Clinical Brief: Recognizing, Reporting and Responding to Dependent Adult Abuse

Stacie A. Salsbury, PhD RN


author email   

Topics in Integrative Health Care 2011, Vol. 2(3)   ID: 2.3008

Published on
October 7, 2011
Text Size:   (-) Decrease the text size for the main body of this article    (+) Increase the text size for the main body of this article
Share:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo


Dependent adult abuse is an under-recognized problem affecting many disabled adults and older persons living in their homes or in institutional settings. Elder abuse, the most common form of dependent adult abuse, may present as physical, emotional/psychological, or sexual abuse; financial exploitation; and neglect, abandonment, or self-neglect. Health care professionals should be aware of the signs and symptoms of dependent adult abuse, and know how to report suspected cases accordingly. Manual therapists may need to modify treatment approaches for patients with a history of dependent adult abuse.


From a medico-legal standpoint, a dependent adult is a “person age 18 years or older who is unable to protect his or her own interests or adequately perform or obtain services necessary to meet essential human needs, as a result of a physical or mental condition which requires assistance from another.”1 Dependent adults often require the assistance of another person or persons to complete their activities of daily living, as well as to manage their home maintenance, transportation, and financial concerns, leaving the individual vulnerable to abuse or neglect from their familial or professional caregivers.2
Dependent adult abuse results from “the willful or negligent acts or omissions of a caretaker” and, pursuant to state-specified legal definitions, may include physical abuse, emotional or psychological abuse, sexual abuse or exploitation, financial exploitation, neglect or abandonment1-2, 4 and, though likely underreported is, unfortunately, a common occurrence. In one recent year, US adult protective services agencies received over 565,000 reports of dependent adult abuse, with over 191,000 reports substantiated on investigation.5 In nearly all cases, a family member, usually an adult child, other relative, or a spouse, is the perpetrator of the abuse.5 In addition to abuse by another person, an adult who does not care for him- or herself may be classified as suffering from self-neglect or self-abuse.4,6 During the same 1-year survey reported above, self-neglect was the most commonly investigated (27%) and substantiated (37%) category of dependent adult abuse, followed by caregiver neglect (24% investigated, 20% substantiated), and financial exploitation (21% investigated, 15% substantiated).5

Elder abuse, the most frequently reported form of dependent adult abuse, is experienced cross-culturally, across socioeconomic groups, and occurs both in elders’ homes and within institutional settings.4,6 The majority of elder abuse victims are female (66%) and over the age of 80 years (43%).5 A systematic review on the prevalence of elder abuse and neglect found that 6% of older adults reported abuse in the past month, while 5% of family caregivers admitted to physical abuse towards a care recipient with dementia in the past year.7 The National Center on Elder Abuse reports that neglect, or “the refusal or failure to fulfill any part of a person’s obligations or duties to an elder” is among the most common forms of elder abuse and one often perpetrated by family members.6 The National Elder Mistreatment Study recently reported that the one-year prevalence for potential neglect of adults age 60 years or older was 5.1% in a randomly selected national sample.8

Recognizing Dependent Adult Abuse

Dependent adult abuse can affect adults of all ages, ethnic and racial backgrounds, socioeconomic and educational statuses, religions, genders, marital standing and sexual orientation.4,6  Elders or dependent adults who report abuse or neglect should be taken seriously, though many people do not verbalize their abuse to others.6 While many screening tools for dependent adult abuse exist,2 the utility of these instruments is debated. Health professionals, therefore, should be familiar with the warning signs of dependent adult abuse, which include signs of physical abuse or neglect (such as bruises, broken bones, unhealed wounds or injuries in various stages of healing), emotional abuse (including withdrawn behavior, change in personality or depression), sexual abuse (such as bruising or bleeding around breasts, genitals or anus), and financial exploitation (like unpaid bills, missing possessions or unexplained money problems).6 Caregivers also may exhibit behaviors that may indicate they are actively perpetrating dependent adult abuse (such as belittling or threatening elder in public, restricting access to the home or limiting contact with the elder, answering for the dependent person, using restraints, or engaging in physical harm in public) or engaging in neglect (like not assuring the elder receives adequate food, supervision, or medications or medical attention or failing to provide adequate housing, exercise, or socialization opportunities).6 A typology of dependent adult abuse, along with warning signs and symptoms, is presented in Table 1. 

Table 1: Typology of Dependent Adult Abuse 2, 4, 6
Type of Abuse
Abusive Acts
Signs and Symptoms
Physical Abuse
Use of physical force resulting in bodily injury, physical pain or impairment
·  Violence behaviors including hitting, pushing, kicking, shaking, pinching or burning
·  Inappropriate medication use, including over- or under-medication
·  Physical restraint use
·  Force feeding
·  Physical punishment
·  Elder report of physical abuse or mistreatment
·  Multiple and/or untreated injuries in various healing stages
·  Bruises, cuts, black eyes, open wounds or other marks on the skin
·  Broken bones, sprains or dislocations
·  Broken personal care items (eyeglasses, dentures, hearing or ambulatory aids)
·  Laboratory findings of inappropriate medicine use
·  Changes in elder or caregiver behavior
Emotional or Psychological Abuse
Verbal or nonverbal acts resulting in emotional pain or distress
·  Verbal assaults, insults or harassment
·  Intimidation or threats
·  Humiliation
·  Social isolation from friends, family or activities
·  “Silent treatment”
·  Treating dependent person as a baby or belittling
·  Elder report of verbal or emotional abuse
·  Changes in elder behavior or emotional responses
·  Tearfulness, agitation
·  Withdrawn behavior
·  Non-communication
·  Caregiver answering for dependent adult
Sexual Abuse or Exploitation
Non-consensual sexual contact of any kind
·  Unwanted touching
·  Coerced nudity
·  Sexually explicit photography or video recording
·  Sexual assault or rape
·  Elder report of sexual abuse
·  Bruises or bleeding around breasts, genitals or anus
·  Torn, bloody or stained underwear
·  Venereal disease or unexplained genito-urinary infection
Financial or Material Exploitation
Illegal or improper use of financial assets or material property
·  Stealing or misusing money or possessions
·  Unauthorized check cashing, bank withdrawal or credit card use
·  Signature forgery on legal documents
·  Improper use of power of attorney or trusteeship
·  Elder report of financial exploitation
·  Unexplained money withdrawal or change in banking practices
·  Changes in legal documents such as a will or guardianship
·  Missing money or possessions
·  Provision of unneeded goods or services
Failure or refusal of responsible individual to provide for basic necessities, healthcare or safety needs of dependent adult
·  Lack of basic necessities including food, water, clothing, shelter, medicine, or utilities
·  Personal hygiene and discomfort not attended
·  Unsafe or unsanitary living conditions
·  Elder report of neglect by family member or other caregiver
·  Dehydration, malnutrition, weight loss
·  Untreated pain, falls or medical conditions
·  Bedsores, lice or other infections and injuries
·  Soiled or inadequate clothing or bedding
·  Spoiled food, fecal or urine odors
Desertion of dependent adult by responsible party
·  Desertion at hospital, shopping center or other public building
·  Leaving dependent adults alone in home with no care provided
·  Elder report of being left alone or caregiver abandonment
·  Elder found in public setting without caregiver or contacts
Self-Neglect or Self-Abuse
Behavior in which a dependent adult puts his or her own health or safety at risk
Does not include the actions of a mentally competent elder who makes a personal choice to engage in self-neglecting behavior and understands its consequences
·  Lack of basic necessities including food, water, clothing, shelter, medicine, or utilities
·  Personal hygiene and discomfort not attended
·  Unsafe or unsanitary living conditions
·  Hoarding
·  Homelessness
·  Poor personal hygiene
·  Dehydration, weight loss, malnutrition
·  Untreated medical conditions, infections or injuries
·  Spoiled food, fecal or urine odors, animal or pest infestations

Reporting Dependent Adult Abuse

Health care professionals, including medical doctors, nurses, dentists, psychologists, pharmacists, and chiropractors are mandatory reporters of dependent adult abuse in nearly all of the 50 states, with many states instituting voluntary reporting procedures for any person with knowledge of dependent adult abuse.3,6 As mandatory reporters of abuse, healthcare providers are required to report suspected cases of dependent adult abuse to the appropriate state agency, often called Adult Protective Services, for further evaluation.5 The National Center on Elder Abuse maintains a list of state directories for elder abuse prevention, laws and regulations, and helpline services.9 However, when a dependent person is in immediate, life-threatening danger, health professionals should call the police or 9-1-1.6 While specific details for suspected dependent adult abuse will vary by state, in general reports will require: 1) dependent’s name, address, and other contact numbers; 2) the caretaker’s name, address, and other contact numbers; 3) a statement regarding the type of abuse suspected; and 4) reporter’s name, address, and contact numbers. 

Responding in Dependent Adult Abuse

As chiropractors and other manual therapists often care for patients over extended periods of time, assess their physical and emotional responses to body-based practices, may review x-ray or other diagnostic imaging, and often meet or treat family members during a course of care, these healthcare providers may be among those best positioned to identify and intervene in cases of dependent adult abuse.10,11 Recently published consensus recommendations on best practices for chiropractic care for older people encourage doctors of chiropractic: a) to consider both unexplained injuries without a history of trauma or other identifiable underlying cause (for example, bruising related to anticoagulant use) and other possible indicators of abuse as “red flags” requiring referral for further evaluation, and b) to report suspected cases of dependent adult abuse to the designated social services organizations for further investigation.12 Unfortunately, in one recent survey, chiropractors in general practice underestimated the prevalence of intimate partner violence and had only fair knowledge of clinical indicators, common injuries, and victim management of this form of interpersonal abuse.13
Providers of manipulative and body-based therapies may need to provide counseling and psychosocial support to patients who have experienced dependent adult abuse and adapt their techniques to optimize healing within a non-threatening therapeutic environment.11 Healthcare professionals also might link dependent adults and their family members with specific eldercare services before abuse occurs. In 2000, the National Family Caregiver Support Program was established to assist state governments, local communities and social service agencies in offering information, access to services, and respite programs to help family caregivers keep their loved ones safely at home as long as possible.14 The Eldercare Locator, a public service of the US Administration on Aging,15 which is the direct result of this legislation, can be searched on-line for elder care services by zip code, city/state, or topic, or an information specialist can be contacted by telephone at 1-800-677-1116.


This project was conducted in a facility constructed with support from Research Facilities Improvement Program Grant Number C06 RR15433-01 from the National Center for Research Resources, National Institutes of Health.

Share:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo



Iowa Department of Human Services. Dependent Adult Abuse. Accessed May 20, 2011.


Fulmer T, Guadagno L, Dyer CB, Connolly MT. Progress in elder abuse screening and assessment instruments. J Amer Geriatr Soc 2004, 52(2), 297-304.


Stiegel L, Klem E. Explanation of the “Reporting Requirements: Provisions and Citations in Adult Protective Services Laws, by State” and “Mandatory Reporters: Comparison Charts of Categories in Adult Protective Services Laws, by State” charts. Washington, DC: American Bar Association Commission on Law and Aging, 2008. and


National Research Council. Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America. Panel to Review Risk and Prevalence of Elder Abuse and Neglect. Bonnie RJ and Wallace RB, Eds. Washington DC: The National Academies Press, 2003.


Teaster PB, Dugar TA, Mendiondo MS, Abner EL, Cecil KA, Otto JM. The 2004 Survey of State Adult Protective Services: Abuse of Adults 60 Years of Age and Older. Washington, DC: National Center on Elder Abuse, 2004.


National Center on Elder Abuse, US Administration on Aging. Accessed May 20, 2011.


Cooper C, Selwood A, Livingston G. The prevalence of elder abuse and neglect: A systematic review. Age Ageing 2008, 37, 151-160.


Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W, Kilpatrick DG. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. Amer J Public Health 2010, 100(2), 292-297.


National Center on Elder Abuse. State directory of helplines, hotlines and elder abuse prevention resources. Newark, DE: NCEA. Accessed August 29, 2011.


Terre L, Globe G, Pfefer MT. How much health promotion and disease prevention is enough? Should chiropractic colleges focus on efficacy training in screening for family violence? J Chiropr Educ 2006;20(2):128-137.


te Kolstee R, Miller JM, Knapp SFC. Routine screening for abuse: opening Pandora’s box? J Manip Physiol Ther 2004;27(1):63-65.


Hawk C, Schneider M, Dougherty P, Gleberzon BJ, Killinger LZ. Best practices recommendations for chiropractic care for older adults: Results of a consensus process. J Manip Physiol Ther 2010;33(6);464-473.


Shearer HM, Forte ML, Dosanjh S, Mathews DJ, Bhandari M. Chiropractors’ perceptions about intimate partner violence: a cross-sectional survey. J Manip Physiol Ther 2006;29(5):386-392.


US Administration on Aging. National Family Caregiver Support Program. Accessed May 20, 2011.


US Administration on Aging. Eldercare Locator: Connecting you to community services. Accessed May 20, 2011.