Mistreatment between residents is an underrecognized problem in long term care settings, with potentially serious consequences.
Most research about elder abuse pertains to abuse by long term care staff or caregivers, but elder-to-elder abuse—or “elder-to-elder mistreatment” as it’s also been termed—is an issue that demands more attention. While there’s no epidemiological evidence for the incidence of this type of maltreatment—and this issue remains vastly understudied—there’s significant indirect evidence that points to it being a serious concern in long term care settings across the nation.
There are various definitions of elder-to-elder abuse, but the phenomenon can be understood most simply as negative behavior between long term care residents (from one resident against another) including, most commonly, physical, sexual, and verbal abuse. This issue can be exceedingly complex, with many factors to consider.
According to Ronan Factora, MD, chair of the Special Interest Group on Elder Abuse and Mistreatment at the American Geriatrics Society and a Cleveland Clinic geriatrician, elder-to-elder abuse can show up in different ways and always takes place in long term care community settings in which residents already are in close contact with one another.
Factora says this abuse could occur between roommates or between residents who have contact with one another in public settings within the long term care facility. It might also take place, he adds, when a resident wanders in and out of another resident’s room.
While resident-on-resident abuse frequently happens behind the scenes, with caregivers and health care providers unaware of the behavior, there may be situations in which long term care staff might turn a blind eye. Some indirect evidence seems to point to the fact that elder-to-elder abuse is often accepted to some degree by long term care staff. According to a study published in the Journal of Elder Abuse & Neglect in 2012, for example, incidents of yelling and verbal insults among residents were not viewed as abuse by nurse aids and so were not reported. Some long term care employees even view this behavior as normal.
Recognition of abuse may be a judgment call based on staff’s perception of a problem, says Julie Ellis, PhD, RN, GCNS-BC, of the University of Wisconsin-Milwaukee College of Nursing. Having worked in long term care settings, she’s witnessed resident-to-resident abuse and observes that it can take many forms. “It might involve physical contact in the dining room when a resident becomes agitated. It could also involve a resident wandering uninvited to another resident’s room and initiating physical contact or perhaps even taking something that doesn’t belong to them,” Ellis says. “Because you must factor in that it may involve dementia [on part of the perpetrator], there is sometimes no intent associated with the action, so this becomes a very complicated issue.”
According to Factora, there are also risk factors associated with long term care communities themselves that could make elder-to-elder abuse more prevalent, such as understaffing or large populations of residents with cognitive impairment and mobility issues. “If you have residents who are not ambulatory, they may be at an increased risk simply because they cannot get away from the perpetrator,” Factora says. “Unfortunately, we lack good data surrounding this issue, but these are points to consider as you evaluate whether your long term care facility might pose increased risks simply due to its population.”
Keep in mind, Ellis says, that perpetrators might have been perpetrators in their younger years, as well. If you have men—or women, though Ellis says it’s more often men—who have a history of engaging in physical or sexual abuse, that behavior might be part of a lifelong pattern. “However, there are also many instances where the person does not have an abusive history but might be confused and experiencing aggression that they never exhibited before,” she adds. “Dementia-related agitation is a legitimate concern.”
Red Flags of Elder-to-Elder Abuse
“In terms of physical abuse, you might see bruises, cuts, scratches, fractures, slap marks, kick marks, eye injuries, and burns,” Malmedal says. “But for psychological abuse, you might see depression, withdrawal, apathy, feelings of hopelessness, insomnia, appetite change, unexplained paranoia, agitation, tearfulness, excessive fears, and confusion. You must also be aware when a person shows anxiety and fear for a certain person. An important indicator of abuse is if an older person tells you about being abused. Often, they are not believed due to old age and possible cognitive decline; nevertheless, they should be listened to and what they tell should be investigated.”
Factora points out that sometimes the red flags can come from the perpetrator rather than the victim. If you notice increased signs of aggression or agitative behavior or observe that a resident is suddenly spending more time around another resident, it would be prudent to be more watchful, he says.
Elder-to-Elder Sexual Abuse
“Some older victims of elder sexual abuse may have unexplained genital infections or venereal diseases,” she continues. “Their underclothing may be torn, stained, or bloody, and some may have difficulties in walking, standing, or sitting. Shame and embarrassment are even more present, and this reduces the likelihood of disclosure of the abuse. It’s important to be familiar with the different forensic markers—these very specific signs and symptoms that indicate elder sexual abuse. It’s also important to be responsive to any verbal or nonverbal disclosure from the older person. It might not be that they are using direct language to disclose sexual abuse but may ‘beat around the bush.’”
Ellis adds that the issue of sexual abuse becomes increasingly complicated when confusion or dementia is involved. While she describes physical abuse as “cut and dry,” sexual abuse involves quite a bit of “gray area.”
“Sexuality is encouraged in older adults if they are alert and oriented, but when you start talking about one person having dementia or even just confusion, lines can quickly become blurred,” Ellis explains. “Take for instance, a woman who seemingly consents to sexual activity because she believes the person is her husband. Is that abuse? It’s a gray area, but in my opinion, consent cannot occur when there is confusion involved. Sexual abuse is a serious issue, and I think when there is any doubt or gray area, the clinicians need to be involved in protecting the resident.”
There are also reasons some residents may choose not to come forward, adds Julie Schoen, JD, deputy director at the National Center on Elder Abuse, Keck School of Medicine at the University of Southern California, particularly when they’ve experienced physical or sexual abuse. This is why it’s imperative for long term care providers to remember that signs of abuse may not always be evident.
“I do think a lot of this is occurring behind closed doors, making it incredibly important that clinicians are paying close attention,” Schoen says. “Oftentimes there is a lot of fear associated with reporting. The resident may be fearful that they’ll lose the place where they’re living, that there will be retaliation, or even just that they won’t be believed.”
Societal attitudes toward elder abuse—particularly sexual abuse—have also made it difficult for residents to come forward, Malmedal says. “Societal ignorance and disbelief regarding elder sexual abuse may play an important role in regard to why cases are not detected and that the victims are not getting adequate help,” she says. “Sexual abuse of older adults is still not recognized as a social problem in many countries, and along with lack of a mandatory reporting system, this problem is often hidden and not acknowledged among professionals or in society in general. Some countries and states do have mandatory reporting of elder abuse cases, but even where this exists, the health care providers are not always aware of the mandatory reporting laws or how to enforce those.”
“This attitude must change,” she insists. “Educational programs are important to raise awareness of this topic. There are also a lot of useful websites, e-learning programs, and YouTube videos that could be used by staff to gain knowledge and spread the word about this issue.”
Ellis adds that verbal abuse is often the most likely to be overlooked, but it can be psychologically damaging and should not be ignored. “Verbal abuse can lead to depression and lead residents to withdraw or even to stop eating,” she adds. “It’s so important to watch for this and not to just dismiss it. It’s the staff’s responsibility to take care of this issue. Sometimes the resident committing the verbal abuse needs help. Just saying ‘don’t go near that person’ is not a solution. Action needs to be taken.”
A study published in the Journal of Continuing Education in Nursing looked at whether utilizing the SEARCH approach—Support, Evaluate, Act, Report, Care plan, and Help—could be effective in managing elder-to-elder abuse. The SEARCH approach provides clear guidelines for long term care staff to follow in terms of reacting to elder-to-elder abuse. The study applied this approach to three case studies and found it was effective in enhancing knowledge, recognition, and reporting of elder-to-elder abuse.
Education is certainly an important part of the solution, Factora says. Along with that comes the implementation of protocols—including reporting protocols. What should happen after witnessing or hearing a disclosure regarding abuse?
“I think there is a lot of confusion regarding who the appropriate authority to contact is,” Factora says. “Some issues may be able to be handled internally, but it often needs to go beyond that. Along with that, there needs to be a clear pathway for concerns to be communicated. It should never be assumed that somebody else already reported or handled an issue—the communication paradigm must be addressed. There should be a protocol in place for any suspicion of abuse.”
While external help may be called for, it’s also important to recognize that law enforcement often does not know how to deal with or address these issues, Schoen says. They are rarely well versed on how to deal with elder abuse and often view it as an internal issue that the long term care facility needs to handle.
Social workers, on the other hand, are typically well-versed in dealing with elder abuse and should always be brought into the conversation, Ellis adds. They have experience with psychosocial needs and a better understanding of how to approach this issue.
“The family should also become part of this conversation, as they likely may not be aware that any of this is occurring,” Factora says. “The last thing that any long term care facility wants is for an abuse concern to come to their attention through other means. Families should always know what’s going on so that they have the ability to be involved in any decision making that would naturally follow an abuse allegation.”
It’s also necessary to inform the family of a perpetrator about incidents of abuse. “The perpetrator’s family also likely has decisions to make—including whether they might be better served in a different community,” Factora says. “A perpetrator’s family has just as much right to know what’s going on.”
Looking to the Future
— Lindsey Getz is an award-winning freelance writer based in Royersford, Pennsylvania.