Elder Abuse Reporting | Why Families Should Report But Don’t

Elder abuse includes physical, sexual, and emotional abuse, financial exploitation, neglect, and self-neglect of older adults and adults with disabilities. Hesitance exists among family members, family caregivers, friends, and professionals to report elder abuse.
Encouraging family members, caregivers, and professionals to follow through with elder abuse reporting can be challenging for many reasons. Older adults who are abused by their caregivers or family members may lose their self-esteem and believe they deserve the abuse.
Some say nothing because of fear of retribution or harm by the abuser. Others fear confronting the abuser so they do nothing. Persons with dementia or Alzheimer’s may lack the cognitive ability to report elder abuse.
Additionally, a lack of trust in government, legal, and healthcare systems results in a failure by consumers to report elder abuse. Families report mixed experiences, positive and negative, working with Adult Protective Services (APS), the police, ombudsman, Departments of Health and Human Services, the Attorney General’s office, and others. Individuals also fear that if they report, they will be accused of elder abuse.

Research on Elder Abuse is Government-Focused

Identifying, preventing, and resolving elder abuse requires a multifaceted approach that necessitates collaboration among individuals, family members, organizations, and agencies. Family members who serve as primary caregivers for the elderly can lack trust in the justice system, probate court system, healthcare, and other providers perceived to have positional power and control.
While suspected criminals are assumed innocent until proven guilty and provided with legal representation, family members often receive little to no support from the legal system unless they have the financial means to pay for representation.
The prevalence of research on elder abuse and maltreatment originates from the Department of Justice (DOJ) Office of Justice Programs (1.2.3.4), Health and Human Services (HHS) (5,6,7,9) the Administration for Community Living (ACL) (3,5,8,9), the Centers for Medicare and Medicaid Services (CMS) (6,7), National Institutes of Health (NIH) (10,11), National Science Foundation (12) other operating divisions of HHS, universities, clinical researchers, and non-profit professional, aging, social service, or advocacy organizations.

Elder Abuse and Maltreatment Are Under-Recognized

“CREST research: advancing the field for practitioners” confirms a critical problem in self-neglect and the various forms of elder mistreatment is the under-recognition of cases and the need to put a face on self-neglect. (10)
Less data exists on understanding the experiences and perceptions of elder abuse reporting from individuals, their caregivers, and family members, and why they remain silent or report to Adult Protective Services (APS).
An HHS public access manuscript, “Elder Mistreatment in Underserved Populations,” calls attention to underserved and disadvantaged populations with increased vulnerability factors, including low income, race, and ethnicity, living in rural areas, and sexual identity.
The article confirms that work to understand underserved populations is critical to understanding the perceptions of elder abuse from underserved groups. Also mentioned is a concern that siloed research is preventing the advancement of efforts in the elder mistreatment field. (11)
Many family caregivers lack knowledge about duty of care and standards of care requirements for providers of services to the elderly. Gaining an understanding of the responsibilities of in-home care agencies, medical care agencies, and care communities can help family caregivers identify potential abuse.

The Growing Population of Older Adults Is Increasing the Need for Elder Abuse Reporting

The growing population of adults over age 65 with chronic illnesses, including cognitive impairment, is likely to continue to drive increases in older adult abuse and the need for elder abuse reporting.
According to the 2023 Profile of Older Americans, by 2040, approximately 78.3 million people will be 65 or older, more than twice the number in 2000. (8)
Support from family caregivers is a primary factor enabling older adults with multiple health conditions and disabilities to remain in their homes. Yet, complicated family dynamics and chronic disease can hinder the provision of care or self-care for older adults.
Many family caregivers who agree to the role of agent under medical or financial power of attorney find themselves ill-equipped to manage care for elderly loved ones when dementia or Alzheimer’s advances. Care refusals, agitation, and behaviors can prevent needed care and result in unintentional neglect.
In other cases, a sibling appointed as a power of attorney agent may misuse their authority, isolate a parent, or use a parent’s money for their own benefit. While it might be easier to ignore the situation, potential abuse should not be ignored, especially when a parent may be unable to speak up and ask for assistance.
In these situations, learning about the difference between power of attorney and guardianship, or how to get guardianship of an elderly parent, can be helpful.

Aging and Living Alone Are Contributing Factors

While professionals are the largest source of APS reporters at 65.5%, relatives (15.7%), other non-professionals (8.7%), self (5.3%), and caregivers/decision-makers (4.6%) follow. (5)
According to the Administration for Community Living 2023 Profile of Older Americans, in 2023, about 28% (16.2 million) of all older adults living in the community lived alone (5.7 million men, 10.5 million women).
Individuals living alone in the community represent 22% of older men and 33% of older women. The proportion of people living alone increases with advanced age for both men and women. (8)
In addition to older adults living alone in the community, “Flying solo, experiences of older adults who are aging alone,” confirms a population segment known as “solo agers” that refers to individuals who are unmarried, live alone, and do not have children to rely on as they age.
In 2022, according to the U.S. Census, there were approximately 22.1 million solo agers in the United States. (12) Because of the unique characteristics of this demographic, these individuals who lack family support can become unintentional self-neglectors.
The Adult Maltreatment 2020 Report confirms that the percentage of APS self-neglect victims (65%) is higher than the following four ranking types of elder abuse: neglect (14.4%), financial exploitation (14.4%), emotional abuse (9.8%), and physical abuse (8.2%). (5)

Dementia and Alzheimer’s Increase the Likelihood of Self-Neglect

Individuals with cognitive impairment diagnosed as dementia or Alzheimer’s who have difficulty performing multiple activities of daily living are at higher risk of self-neglect. The percentage of APS clients with one or more disabilities (5) is identified as:
Cognitive (27.1%)
Ambulatory (26.2%)
Independent living (24.9%)
Self-care (16.5%)
Unknown disabilities (16.7%)
Communication (5.1%)
Vision (3.8%)
Hearing (3.5%)
Pickens et. al., “Development of a Conceptual Framework For Severe Self-Neglect” report that executive dysfunction is highly correlated with self-neglect and functional disabilities, even in persons with normal MMSE (Mini-Mental State Examination) scores, and those who are highly educated. (13)
In simple terms, this means that highly educated individuals who can pass a cognitive task like the MMSE may still experience self-neglect due to difficulties with following instructions, remembering details, staying on task, adapting to change, planning and organizing, reasoning and problem-solving, and controlling moods and behaviors.
The article confirms that self-neglecters come to the attention of APS or medical professionals when informal caregivers can no longer tolerate the self-neglecter’s state of living.

Alzheimer’s and Dementia Caregivers Struggle to Provide Care

According to the Alzheimer’s Association, 6.9 million people age 65 and older in the U.S. are living with Alzheimer’s dementia. Many older adults with dementia are undiagnosed. 
Seventy percent of dementia caregivers report that coordinating care is stressful, with fifty-three percent saying navigating health care is difficult, and sixty-six percent having difficulty finding resources and support for their needs. (14)
As a result, family caregivers of loved ones with cognitive impairment often struggle with concerns about care refusals or self-neglect.
Many lack knowledge about the appropriate actions to take. Spouse caregivers who caregive 24-hours-a-day and 7-days-a-week quickly wear out.
Without support, education, and intervention processes for identifying and solving elder abuse concerns, family members may not recognize or relate cognitive impairment, care refusals, self-neglect, or financial abuse as elder abuse. Thus, they may fail or hesitate to act.

Family Members May Not Recognize Aspects of Elder Abuse

Elder abuse is not a dinner table discussion in families. When asked, many family can describe caregiving concerns in their families; however, these concerns are not recognized in the context of elder abuse, as evidenced by physical, sexual, and emotional abuse, financial exploitation, neglect, and self-neglect.
Even when recognized, a fear of taking action paralyzes many family members who feel ill-equipped to call out the abuser. This description of potential elder abuse and financial exploitation illustrates hesitance by a power of attorney agent to intervene.
My friend has a problem. Her mom has dementia, and her mom’s best friend has talked her into moving most of her money out of the bank account with her daughter (POA) into an account with her. Her mom will always listen to her friend over her daughter. She loves this woman like a mother; however, we all know what money can do to a person. Several thousand dollars have already been transferred out of her account into a joint account with only their two names. Her mom cannot make logical decisions and trusts this woman with her life. Her children were never told about this new account, so there is a considerable amount of suspicion. If guardianship was attempted, all relationships would be destroyed. With her mother’s condition, she can be taken advantage of so easily, and it seems as if it may already be happening.

Family Caregivers Lack Skills to Navigate Dysfunctional Systems

An inability to self-manage chronic disease, perform activities of daily living (ADLS), and instrumental activities of daily living (IADLS) can contribute to elder abuse. When programs addressing or identifying elder abuse are offered in silos from different agencies and providers, practical and effective solutions that exist can be overlooked.
Family members lack the skills to navigate dysfunctional systems. For example:

• Comprehensive Study of Oregon Courts’ Guardianship and Conservatorship Monitoring Systems and Practices, supported by ACL and HHS grants, identifies significant issues with the Oregon probate system. (9)

The goal of guardianship and conservatorship, and to a lesser extent, power of attorney appointments, is to ensure that legally documented wishes made prior to the onset or advance of cognitive impairment are carried out in circumstances of illness, injury, or incapacity. However, for older adults without knowledgeable family or strong advocates, the outcomes are not always positive.
Many family members with good intentions lack the financial means to hire a litigator. The result is that court systems, funded by tax dollars, can oppose rather than support innocent family members suspected of elder abuse.
Another example of financial exploitation occurred at a bank where a bank employee permitted a son to change the title of his father’s bank account and remove the account access of his brother, who was the financial power of attorney.
The father was at the bank at the time of the transaction, but was not asked directly by the bank employee whether the account change was his uninfluenced decision.
The employee, when questioned, later admitted that the bank had not provided training on the financial exploitation of the elderly.

Gaps in the Criminal Justice and Social Services Systems Contribute to Under-Reporting and Under-Prosecuting Elder Abuse

Furthermore, “Developing a Model for Providing Feedback to Reporters of Elder Abuse” by Haggerty et al., published in 2024 and supported by the National Institute of Justice, confirms the need to move the elder justice movement upstream. (15)
“Mandated reporters need to be considered essential abuse prevention and intervention partners. Establishing improved feedback and communication practices between Adult Protective Services and reporters is a critical next step in improving elder mistreatment response.” (15)
The October 2024 Annual Report to Congress on Department of Justice Activities to Combat Elder Fraud and Abuse provides an overview of high-level criminal and civil cases involving transnational and domestic fraud schemes, as well as nursing home operators and owners. A focus should also be placed on home care agencies and other providers offering services in the homes of older adults.
Two other reports, Protecting America’s Senior Citizens (1) and the Prosecution Guide to Effective Collaboration on Elder Abuse (2), confirm that:

• Only a small minority of local prosecutors’ offices emphasize early involvement in elder abuse cases.
• The most difficult challenges facing local prosecutors in elder abuse cases revolve around the victims’ physical and mental capacities, as well as the victims’ degree of cooperation in their cases.
• Crimes of elder abuse, neglect, and exploitation have historically been under-prosecuted
• Gaps exist in criminal justice and social service systems charged with protecting the welfare of older persons.
• A lack of specialized elder abuse detectives and prosecutors who have training and experience in the investigation and prosecution of these crimes exists, as well as a scarcity of expert witnesses with Daubert or 702 qualifications.

Gaining knowledge that these challenges exist, it’s no wonder that elder abuse is under-reported and under-prosecuted.
So what can family caregivers and mandatory reporters do to be more effective elder abuse identifiers and reporters?
Sometimes consulting an expert can help separate emotions from facts to develop a plan for reporting that family members feel comfortable with. Many family members are uncomfortable navigating family conflict and confronting the abuser.

Pamela D Wilson Elder Abuse and Neglect Expert Witness Services

For individuals who are hesitant to confront a family member or make a formal report, gaining information about what information to provide and how to report can be helpful. 
Pamela D Wilson is an expert witness for elder justice agencies, law firms, and families on the topic of elder abuse, guardianship, conservatorship, abuse, and neglect by care communities and home care agencies.
With over 25 years of experience as a caregiving expert and advocate, including serving as a court appointed guardian, conservator and power of attorney agent, she has the knowledge, skills, and compassion to support families experiencing challenges with elder abuse and financial exploitation. 
To learn more and contact Pamela, visit her expert witness services pages for Caregiving, Home Care, Guardianship, and Conservatorship and Guardianship.

Coordination and Collaboration Can Have Positive Results

Examples and research cited confirm that a lack of coordination, communication, and collaboration exists between public agencies and reporters.
Programs offered by agencies to help older adults with chronic disease management can have a greater impact if considered along with programs to solve public health problems like maltreatment and cognitive impairment.
Two examples below identify programs from the Centers for Medicare and Medicaid Services that address older adult health, access to programs and services, and support for family caregivers.

• The CMS Guide Model of 2024 (GUIDE) helps persons with dementia and their unpaid caregivers to access clinical and non-clinical services to help people with dementia remain at home, reduce emergency room visits, and reduce post-acute and nursing home care. (6)
• The CMS Medicare Annual Wellness Visit helps create a tailored plan specific to an individual’s current health status and risk factors, including screenings, immunizations, lifestyle changes, and a cognitive impairment assessment. Memory loss is a contributor to self-neglect. (7)

Both of these programs support vulnerable elderly adults and their caregivers in identifying early health concerns that can lead to self-neglect or elder abuse or neglect by an exhausted caregiver. By being proactive families can avoid situations that lead to elder abuse.

More Reasons Why Elder Abuse is Under-Reported

Identifying, preventing, and solving maltreatment can benefit from increased coordination with the DOJ (16) and Health and Human Services (17), as well as consumers and organizations at the federal, state, and county levels.
Family members who serve as the primary caregivers for the elderly—who are the individuals who can potentially identify and report maltreatment—experience high levels of stress, have difficulty navigating health care, and finding resources to support their needs. Solo agers, who live alone without the support of close family members, may find themselves in a similar situation that leads to unintentional self-neglect.

Building Support For Reporting

Individuals who feel supported in a safe environment are more likely to share personal information that is difficult or embarrassing. When given options and concrete steps, they are more likely to take action to implement solutions, which may include working with adult protective services, the elder justice system, the probate system, and a caregiving expert who can offer guidance.
Because individuals and families struggle with coordinating care, navigating health issues, and finding resources, they tend to procrastinate or make rushed decisions in crisis situations, which often have unexpected consequences. Others do not want to create or lack the confidence to address conflict in the family, even though they witness elder abuse.
Providers of services to older adults often face similar challenges. Care staff in private homes, adult family homes, assisted living, or nursing homes witness peers rushing or neglecting care and fear reporting. The same care providers witness family members engaging in maltreatment and are unsure what steps they can or should take.
These organizations and their employees may lack the education and knowledge necessary to communicate and collaborate effectively with healthcare and justice systems.

The Importance of Normalizing Conversations Around Elder Abuse

By normalizing conversations around elder abuse, as has happened with discussions around mental health, fear around reporting can be reduced.
Physicians willing to identify self-neglect as a treatable health diagnosis, ICD-10-DM T74, 91XA, can help solo-agers and adults who live alone be aware of concerns and conditions that place their well-being at risk. (19)
Having conversations around elder abuse in the family and requiring physicians to evaluate older adults for self-neglect can reduce the incidence of self-neglect, identified at 65% of all maltreatment types.
Monitoring care for aging loved ones living in care communities and nursing homes is critical to avoid elder abuse and neglect.
Fostering collaboration and behavior change around maltreatment between consumers, the elder justice system, and other government and local organizations can help change biases and perceptions, and reduce hesitation to call attention to a trend that will continue to increase without practical, tested, coordinated, and concrete solutions.

Potential Elder Abuse Solutions and Interventions

Family members have the most significant opportunity to reverse elder abuse trends and identify solutions for self-abuse, financial exploitation, and neglect. Collaboration with state, federal, and government agencies offers potential if roadblocks that create family hesitation can be eliminated by these agencies.

How to reverse elder abuse trends:

• Breaking down silos, obtaining participation and buy-in at federal, state, and county levels, including operating divisions to work with consumers to share information, collaborate, and solve elder abuse concerns.
• Ensuring that consumers feel safe identifying, preventing, and reporting elder abuse by asking for assistance from the government, healthcare, and other organizations to address and eliminate elder abuse.
• Increasing consumer and organization desire and confidence to work with government systems because of positive experiences and public education.
• Building consumer confidence that elder abuse can be resolved within the family or with coordination with the elder justice system, probate court system, caregiving experts, providers, and others.

To accomplish these goals, consumers, family caregivers, and others must raise awareness of the gaps between government and social service agencies, healthcare agencies, and other relevant organizations. Individuals should contact their local government representatives to request accountability, efficiency, and support for investigations into elder abuse.
While programs with similar goals exist across many parts of the U.S. government, there is little to no integration among them, resulting in the ineffective use and duplication of tax dollars and funds allocated to these programs.
Policies to address elder abuse and maltreatment must be implemented at the federal, state, county, and local levels to create alliances with the government, family caregivers, and mandatory reporters of elder abuse.
In the meantime caregiver support and education programs around elder abuse can be helpful to increase awareness and reporting so that elder family members remain protected and safe from abuse and neglect.

If you are experiencing or witnessing elder abuse and are not sure what steps to take, schedule a 1:1 consultation with Pamela D Wilson or contact Pamela about Elder Abuse Expert Witness Services.

References:
1) Miller, Mark L., and James L. Johnson, Protecting America’s Senior Citizens: What Local Prosecutors are Doing to Fight Elder Abuse. APRI American Prosecutors Research Institute Funded by the Office of Justice Programs Grant No. 98-LS-VX-0002. 2023.
2) Keilitz, S. et al. Prosecution Guide to Effective Collaboration on Elder Abuse. National Center for State Courts. Funded by the Office of Justice Programs. Grant No. 2009-DB-BS-K034.
3) Financial Exploitation and Family Dynamics, Presented by Costello, Long, Seal, and Shannon. National Center on Law and Elder Rights and the Administration on Community Living, April 25, 2024. https://pfs2.acl.gov/strapib/assets/Financial_Exploitation_and_Family_Dynamics_Slides_9780f4f3dc.pdf
4) Berchtold, Jim. Equitable Guardianship Reform Series. Part One: Addressing Bias in the Guardianship Process. Justice in Aging Issue Brief. February 2024.
5) McGee, L. & Urban, K. (2021). Adult Maltreatment Data Report 2020. Submitted to the Administration for Community Living. U.S. Department of Health and Human Services.
6) Guiding an Improved Dementia Experience (GUIDE) Model CMS.gov https://www.cms.gov/priorities/innovation/innovation-models/guide
7) Medicare Wellness Visits. CMS MLN Educational Tool. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html
8) 2023 Profile of Older Americans, The Administration for Community Living. https://acl.gov/sites/default/files/Profile%20of%20OA/ACL_ProfileOlderAmericans2023_508.pdf
9) Petty, J.M. JD, A Comprehensive Study of Oregon Courts’ Guardianship and Conservatorship Monitoring Systems & Practices, Juvenile and Family Courts Program Division. Publication supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS)
10) Mosqueda. L.M. et al. CREST Research: Advancing the Field for Practitioners. J Am Geriatr Soc. 2008. November; 56(Supply 2): S276-S280. Doi: 10.1111/j.1532-5415.2008.01981. x. The funding for the original CREST Model was from the National Institutes of Health, Award #IP20RR020636-01 to Dr. Carmel B. Dyer (PT)
11) Jervis, Lori L. et. al. Elder Mistreatment in Underserved Populations: Opportunities and Challenges to Developing a Contemporary Program of Research. J. Elder Abuse Neglect 2015: 28(4-5): 301-319. Doi: 10-1080/08946566.2016.1245644. Funding provided by the National Institutes on Health and other sources.
12) Flying Solo, Experiences of Older Adults Who Are Aging Alone. The Mather Institute. https://www.matherinstitute.com/wp-content/uploads/2023/12/MI_FlyingSoloReport_FNL.pdf?hsCtaAttrib=184634819895
13) Pickens S., Daniel, M. Jones, Erick, and Jefferson, Felicia. Development of a Conceptual Framework for Severe Self-Neglect (SN) by Modifying the CREST Model for Self-Neglect. Frontiers in Medicine. Volume 8 (2021). Research supported in part by funding from the U.S. National Science Foundation Awards. https://www.frontiersin.org/journals/medicine/articles/10.3389/fmed.2021.654627, DOI=10.3389/fmed.2021.654627. ISSN=2296-858X
14) 2024 Alzheimer’s Disease Facts and Figures. https://www.alz.org/news/2024/new-alzheimers-association-report-reveals-top-stressors-caregivers
15) Haggerty, Kristin Lees, Olanike Ojelabi, Randi Campetti, Athi Myint-Y, and Kathy Greenlee (2024). Developing a model for providing feedback to reporters of elder abuse. Journal of Elder Abuse and Neglect, 36:5, 439-457. DOI: 10.1080/08946566.2024.2361.1633. Research supported by the National Institute of Justice under Grant 2020-75-CX-0003.
16) DOJ Organizational Chart.https://www.justice.gov/d9/2023-09/DOJ%20-%20AG%20signed%20%20Approved%2008.17.2023.pdf
17) HHS Organizational Chart. https://www.hhs.gov/about/agencies/orgchart/index.html
18) National Center on Domestic and Sexual Violence. Power and Control Wheel Model. https://www.ncdsv.org/wheels-adapted-from-power-and-control-wheel-model.html
19) ICD10Data.com Unspecified adult maltreatment. https://www.icd10data.com/ICD10CM/Codes/S00-T88/T66-T78/T74-/T74.91XA
20) Peterson, J.C., et. al. Financial Exploitation of Older Adults: A Population-Based Prevalence Study. J Gen Intern Med. 2014. July 25;29(12):1615-1623. Doi: 10.1007/s11606-014-2946
21) Heath, Sara. Understanding the Power Hierarchy in Patient-Provider Relationships. https://www.techtarget.com/patientengagement/news/366585195/Understanding-the-Power-Hierarchy-in-Patient-Provider-Relationships\
22) Bureau of Justice Assistance. Protecting America’s Senior Citizens: What Local Prosecutors Are Doing to Fight Elder Abuse.
23) National Center for State Courts. Prosecution Guide to Effective Collaboration on Elder Abuse. https://biblioteca.cejamericas.org/bitstream/handle/2015/3198/protecting_americas_senior_citizens_2003.pdf?sequence=1&isAllowed=y
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