Abuse and Neglect against Elderly Adults in Nursing Homes in the United States

By Erica Bassett

Published Spring 2021

Special thanks to Harper Forsgren for editing and research contributions

Summary+

Elder abuse and neglect in nursing homes has been publicly regarded for several decades but is likely to increase as the Baby Boomer generation ages into retirement. Certain demographics are more at risk for abuse and neglect, particularly patients with dementia or Alzheimer’s disease. Abuse can include physical abuse, psychological abuse, sexual abuse, emotional abuse, neglect, and other inappropriate behaviors. Current internal structures such as poor patient-staff ratios, poor staff credentials, and staff burnout contribute to the prevalence of abuse and neglect against elderly patients, who often are dependent on staff for care. As a result of abuse, elderly victims are more at risk for physical maladies, depression and loneliness, poor physical health, and premature death. Although education on prevention and detection has been proposed as a potential deterrent, there is limited data on its impact among nursing staff.

Key Takeaways+

The number of elderly adults in the United States is expected to significantly increase, requiring more elderly adults to receive consistent care from family or from care facilities. The number of elderly adults with cognitive disabilities is also projected to increase.

Approximately 64.2% of staff in nursing care facilities reported they had committed some form of abuse in the past year. Neglect is also a common aspect of abuse in nursing homes.

In addition to poor patient-to-staff ratios in nursing homes, elderly patients receive an average of 3.8 hours of direct staff care per day, of which only 0.64 are RN hours.

Most patient care is performed by LPNs and aides, who are only certified for daily tasks like bathing, cleaning, and dressing and often lack vital training, resulting in unsafe care.

Elderly patients who are abused or neglected are at risk for physical maladies like pressure ulcers, mental health challenges like depression, and premature death compared to their unabused counterparts.

Key Terms+

Abuse—Chronic mistreatment of an individual at the hands of another, which can take on many forms, such as physical, psychological, emotional, mental, or sexual.¹ Neglect is also an instance of abuse.

Neglect—The act of giving insufficient attention or regard to someone. For elderly patients, neglect can include several hours without seeing a staff member.

Elderly adult—An individual over the age of 65 years.

Dementia—A degenerative mental disability that mostly affects elderly adults and impacts an individual’s ability to think, remember, communicate, reason, and make decisions.²

Care facilities—A private or public institution that provides long-term residential care to elderly or disabled individuals. A nursing home is an example of a care facility.³

Burnout—Mental, physical, and emotional exhaustion caused by prolonged stress.⁴

Context

In 1975, two British scientific journals released publications on violence against elderly adults, using the term “granny battering” to describe the phenomenon. As a result of these articles, the mistreatment of elderly adults entered the national stage as a pressing issue that needed government and public intervention.^{5, 6} In the 1980s, further scientific research and government reports from the US, Canada, Australia, China, Norway, Brazil, India, Israel, the UK, and other regions proved the prevalence of elder abuse around the world.⁷ Their evidence opened up a discussion on this social issue in the United States.

The number of elderly adults (over the age of 65 years) entering nursing homes is expected to increase in the upcoming decades. In the United States, the number of elderly adults over 65 is projected to grow from 47.8 million in 2015 to 87.9 million in 2050 as the Baby Boomer generation ages past 65 years.^{8, 9} In several states, the number of elderly adults is expected to at least triple, including in Alaska (650%), Nevada (474%), Georgia (375%), and Virginia (397%).¹⁰ By 2050, about 22% of the US population will be elderly adults.¹¹ As more adults age past 75 years, the number of dementia cases is also expected to triple by 2050,¹² requiring more elderly adults to receive regular care from outside sources.¹³

Outside of care from family members, several long-term care facility options exist for elderly adults in the United States. In 2016, about 65,600 long-term care facilities provided care to more than 8.3 million people in the United States. Of these facilities, 15,600 were nursing homes, 12,200 were home health agencies, 4,300 were hospices, and 28,900 were assisted living and residential care communities.¹⁴ In 2016, 15,600 nursing homes in the US provided more than 1.6 million beds for patients, with an average of 106 certified beds per nursing home facility.¹⁵ Although abuse and neglect are also common in a home setting by family members, this brief will focus primarily on nursing homes in the United States due to their high rates of abuse and due to the prevalence of data. It should be noted however, that research identifies family members and neighbors as the most common abusers outside of nursing homes.^{16, 17}

Nursing homes are typically staffed by a variety of workers. Administrators oversee nursing home operations, including quality assurance, finance, activities, food services, and other administrative tasks that distance them from elderly patients.¹⁸ The most common staff member is a nursing aide, followed by licensed practical nurses (LPNs), and registered nurses (RNs). Other facility-supporting occupations include maids and housekeepers, food preparation workers, recreation workers, laundry workers, and non-restaurant food servers.¹⁹ Of these workers, nursing aides are most likely to commit abuse or neglect elderly patients, most likely due to their direct relationship with the patients.²⁰

Care facilities such as nursing homes have the highest reported rates of abuse, with 2 in 3 staff reporting some form of abuse in the past year.²¹ Across nine studies conducted in 2019, 64.2% of staff admitted to some form of elder abuse in the past year.²² Similarly, in a national survey of nursing home staff, 40% admitted to psychologically abusing their patients.²³ In lieu of this data, abuse by staff against elderly adults can manifest in different ways. As reported by the National Adult Mistreatment Report System (NAMR), abuse includes neglect, financial exploitation, emotional abuse, physical abuse, sexual abuse, and abandonment.²⁴ (This brief will not examine financial exploitation, although this type of abuse is commonly employed by family members and other loved ones.²⁵) The true prevalence of sexual abuse is unknown among nursing care patients, although there are recorded instances.^{26, 27} Sexual abuse can include unwanted intimate touching, sexualized kissing, rape, forced nudity, taking sexually explicit photos, and other forms, and is often the result of coercion, manipulation, or deception.²⁸ It is more common among female patients or patients with dementia,^{29, 30} but both male and female patients can be victims.^{31, 32} Physical and emotional abuse can include physically restraining elderly patients, leaving them in soiled clothes, yelling at them, depriving them of choice, allowing them to develop pressure sores, withholding medication, as well as other examples.³³ Among states that reported to adult protective services programs in their respective states, neglect was the most common form of abuse in 2017 at 31.2% of victims.³⁴

Certain demographics of elderly adults have reported more experiences of abuse. According to the National Adult Mistreatment Report (NAMR) in 2017, elderly adults ages 75 to 84 were 33.4% of reported victims, with adults ages 85 and older at 23.4%.³⁵ Of these reported victims, 66.2% were white, 11.9% were African American, and 17.1% were unknown.³⁶ In reporting states, 64.3% of victims were female, 34.8% were male, and approximately 0.11% were either unknown or transgender.³⁷ Although the NAMR system provides a comprehensive view on demographics of abused patients, these trends may reflect the overall distribution of individuals in nursing homes. Women, for instance, reportedly make up more than two-thirds of the patient population in nursing homes. Similarly, approximately half of residents are over the age of 85, and around 89% of elderly patients are white with African American patients making up around 9% of the patient population.³⁸ Thus, while women are more likely to have persistent and severe forms of abuse or injury, these figures could represent the simple reality that more female patients live in these care settings and are thus at higher risk.³⁹ The same can be said for white patients and patients over 85, who experience higher rates of abuse. Other patient circumstances put elderly adults at lesser or greater risk; dementia patients, for instance, are more at risk for abuse or injury.^{40, 41} In a study among staff for dementia patients, 55% of staff admitted to some sort of abuse, with verbal abuse being the most common.⁴²

Unfortunately, despite rigorous data, only an estimated 1 in 24 cases of elder abuse are reported to authorities in a given year.^{43, 44} Elderly adults are less likely to report due to various reasons, including physical or mental inability to report; dependency on the abuser for basic needs; fear of retaliation; shame or concern that the report will lead to the abuser losing his or her job, etc.⁴⁵ Though the Elder Abuse Prevention and Prosecution Act, which identified the need for further data on elder abuse in order to protect older adults, was signed into law in 2017, the effects of this law will likely not be seen for a few more years as facilities adjust their monitoring and evaluation protocols to align with the statutes. This brief will examine existing data despite the gap in reported abuse.

Contributing Factors

Poor Infrastructure

Poor Patient-Staff Ratios

As a result of competitive pricing, it is common practice for nursing care facilities to operate with poor patient-staff ratios. Many nursing homes report housing an average of 86 patients per day, with 30.6% serving more than 100 patients each day. These figures represent around 90 or 95 percent capacity, according to a New York state sample.⁴⁶ In a care facility where a 1 to 3 ratio is advised, facilities typically assign an average of 15 or so patients per staff member. Some facilities even have a patient-staff ratio closer to 30 patients per staff member.⁴⁷ This disproportionate number of staff to patients impairs the staff’s ability to give little more than rudimentary care. As a result of having too many patients and too little staff, staff often neglect toileting, turning a patient, ensuring a patient’s comfort, tending to a patient’s oral care, and other tasks because staff have limited time to accomplish their tasks.⁴⁸ Thus, neglect is prevalent in nursing homes that operate with poor patient-staff ratios. Similarly, high stress because of high patient demand can lead to some staff feeling frustrated, experiencing burnout, and lashing out against their patients. Poor patient-staff ratios open the door for impersonal and abusive relationships between staff and patients.^{49, 50}

Limited Staff Credentials and Care Hours

The type of staff at nursing care facilities also has a significant effect on care, as limited staff credentials may impede a staff member from providing safe and informed care to their patient. In 2016, about 945,700 individuals were staffed in nursing homes as RNs, LPNs or aides. More than two-thirds of staff members were aides (63.9%) or LPNs (22.4%),⁵¹ who are certified to provide basic care like bathing, dressing, medicating, and feeding.^{52, 53} LPNs and aides are certified through occupation-specific examinations and certifications to accomplish these tasks.⁵⁴ Unfortunately, concerns of inadequate care have heightened due to the increasingly complex healthcare needs of patients (particularly those with dementia or other cognitive disabilities) and reports of unsafe and unsanitary conditions. These reports include medication errors, poor response to the behavior of patients with dementia, inappropriate use of physical restraint, use of psychotropic drugs to calm patients, and other concerns.^{55, 56} For example, one report found that one-third of their sampled staff did not meet state-required medication training.⁵⁷ As a result of limited training, aides and LPNs are more likely to maladminister medication, overlook issues like pressure ulcers, and neglect other needs.⁵⁸

With additional examinations and required credentials, RNs are authorized to assess patient needs, create nursing care plans, and serve in an informed administrative role with greater responsibilities.⁵⁹ RNs are also more likely to notice issues like pressure ulcers through their additional training and can respond to more complex healthcare situations. However, in 2016, only 11.9% of nursing home staff were RNs,⁶⁰ with the remaining percentage of staff being either LPNs (22.4%) or aides (63.9%).⁶¹ This means that the overwhelming majority of staff available to assist patients are restricted to performing day-to-day tasks with limited training.

In addition to low percentages of RNs in nursing homes, the average number of hours of care from RNs that patients receive per day is low. In 2010, nursing care patients received an average of 3.8 hours of direct staff care per day, of which only 0.64 were RN hours.⁶² According to an independent report, RN hours per resident per day correlates strongly with better nursing facility measures, particularly in the interest of the patient’s health and wellbeing. States with higher RN hours reported “lower rates of pressure sores, lower use of restraint, and fewer hospital admissions.”⁶³ Thus, fewer RN hours and involvement with staff introduces further opportunities for neglect and abuse.

Burnout of Nursing Staff

The emotional and physical health of staff also affects the quality of care among elderly patients, as staff burnout contributes to abuse and neglect. Burnout is defined as a reaction to chronic stress at work and can affect both physical and mental health.⁶⁴ The effects of burnout include emotional exhaustion, low sense of personal accomplishment, and depersonalisation (an indifferent and distanced attitude towards people and work).⁶⁵ Burnout is also correlated with physical and psychological aggressiveness such as hitting or withholding medication from patients who refuse to cooperate,⁶⁶ which can be particularly distressing for patients who rely on staff care for basic needs. This reaction to chronic stress is particularly high for staff tending to patients with dementia, as care is intensive and emotionally demanding because of the patients’ cognitive impairment.⁶⁷ Prolonged burnout is associated with low work satisfaction and risk of staff members not showing up for work, which exacerbates the issue of patient-to-staff ratio.⁶⁸ Thus, burnout has both physically and psychologically detrimental effects on both staff and patient health and often increases instances of abuse and neglect.

For nursing staff in particular, cases of burnout at nursing care facilities are extremely high due to the previously mentioned poor patient-staff ratios and consistent care required. One study conducted among care facility staff outside the United States found that 22.1% of staff members were experiencing emotional exhaustion.⁶⁹ Another source claims the burnout rate is closer to 37%.⁷⁰ Staff members face several stress-inducing factors related to their work, including direct contact with patient suffering and needs; difficult work conditions like twelve-hour shifts; poor salaries; and hostile work environments.⁷¹ For instance, a staff member may be asked to work with a patient who, often due to the effects of dementia, may direct physical and verbal attacks towards the staff member.⁷² These and other conditions correlate with higher levels of stress, fatigue, irritation, and mood alterations, which negatively affect the staff member’s quality of life and care-giving.^{73, 74} As a result, some staff members inappropriately abuse or distance themselves from their elderly patients as a coping mechanism for burnout and stress.

Patient-Staff Relationship

Patients are dependent on staff to provide basic and ongoing needs, as typical care requires help with dressing, bathing, toileting, taking medication, and other tasks, depending on the needs and abilities of the patient. While family members may pay visits or call their elderly relatives and there are usually recreational activities available for most patients (though it varies how many activities are offered each day and how able the patients are to participate in these activities), these elderly patients spend most of their time either alone or one-on-one with a staff member.^{75, 76} This one-on-one relationship and dependency for needs create feelings of vulnerability and helplessness among patients, particularly among dementia patients who need additional monitoring. Generally, elderly adults are at risk for low-life satisfaction and mental health issues without proper social and emotional support. This need for support and connection turns patients consistently to their surrounding social network, which is often limited to the potentially impartial staff they see each day.⁷⁷ This, coupled with negative stereotypes that elderly adults are frail, weak, and burdensome, means that elderly adults in nursing homes live in an environment of disconnect and dependency, which can mean there is a greater likelihood of abuse and neglect.

Because so many patients are physically dependent on their caregivers, a majority of victims hesitate to report out of fear that they would be further neglected. In the state of North Carolina, for instance, more than half of all complaints raised against staff were filed by friends, family, and/or legal representatives rather than the victims themselves.⁷⁸ In 2016, the National Adult Maltreatment Report System (NAMRS) began collecting data from 26 states on maltreatment of elderly adults, including physical abuse and neglect. Despite the 143,146 reports of abuse against adults ages 60 and older in 2017, the NAMRS estimates that only about 1 in 24 cases of elder abuse are reported to authorities.^{79, 80}

Consequences

Physical Maladies

The effects of neglect can lead to serious physical injury among elderly patients. A common physical injury due to neglect is pressure ulcers, which are sores created when an area of skin breaks down due to pressure or friction.⁸¹ These ulcers can develop within 4–6 hours of sustained pressure.⁸² Without regular treatment and care from staff, the risk for pressure ulcers increases, particularly in patients older than 85.⁸³ According to the CDC, about 2–28% of nursing home patients develop pressure ulcers.⁸⁴ Patients who remain in bed or are confined to a wheelchair for several hours at a time are especially prone to develop pressure ulcers, which can worsen over time and damage underlying tissue.⁸⁵ Without proper treatment in nursing care facilities (including staff regularly monitoring patients’ skin), it is likely that elderly patients develop pressure ulcers, which can open the body up to potential systemic infections if not properly treated.⁸⁶

Poor oral hygiene is also a consequence among elderly patients experiencing neglect and abuse, particularly as staff are often responsible for daily cleanings. These cleanings are time consuming, resulting in nearly 80% of elderly patients not receiving daily oral care. For dementia patients, cleanings are an additional challenge as patients may resist or potentially injure staff.⁸⁷ The results of poor oral hygiene include cavities, gingival bleeding, root caries, periodontitis, and dry mouth.⁸⁸ For elderly patients, poor oral health can result in pain, discomfort, inability to chew, nutritional problems, and difficulty speaking or swallowing.^{89, 90} Oral diseases are also associated with increased risk of diabetes and cardiovascular disease.^{91, 92} Oral hygiene is an important aspect of individual health and can lead to poor physical health among elderly patients if neglected by staff.

Traumatic Injuries

Although less common than verbal abuse, physical abuse against elderly patients may be seen as a response to inadequate coping mechanisms by stressed and irritable staff and can lead to serious injuries for patients.⁹³ Common physical injuries due to abuse by staff are bruising and neck and head injuries. A recent study examined medical, police, and legal records of elderly adults from 2001–2014. The study found that physical abuse victims were more likely than unintentional fallers to have bruising (78% versus 54%, respectively) and injuries around the face (67% versus 28%, respectively). Physical abuse victims were more likely to have fractures and injuries in the upper extremities than the lower and were also more likely to have injuries in specific locations, including on the left cheek, the neck, and the ear.⁹⁴ In another study, approximately 42% of elderly adults visiting the ER had suspicious injuries, although it is unclear how many elderly adult visits came from nursing care facilities.⁹⁵ In environments of abuse and neglect, elderly adults are at increased risk for physical injury caused by burned out and inappropriately aggressive staff, with elderly patients sustaining injuries that are often more serious in this age group.

Mental Health Challenges

Mistreatment affects the psychological well-being of patients, leading to serious mental health challenges. In a survey of elderly adults in the general public, adults reported lower scores on psychological well-being measures when in situations of mistreatment.⁹⁶ Instances of mistreatment correlated with more anxiety symptoms, greater feelings of loneliness, and worse health among mistreated elderly adults in comparison to elderly adults who reported no mistreatment.⁹⁷ Similarly, a study conducted in South Carolina among elderly adults found a significant correlation between emotional abuse and emotional symptoms, which include anxiety and depression.⁹⁸ Furthermore, nearly 19% of elderly adults reported feeling anxious, depressed, or irritable, with higher percentages among widowed or single participants.

Greater Risk of Death

Abuse and neglect against elderly adults can lead to serious long-term effects, including greater risk of premature death.⁹⁹ A 13-year longitudinal study examined elderly adults who experienced abuse but did not control for the residential status of victims; the data therefore applies to abused elderly adults within and without nursing homes. Results of the study indicate a general increased risk for mortality among abused elderly adults, a conclusion that can be logically applied to those in nursing homes. In the study, victims of elder abuse had poorer survival rates, even after adjusting for other factors like chronic disease, demographics, social network, cognitive and functional status, and depressive symptoms.¹⁰⁰ Victims of elder abuse and mistreatment are reportedly two times more likely to die prematurely than elderly adults who are not victims, perhaps as a result of victim stress.¹⁰¹ This increased risk could be due to not receiving proper doses of medication, the chronic effects of victim stress, or the lack of adequate daily physical and mental stimulation.

Practices

Abuse Prevention Curriculum

Curriculum for nursing staff that focuses on prevention has been proposed to the public for several decades. In 1992, the Coalition of Advocates for the Rights of the Infirm Elderly (CARIE) developed additional training and certification curriculum for nursing staff based on eight training modules.¹⁰² The goals of this specialized staff training were to increase staff awareness of abuse and neglect; equip staff with appropriate conflict intervention strategies; reduce abuse in care facilities; and provide a dignified existence for elderly patients. Unfortunately, CARIE’s developed training remains purely theoretical, so no data exists on the impact of this prevention curriculum on staff or on instances of abuse and neglect in nursing homes.

Similarly, a 2009 study made training recommendations based on interviews with nursing staff, policy makers, and other professionals.¹⁰³ The study’s own prevention curriculum included interpersonal skills, managing difficult situations, conflict resolution, stress reduction, basic information about dementia, and how to report witnessed abuse. Although this curriculum has yet to be implemented (and thus no impact data exists), researchers in the study hoped that the prevention curriculum would help staff be conscious of their own actions, leading to fewer instances of thoughtless retaliation or inappropriate actions against elderly patients. They also theorized that training would promote a more cooperative work environment, which would reduce negative feelings among staff and create a safer environment for residents and staff alike. This study, alongside CARIE, represents an overall trend: despite calls for prevention curriculum, no framework exists at this time. As a result, little data exists to analyze the impact of this curriculum on staff members and the prevalence of abuse as a whole in nursing home settings. One 2015 study found that educational interventions did reduce tolerance for elder abuse, though this study was conducted among young adults and not nursing staff.¹⁰⁴ Regardless, numerous sources argue that educational intervention improves staff behavior and quality of care in nursing homes.^{105, 106, 107}

It should also be noted that while abuse prevention curriculum helps staff members manage their stress levels in respect to their relationship with patients, this curriculum does not directly address sources of stress in staff members’ lives. For instance, this prevention curriculum does not reduce staff burnout or alleviate poor patient-staff ratios. As a result, further interventions outside this curriculum should address the poor infrastructure that is prevalent in many nursing care facilities and thus reduce the source of stress in staff members’ lives, thereby reducing instances of abuse and neglect against elderly patients.

Detection Training

Detection training teaches third parties such as local law enforcement and hospital staff how to recognize and report instances of abuse after they have occurred. Unlike abuse prevention curriculum, which is proactive and administered among nursing home staff, detection training among third parties can increase reports to authorities, leading to proper response and prosecution where necessary. Several programs currently exist, including federal and hospital programs. For instance, the Prevention of Elder Abuse, Neglect, and Exploitation program as developed by the US Administration of Aging trains law enforcement, health care providers, and others on how to recognize and respond to elder abuse.¹⁰⁸ The program’s efforts are primarily education and outreach campaigns to increase public awareness. Although the program has been implemented across the country since 1987, little data is available on the actual impact of this program on public awareness, and it is unclear how the program affects the number of reports of abuse from nursing homes.

Similarly, the National Center on Elder Abuse (another program established by the Administration of Aging) provides research, training, materials, and financial support to state and community organizations working to combat the prevalence of elder abuse. Current data on the Center’s efforts are primarily related to outputs; in 2010, the Center had more than 1,700 subscribers to its newsletter, provided training to over 1,100 professionals, and supported 22 local communities.¹⁰⁹ However, these materials cater to the general public and do not cater to family members themselves, who are either involved in abuse or who may have closest access to their abused loved ones.

In a 2020 report, researchers tested the use of an emergency care screening tool for hospital staff, known as the DETECT tool. Using data from Adult Protective Services in the past three years, the study found that medical staff who used the DETECT screening tool reported more instances of elder mistreatment. The study concluded that the tool improves detection, even when factoring in usual changes in reporting, and has the potential to increase frequency of clinicians reporting abuse cases across the United States.¹¹⁰ It should be noted, however, that the DETECT tool focuses on reporting rather than the prevention of abuse and neglect and lacks substantial data for nursing home patients in particular.

Preferred Citation: Bassett, Erica. “Abuse and Neglect against Elderly Adults in Nursing Homes in the United States” Ballard Brief. May 2021. www.ballardbrief.org.

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