in any of our settings or doing anything that might be considered humiliating toward an individual. During the delivery of care, depending on what we are doing with that individual, we need to make sure that we are keeping the person from public view like undressing to do an ADL. We need to make sure that we prevent any unnecessary exposure of body parts. That is what we do all the time normally, but if we did not, it could be potentially considered emotional or mental abuse.

My aunt, who has since passed away, was in a nursing home many years ago. She had dementia but she still knew enough to say I need to use the restroom when she truly needed to go. She had a urinary tract infection at the time was going much more frequently. I remember her saying, "I have to use the bathroom." She did not want me to take her and that was fine. She called for a nurse who came in and said, "Don't you realize you just went about an hour ago? You couldn't possibly need to go again. If you need to go, you're just going to have to go in your diaper." And I sat there and thought, "That's emotional abuse. That's humiliating to say to a person." And, this is in a premier community. There are the things that we need to look out for as they can certainly lead to emotional types of abuse. Whether that mental abuse has occurred or not is really determined by a reasonable person's standard and does not require a specific response from the individual. What I mean by that is a reasonable person would think that that is completely unacceptable. It does not necessarily have to have a response from the individual because that individual may have dementia or something else going on and cannot respond in an appropriate manner. We always use that "reasonable person standard" as our litmus test against whether or not something would be considered emotional or mental abuse.

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kathleen weissberg

Kathleen Weissberg, OTD, OTR/L

Dr. Kathleen Weissberg, (MS in OT, 1993; Doctoral 2014) in her 25+ years of practice, has worked in rehabilitation and long-term care as an executive, researcher and educator.  She has established numerous programs in nursing facilities; authored peer-reviewed publications on topics such as low vision, dementia quality care, and wellness; has spoken at numerous conferences both nationally and internationally, for 20+ State Health Care Associations, and for 25+ state LeadingAge affiliates.  She provides continuing education support to over 17,000 therapists, nurses, and administrators nationwide as National Director of Education for Select Rehabilitation. She is a Certified Dementia Care Practitioner and a Certified Montessori Dementia Care Practitioner.  She serves as the Region 1 Director for the American Occupational Therapy Association Political Affairs Affiliates and is an adjunct professor at both Chatham University in Pittsburgh, PA and Gannon University in Erie, PA. 

Related Courses

Elder Abuse and Child Abuse: Know the Signs and Your Role
Presented by Kathleen Weissberg, OTD, OTR/L
Course: #4370Level: Intermediate1 Hour
Elder abuse and neglect and child abuse and neglect are harsh realities. This course will identify the physical, clinical, and behavioral indicators of physical, emotional, and sexual abuse needed to identify and report to appropriate agencies. Participants will gain an improved awareness of warning signs of abuse, the clinician's role in reporting abuse, and the steps for reporting abuse and getting proper assistance.

Medicare Part B Coding And Billing For OT Services In Long-Term Care: An Update
Presented by Kathleen Weissberg, OTD, OTR/L, CMDCP, CDP
Course: #5687Level: Intermediate2 Hours
An in-depth review of Medicare Part B coding and billing, including CPT coding, unit-to-minute conversion, appropriate use of evaluation codes, reimbursement for assistants under Medicare Part B, and RTM codes will be reviewed. Using multiple examples, therapists will learn how to be compliant with coding, thorough in documentation to support skilled interventions, and detailed to avoid common errors. A review of elements known to trigger medical review including coding and documentation to support the plan of care is offered and tips and strategies for successfully managing medical review will be explored.

Getting Ready for PDPM: Group and Concurrent Therapy
Presented by Kathleen Weissberg, OTD, OTR/L
Course: #4459Level: Intermediate1 Hour
The new Patient-Driven Payment Model (PDPM), going into effect on Oct. 1, 2019, sets a combined 25 percent limit on concurrent and group therapy per therapy discipline provided. What does this mean for your therapy practice? This webinar will review definitions and best practice guidelines, including documentation, for group and concurrent therapy in skilled nursing facilities.

Bullying Among Older Adults: Not Just A Playground Problem
Presented by Kathleen Weissberg, OTD, OTR/L, CMDCP, CDP
Course: #5660Level: Introductory1 Hour
The definition and incidence of bullying in adult living communities and day centers including what older adult bullying looks like in this population are reviewed in this session. Characteristics of older adult bullies as well their targets and gender differences will be explored. The reasons why bullying occurs as well as the five different types of bullies are defined. Interventions for the organization, the bully, and the target will be reviewed to help communities minimize (and prevent where possible) bullying and mitigate the effects on the target. Addressing bullying behavior among older adults is critically important for enhancing quality of life and promoting emotional well-being; strategies to create caring and empathic communities for all residents and staff members are also reviewed.

Professionalism In Occupational Therapy: Meeting The Standards That Matter
Presented by Kathleen Weissberg, OTD, OTR/L, CMDCP, CDP
Course: #5444Level: Intermediate1 Hour
Although professionalism is an elusive concept, it is defined by sets of attitudes and behaviors specific to professions. You know it when you see it. You certainly know it when you don't. This course provides an overview of expected professional behaviors in healthcare including confidentiality, ethics, professional development, communication, and customer/patient service.

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