What makes the situation particularly complex is its hidden nature. Advocates point out that children do not live alone and—once they reach school age—are constantly in contact with a school or other institutions outside the home that can sound an alarm. Elderly people, on the other hand, frequently live in isolation from the outside world. Detection of abuse by outsiders is consequently more difficult, and incidents tend to be under-reported. Nonetheless, a study by the National Center for Elder Abuse found that in the 10-year period between 1986 and 1996, the number of adult protective service reports of elder abuse increased by 128 percent.
The two main categories of abuse are domestic and institutional. “Domestic” abuse takes place in the person’s own home or that of a spouse, adult child or caregiver. The abuse itself can take several forms—physical, psychological or financial. The most blatant is physical abuse, because it can leave visible signs like bruises, black eyes and lacerations. But since it takes place behind closed doors, it may never become known to outsiders who could intervene. Victims themselves are often reluctant to report the matter out of fear of even worse treatment, or a sense of shame that such maltreatment should be suffered at the hands of a family member or other supposedly trustworthy person.
Its counterpart, institutional abuse, also exists to some degree because of isolation from the outside world. As with domestic abuse, it can be difficult to detect and prevent. A study by the Government Accounting Office last year reported that complaints about harm to nursing home residents are frequently not investigated. And yet, under the Older Americans Act, every state is required to have an ombudsman program to address complaints. The study cites examples from around the country. One described a resident in a Michigan nursing home with maggots in his feet, who was not sent to a hospital because the director feared an investigation by a state agency. In another case, a Detroit woman in pain from a broken hip was not X-rayed until her family insisted.
Instances of this kind point to neglect rather than outright abuse. But as Sarah Greene Burger, executive director of the National Citizens Coalition for Nursing Home Reform told America, neglect is a precursor to abuse. In nursing home settings, both can indirectly be the result of understaffing in the 17,000 facilities around the nation. To increase their profits, many pay low wages to the nursing assistants who—frequently with inadequate training—must provide round-the-clock care to aged residents. Strains on limited staffs can lead to forms of neglect like “forced incontinence.” Ms. Burger gave the example of an aide who claimed that because she had so many patients to take care of, she could bring each of them to the bathroom only once during her eight-hour shift.
When physical abuse does take place, Ms. Burger said, it can be hard to prove—particularly if it occurs at night. This is partly because the surveyors responsible for investigations of abuse “almost have to see it,” or else the resident’s allegations may not be believed on the grounds of alleged dementia. Fear of retaliation can also deter residents from complaining of abusive behavior. Families themselves sometimes hesitate to complain, out of the same fear of retaliation by the facility. Councils made up of residents and family members are required by law, and these could, she said, help prevent much of the abuse if they were functioning well and if directors of nursing “really listened to families and stopped being defensive.” Ms. Burger places part of the blame for institutional abuse on the federal government, because it has put too few strings on the money paid to nursing homes through the Health Care Finance Administration that handles Medicaid and Medicare payments.
Without stricter controls and better investigative methods at both the state and federal level, the incidence of domestic and institutional abuse is likely to increase in the decades ahead. Although every state has some form of adult protective service laws, fewer than half provide for civil or criminal penalties. But far better than penalties is prevention—providing more support for caregivers in the home, who may be led to abusive behavior because of stress-related factors, and better training and pay for nursing assistants in institutional settings.