Elder Abuse: Warning Signs

A previous edition of Elder Care provides details about the reporting process if elder abuse is suspected, including what information is needed to make a report, what happens after a report is filed, and common reasons why older adults sometimes fail to report abuse.  This edition will focus on the different types of elder abuse, and some general (not inclusive) warning signs that healthcare professionals should know.


  • Many forms of abuse are co-occurring, i.e.: if someone is being physically abused, they are most likely being emotionally abused as well.
  • All forms of abuse are used to instill fear and gain compliance.
  • Any new or unusual behavioral changes in older adult patients should be noted and monitored.
  • Spend a few minutes alone with each patient – this may be your patient’s only time to freely discuss any concerns/issues/fears about their current living arrangements, personal safety or financial security.

Nationally, it is estimated that each year 1 in every 10 older adults suffers from some type of abuse.  Furthermore, estimates show that 1 in 3 older patients presenting to clinics or hospitals (for any reason) is experiencing abuse or neglect.  It is important to note that while elder abuse occurs in all cultures, the language used to describe it can vary. For example, older Native Americans might make comments about being disrespected, not abused.

Contrasting Palliative Care and Hospice Care
Contrasting Palliative Care and Hospice Care

Impact of Abuse on Older Adults and the Healthcare System

Elder abuse is a serious public health concern.  Older adults who experience abuse in any form have a 300% higher risk of death than older adults who have not experienced abuse.  Abuse victims are also four times more likely to be moved into a nursing home. Additionally, they utilize healthcare services at higher rates.  Direct medical costs associated with physical abuse-related injuries to older adults are estimated to add over $5 billion to the United States’ annual health expenditures.

Screening for Elder Abuse

Although the U.S. Preventive Services Task Force has concluded that there is insufficient evidence to recommend for or against routine elder abuse screening, clinicians should be familiar with available screening tools (Table 1) and determine which might be most suitable for use in their practice when elder abuse is suspected.  Screening tools are also intended to heighten professional awareness and often provide a comprehensive and systematic  documentation process. If abuse is suspected, based on screening or even just on clinical suspicion, it is important for healthcare professionals to know whether their state’s laws require them to report their concerns to Adult Protective Services (APS). While statutes vary, most states define who is considered to be a mandated reporter. The reporter does not need to prove abuse. APS professionals will follow up on each report and determine what or if any next-step actions are required.

Types and Warning Signs of Elder Abuse

Physical Abuse

Elder Abuse: Physical Abuse
Elder Abuse: Physical Abuse

Physical Abuse is the use of force that results in bodily injury, physical pain, or impairment.  Physical abuse can include hitting, pushing, burning, force feeding, using medicines inappropriately to cause sedation or somnolence, or using physical restraints. Warning signs are unexplained bruises, fractures, cuts or abrasions occurring in places they would not normally be expected, fear (patients may flinch or cringe), anger, withdrawal from friends/family or previously enjoyed activities, implausible stories, or contradictory statements. Healthcare professionals might also notice an injury that has not been cared for properly, a history of similar injuries, or too much time between the injury and seeking treatment.

Sexual Abuse

Sexual Abuse is sexual contact that is forced, threatened, or coerced.  Warning signs are not always obvious but can include sexually transmitted diseases, difficulty walking or sitting, increased anxiety or isolation, or bruises around the breast or genital areas.

Emotional Abuse

Elder Abuse: Emotional Abuse
Elder Abuse: Emotional Abuse

Emotional Abuse is mental anguish or distress caused by another person’s verbal or nonverbal behavior. Warning signs can include depression, agitation, withdrawal from normal activities, being anxious to please or submissive in the presence of a caregiver or family member, lack of eye contact, and new or increased use of alcohol or drugs.

Financial Exploitation

Financial Exploitation is the illegal or improper use of funds, property, or assets.  Recent studies estimate the annual monetary loss to elders victimized by financial exploitation is $3 billion. The most common types of financial abuse are misusing someone’s credit/debit cards, taking money from joint accounts, unauthorized money transfers, identity theft, and consumer fraud/scams.  Warning signs include increasing isolation and dependency on a single caregiver, appearing nervous or anxious around a particular person, suddenly having a new ‘friend’ who seems very interested in their health and finances, or comments about missing funds or possessions.


Elder Abuse: Neglect 
Elder Abuse: Neglect


Neglect is a caretaker’s failure or refusal to address basic safety, physical, or emotional needs. Neglect can be hard to detect, but common warning signs are pressure sores, unexplained weight loss, insufficient/inappropriate clothing, lack of cleanliness, and lack of or delayed medical care.


Self-Neglect occurs when someone is unable or unwilling to perform basic self-care tasks such as obtaining and eating food on a regular basis, seeking medical attention when needed, maintaining personal hygiene, and assuring  personal safety. Common conditions that can lead to or are associated with self-neglect are dementia, depression, sedation from over-medication, non-adherence to medication regimens leading to uncontrolled medical conditions, and substance abuse. Warning signs include poor grooming, paranoia, and disoriented or incoherent behavior.

Reasons Why Older Adults Fail to Report Abuse

Reasons Why Older Adults Fail to Report Abuse
Reasons Why Older Adults Fail to Report Abuse

There are many reasons why an older adult might be unwilling or hesitant to report abuse. Cultural beliefs can lead elders to believe abuse is a family issue that can’t be solved by outsiders, or that the objectionable behavior isn’t really abusive. Often they are ashamed of what is happening to them and embarrassed because they can’t control it.  Many times they love the abuser and don’t want them to get into trouble.  They may also fear that reporting will make their situation worse (e.g., being placed in a nursing home). Finally, isolation may limit or eliminate any opportunity to disclose abuse.

Examples of Elder Abuse Screening Tools

  • Brief Abuse Screen for the Elderly (BASE) – to help practitioners assess the likelihood of abuse.
  • Elder Abuse Suspicion Index (EASI) – to raise suspicion about elder abuse to a level where reporting might be necessary.
  • Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) – screening device to identify people at high risk of the need for protective services.
  • Questions to Elicit Elder Abuse – specific questions to determine if abuse is occurring.
  • Screen for Various Types of Abuse or Neglect (American Medical Association) – general questions to screen an older person for various types of abuse or neglect.
  • Suspected Abuse Tool – designed to help recognize common signs or symptoms of abuse.

    *   These screening tools can be found here.

Caregiver Concerns

Approximately 34 million people provide unpaid care to older adults each year in the United States.  Four out of ten caregivers rate their caregiving situation to be highly stressful. Caregivers are often overwhelmed, unable to physically provide necessary care or lack the knowledge or skills, or struggle with their own medical or cognitive issues. If healthcare providers notice interactions between the older adult and caregiver as tense or leading to frequent arguments, they should be concerned about the caregiver’s risk of abuse. Community resources can be provided to help with respite, caregiver skill training, anger and stress management techniques, and caregiver support connections.

          To find Adult Protective Services reporting numbers in your state, go to Eldercare Locator – www.eldercare.gov or call 1-800-677-1116

References and Resources

  • Elder Care: Elder Abuse – Clinician Reporting.
  • MedlinePlus. Elder Abuse.   
  • The MetLife Study of Elder Financial Abuse. 
  • National Adult Protective Services Association.  
  • National Center on Elder Abuse.   
  • National Council on Aging. Elder Abuse Facts.  

 National Editorial Board:  Theodore M Johnson II, MD, MPH, Emory University; Jenny Jordan, PT, DPT, Sacred Heart Hospital, Spokane, WA;  Jane Marks, RN, MS, FNGNA, Johns Hopkins University; Josette Rivera, MD, University of California San Francisco; Jean Yudin, CRNP, University of Pennsylvania

 Interprofessional Associate Editors: Carleigh High, PT, DPT; David Coon, PhD; Marilyn Gilbert, MS, CHES; Jeannie Lee, PharmD, BCPS; Marisa Menchola, PhD;  Francisco Moreno, MD; Linnea Nagel, PA-C, MPAS; Lisa O’Neill, DBH, MPH; Floribella Redondo; Laura Vitkus, MPH, CHES


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