Elder Abuse and Dependent Adult Abuse 

Recognition and Reporting for Nurses and Other Healthcare Professionals

by Adrianne E. Avillion, DEd, MSN, RN and Judy K. Orth, BSN, MA, RN, CHPN

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INTRODUCTION

The abuse and mistreatment of dependent adults and vulnerable older adults is a hidden epidemic, with a massive number of invisible victims. Healthcare professionals are in a unique position to recognize and report this abuse in order to protect their patients, and in some states, they are mandated by law to do so.

The Texas Board of Nursing (BON) requires all RNs, LPNs, and APRNs to take a CEU course on Older Adult and Geriatric Care for 2 contact hours each licensing cycle, which also covers abuse.

The abuse of dependent older adults by family members in particular dates back to ancient times. It often remained a private matter, hidden from public view. Mistreatment of the elderly and dependent older adults was first described in modern scientific literature under the term granny battering (Burston, 1975). Today, this sort of abuse is considered a social welfare issue as well as a public health and criminal justice concern. 

The sadness that accompanies the abuse of older adults and dependent adults is incomprehensible and overwhelming at times. Disabled, dependent, and older adults are sometimes abused by the very people entrusted to help them, including professional caregivers (e.g., personal assistants, health technicians, home health aides, nursing assistants) and family members. These types of abuse are known to occur anywhere: at home, in healthcare facilities, and within the community at large.

When abuse does occur, the dependent or elder adult’s personal health, safety, and emotional well-being becomes eroded and at risk, along with their ability to engage in daily life activities. 

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DEFINITIONS

Following are general definitions related to abuse of elder (older) adults, dependent adults, and vulnerable adults. State laws provide specific definitions relating to such abuse, and all healthcare professionals should familiarize themselves with the laws in their respective states.

Dependent adult typically means a person 18 years of age or older who is wholly or partially dependent upon one or more other persons for emotional and/or physical care and support. Dependent adults have not established financial independence and would be in danger if care or support is stopped (US Legal, 2020).

Vulnerable adult typically describes persons 18 years of age or older who, because of physical and/or mental health disorders, impaired cognition, advanced age, chronic use of drugs or alcohol, or confinement, are unable to meet their own needs or to seek help without assistance (Sitkans Against Family Violence, n.d.).

Vulnerable adult abuse generally refers to any knowing, intentional, or negligent act by a caregiver or any other person that leads to harm, or a serious risk of harm, to a vulnerable adult (Sitkans Against Family Violence, n.d.). 

Elder (older adult) abuse refers to an intentional act, or failure to act, that causes harm or risk of harm to an older adult. According to the Centers for Disease Control and Prevention (CDC, 2020) an older adult is a person age 60 or older.

Caretaker is a person or institution that has responsibility for the care of an adult because of a family relationship or who has assumed the responsibility for the care of the adult voluntarily or by contract or agreement (Law Insider, 2020). 

Disability, according to the Americans with Disabilities Act (ADA), is “a physical or mental impairment that substantially limits one or more major life activity.” Persons with a disability include those who have a record of such impairment even if they do not currently have a disability. The ADA also makes it unlawful to discriminate against someone because of their association with a person with a disability (ADA National Network, 2020). 

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EPIDEMIOLOGY

Dependent adult abuse and older adult abuse are two of the largest underrecognized and underreported problems within the United States. About 1 in 10 Americans aged 60 and older have experienced some form of elder abuse. However, it is estimated that only 1 in 14 cases of abuse are reported to authorities (NCOA, 2020).

Most states have penalties for abusers of older and dependent adults. Throughout the United States, members of law enforcement and prosecutors are trained on elder abuse and ways to use criminal and civil laws to bring abusers to justice (NCOA, 2020). 

Certain data that have been collected by independent researchers illustrates a troubling reality:

• Dependent adults who experience abuse had a 300% greater risk of death when compared to those who had not been abused.
• In nearly 60% of elder abuse and neglect incidents, the perpetrator was a family member; two thirds of perpetrators are adult children or spouses of those who have been abused.
• Financial abuse and fraud costs for older Americans are estimated at over $36.5 billion annually.
• Roughly 50% of older individuals with dementia are abused or neglected by caregivers.

(NCOA, 2020)

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Care Facilities

Data on the extent of dependent adult abuse in institutions, nursing homes, and other care facilities are scarce, however, research and surveys suggest high rates of abuse in such facilities, when proper Elder Care is not provided.

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ABUSE IN CARE FACILITIES

Nursing home abuse is described by the Nursing Home Abuse Center (NHAC) as any type of harm that comes to older adults in long-term care facilities, including physical or emotional injuries, sexual assault, financial exploitation, or other types of abuse.

The NHAC has compiled the following data regarding abuse in nursing homes:

• Between 2017 and 2018, 1 in 6 adults 60 years of age or older suffered some type of abuse while in a community setting.
• 2 in 3 nursing home staff members reported that they abused nursing home residents over the past year.
• Almost 1 out of 3 nursing homes in the United States have been issued citations for abuse.
• Nursing home abuse is significantly underreported.

(NHAC, 2020a)

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Abuse Statistics among Individuals with Disabilities

Research that focuses on abuse of people with disabilities is limited. Unfortunately, there is no definitive research that details how many people with disabilities experience abuse. The research findings that are available suggest that people with disabilities are one of the most harmed groups in the United States.

Available research suggests that people with disabilities are:

• 3 times more likely to experience violent victimization as adolescents and adults
• 3 times more likely to experience rape, sexual assault, aggravated assault, and robbery
• 3 times more likely to be sexually abused as children
• 1.5 times more likely to experience repeated abuse or neglect as children

(CVS, 2020)

There are a number of factors that increase the risk of abuse in people with disabilities. Groups at higher risk include:

• Women with disabilities
• People with cognitive or developmental disabilities
• People with psychiatric disabilities
• People with multiple disabilities

(CVS, 2020)

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WHAT ARE THE 7 TYPES OF ELDER ABUSE?

Dependent adult and elder abuse fall into several categories, all resulting from the willful, negligent acts or omissions, including misconduct, gross negligence, or reckless acts, of a caretaker:

1. Physical abuse
2. Sexual abuse
3. Emotional/psychological abuse
4. Financial abuse
5. Neglect (also referred to as deprivation or denial of critical care)
6. Self-neglect
7. Abandonment

Following are general descriptions of these categories. Individual states provide specific descriptions for what constitutes dependent adult abuse and elder abuse in their jurisdictions, and healthcare professionals should familiarize themselves with the laws in their state.

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What Constitutes Physical Abuse?

Physical abuse is described as the use of physical force that may result in bodily injury, physical pain, functional impairment, or death. Physical abuse may include, but is not limited to, acts of violence such as striking (with or without an object), hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching, and burning. In addition, inappropriate use of drugs and physical restraints, force-feeding, locking the older adult in a room, and physical punishment of any kind are also examples of physical abuse (CDC, 2020; NIH, 2020).

It is important to differentiate between injuries due to accidents and physical abuse. The following injury patterns can help to differentiate between the two:

• Persons who are abused often have head or neck injuries without visible harm to other parts of the body. Neck injuries are suspicious because the neck is often protected by the head or face during an accidental fall.
• Injuries such as scrapes or injuries below the waist are more likely to be due to accidents. 
• Spiral fractures in adults may indicate abuse. Such fractures may be due to violent twisting of the arm.
• Injuries that cause specific patterns are often indicative of abuse. Examples of such patterns include round burns that may be due to a cigarette or bruises in the shape of a belt buckle or handprint.

(JEMS, 2020)

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What Constitutes Sexual Abuse?

Sexual abuse is defined as nonconsensual sexual contact of any kind with an elderly or dependent adult. Sexual contact with any person incapable of giving consent is also considered sexual abuse. It includes, but is not limited to, unwanted touching; all types of sexual assault or battery, such as rape, sodomy; coerced nudity; sexually explicit photographing; and forced viewing of sexually explicit images (NHAC, 2020b).

Sexual abuse is the least common type of abuse, but it is also the least reported type of abuse compared to all other types of abuse. In nursing homes, there have been over 20,000 complaints of sexual abuse over the past 20 years. Female residents and residents with dementia are at a higher risk of sexual abuse compared to other residents (NHAJ, 2020).

Signs of sexual abuse include:

• Bleeding from the anus or genitals
• Bruising on the inner thighs or genitals
• New sexually transmitted disease
• Pain of the anus or genitals
• Panic attacks
• Pelvic injuries
• Problems walking or sitting
• Social or emotional withdrawal
• Torn, bloody, or stained underwear

(NHAC, 2020b)

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What Constitutes Emotional/Psychological Abuse?

Emotional or psychological abuse is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts. Emotional/psychological abuse includes but is not limited to verbal assaults, insults, threats, intimidation, isolation, humiliation, name calling, terrorizing, and harassment. In addition, treating an older person like an infant; isolating an elderly person from his/her family, friends, or regular activities; giving an older person the “silent treatment”; and enforced social isolation are examples of emotional/psychological abuse (NHAC, 2020b).

Signs of emotional and psychological abuse include:

• Appearing depressed or withdrawn
• Appearing frightened 
• Attempting to hurt others
• Avoiding eye contact
• Changes in sleeping or eating patterns
• Isolation from friends and family
• Low self-esteem
• Mood swings

(NHAC, 2020b)

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What Constitutes Material/Financial Exploitation?

Financial abuse of the older adult is the illegal, unauthorized, or improper use of the older adult’s resources by someone the adult trusts. Some warning signs of material/financial abuse include:

• A pattern of missing belongings
• Older adults who do not know about or understand their finances
• Someone other than the older adult showing unusual interest in their finances
• Unexplained withdrawals from bank accounts
• Evidence of unpaid bills 

(NHAC, 2020b)

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What Constitutes Neglect?

Neglect is failure of a caregiver to protect an older adult from harm or failure to provide items of basic necessity, such as:

• Food
• Shelter
• Clothing
• Supervision
• Medicine
• Physical or mental healthcare
• Other care necessary to maintain that individual’s life or health

Neglect is the most common type of older adult abuse. Evidence of neglect includes:

• Malnutrition
• Dehydration
• Evidence that medicine is not being taken (e.g., blood pressure is too high even though the individual is supposed to be taking antihypertensive medication)
• Clothing that is inadequate for the weather
• Dirty clothing
• Lack of hygiene evidenced by body odor, overt soiling, smell of urine or feces, etc.

(NHAC, 2020b)

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What Constitutes Self-Neglect?

Self-neglect means situations in which the neglect is the result of the acts or omissions of the older or dependent adult themself. This may take the form of the individual refusing care or being unable to provide for their own care, resulting in a threat to their health or safety.

Evidence of self-neglect includes an individual’s refusal or inability to properly:

• Maintain adequate nutrition or hydration
• Dress themself
• Maintain basic hygiene
• Take medicine
• Manage finances

Signs of self-neglect include:

• Poor hygiene
• Malnutrition
• Dehydration
• Unpaid bills
• Unclean or unsafe home

(NHAC, 2020b)

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What Constitutes Abandonment?

Abandonment occurs when someone who is responsible for the care and welfare of an older adult deliberately deserts them. Persons who are abandoned may be left at such places as a hospital, nursing home, or shopping center. The older adult is frightened and may be confused, lost, or depressed. There may be evidence of malnourishment or poor hygiene (NHAC, 2020b).

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RECOGNIZING ELDER ABUSE AND DEPENDENT ADULT ABUSE

Healthcare professionals should be aware of possible indicators of abuse when caring for adults who may be victims of elder abuse or dependent adult abuse. This abuse can be recognized by many indicators, both among those adults who are victims of such abuse as well as among their abusers. It is important to be aware, however, that signs and symptoms of adult abuse vary according to the type of abuse and that the indicators described below do not always indicate abuse. 

The complexity of cases of abuse makes it difficult to establish assessment criteria to meet profiles of signs and symptoms of victims. There have been a succession of tools—such as the EASI (Elder Abuse Suspicion Index)—introduced and used with some success (McGill University, 2020). (See “Resources” at the end of this article.)

Common recommendations described within the literature for abuse assessment with dependent adults include:

• Separate the dependent adult from the caregiver when carrying out an assessment.
• Pay special attention to the physical and psychological aspects of the assessment.
• Be aware that physically abused older adults may have large bruises and will, if able to communicate, identify the cause of injury.
  • Bruises will most likely occur on the face, lateral aspects of the right arm, and the posterior torso (i.e., back, chest, lumbar, and gluteal regions).
  • Bruises may be in various stages of healing from frequent falls, fractures, dislocations, burns, and human bite marks.

(Boltz et al., 2020)

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Victim Indicators

A detailed summary of possible victim indicators of dependent adult or elder abuse are described below, grouped into the categories of physical, behavioral/psychological, environmental, and financial. This list is not all-inclusive and expands on indicators mentioned above (Boltz et al., 2020; CDC, 2020; NHAC, 2020b). 

Substance use and abuse affect the older population as well as younger adults. Older adults should also be assessed for substance use issues.

WHAT ARE POSSIBLE PHYSICAL SIGNS OF ELDER ABUSE?

• Lack of medical care
• Lack of personal cleanliness and grooming, body odors
• Swollen eyes or ankles 
• Decayed teeth or no teeth
• Bites, fleas, sores, lesions, lacerations
• Injuries in various stages of healing and incompatible with explanation
• Bruises, broken bones, or burns
• Untreated pressure injuries
• Signs of confinement (i.e., tied to furniture, locked in a room, etc.)
• Obesity, malnourishment, or dehydration
• Broken glasses (frames or lenses)
• Drunk, overly medicated, or under-medicated
• Lying in urine, feces, old food
• Petechiae (small, purplish, hemorrhagic spots on the skin) from strangling, which can be found anywhere along the path of injury, such as on the eyelids, in the lower eyelid, on the scalp, and over the ear canals, nose, face, and/or mouth
• Dislocated joints (especially the shoulder from being grabbed)

POSSIBLE BEHAVIORAL AND PSYCHOLOGICAL INDICATORS

Not dressing appropriately for the weather conditions

• Wearing all of one’s clothing at once
• Living on the street (homeless)
• Intentional physical self-abuse, suicidal statements
• Refusing needed medical attention
• Refusing to take medications
• Not following medication directions
• Threatening or attacking others physically or verbally
• Refusing to open the door to a visitor
• Spending the day in total darkness
• Denying obvious problems (i.e., medical condition, etc.)
• Exhibiting increased depression, anxiety, or hostility
• Being withdrawn, reclusive, suspicious, timid, unresponsive
• Refusing to discuss the situation
• Expressing unjustified pride in self-sufficiency
• Disoriented as to place and time
• Exhibiting diminished mental capacity (i.e., dementia)
• Longing for death, with vague health complaints

POSSIBLE ENVIRONMENTAL INDICATORS

• No food in the house or rotten/infested food
• Lack of proper food storage
• Clothes extremely dirty or uncared for
• Utilities cut off or lack of heat in winter
• Lack of water or contaminated water
• Doors or windows made out of cardboard
• Unvented gas heaters, chimney in poor repair
• Gross accumulation of garbage, papers, and clutter
• Large number of pets with no apparent means of care

POSSIBLE FINANCIAL INDICATORS

• Sudden changes in bank account practices
• Unexplained withdrawal of a large sum of money
• Adding names on a bank signature card
• Unapproved withdrawal of funds using an ATM
• Sudden changes in a will or other financial documents
• Unexplained missing funds or valuables
• Unpaid bills despite having enough money
• Forged signature for financial transactions or for the titles of property
• Sudden appearance of previously uninvolved relatives claiming rights to a person’s affairs and possessions
• Unexplained sudden transfer of assets
• No knowledge of one’s own finances
• Caretaker overly interested in finances of the dependent adult
• Isolation of the dependent adult
• Caregiver refusing to allow visitors (socialization) to see the dependent adult alone
• Loss of personal belongings such as art, silverware, jewelry, or other valuables

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Perpetrator Characteristics

Characteristics of the perpetrators of older adult abuse include:

• History of, or current existence of, depression or other mental health disorders
• Stress of providing care to the older adult
• Lack of support from other possible caregivers
• Perception that taking care of the older adult is too much of a burden
• Abusing alcohol or other drugs
• Being socially isolated due to the demands of caregiving
• History of domestic violence in the home
• Being abused by the older adult in the past
• Financial difficulties because of having to care for the elder

(Help Guide, 2019; Meiner & Yeager, 2019)

CHARACTERISTICS AND RISK FACTORS OF ABUSERS WORKING IN A FACILITY SETTING

• Frustration if the older adult has been physically or verbally combative toward caregivers
• Not perceiving certain behaviors as abusive
• Being an unwilling or inexperienced caregiver
• Having a lack of training regarding caring for older adults
• Being under financial stress/inadequate wages
• Having substance abuse problems
• Feeling job dissatisfaction, personal stress, burnout
• Having negative attitudes toward dependent older adults
• Working in a poorly run facility

(Meiner & Yeager, 2019; NHAC, 2020c)

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HOW TO REPORT SUSPECTED ABUSE

All states have a mandatory reporting statute for elder abuse, although statutes vary as to the following areas:

• Who is required to report abuse or suspected abuse (“mandated reporters”)
• What activities constitute or require reporting
• Whether or not the victim lacks capacity
• Whether or not the victim resides at home or in an assisted living facility or nursing home

(For information on locating each state’s elder abuse statutes, see “Resources” at the end of this blog.)

Dependent adult abuse and elder abuse laws provide for evaluations and assessments of alleged abused dependent adults and elders. These laws seek to provide services and make referrals to assist abused adults to acquire a safe living arrangement. Adult Protective Service agencies are available in most jurisdictions. 

The primary purpose of the reporting process is to obtain available and pertinent information regarding the allegation of abuse. The ability of the reporter to gather this information is critical to the evaluation and assessment process and is often the first step taken to initiate safeguards for the dependent adult at risk. The intent of reporting laws is to accept and process valid reports while not infringing on an adult’s right to privacy. 

A thorough intake will provide:

• Protection for the dependent adult
• Necessary information for the assigned Adult Protective Services worker
• Information and referral

All allegations of abuse must be taken seriously whether they come from the patient, family, healthcare professional, neighbor, friend, or other service provider. Concerns must be reported to those responsible for assessment and followed up by inquiries about the nature and circumstances of the allegation.

Who Must Report Abuse?

MANDATED REPORTERS

All states have laws designating certain professionals as mandated reporters of dependent adult abuse (Meiner & Yeager, 2019; Phelan, 2018). By law, many organizations and individuals who are responsible for the care or custody of the elderly or dependent adults are required and mandated to report situations of abuse. Mandated reporters may include, but are not limited to, the following: 

• Healthcare professionals
• Care custodians
• Employees of Adult Protective Services agencies
• Employees of financial institutions
• Law enforcement officers
• Clergy members

PERMISSIVE REPORTERS

Any person who believes a dependent adult has suffered some form of abuse may report the suspected abuse to the local Adult Protective Services (or equivalent governmental agency) or to law enforcement. This is referred to as permissive reporting. For example, a local shop owner may voluntarily report suspected financial exploitation of a dependent adult, or a neighbor may report suspected self-neglect of an older adult.

It is important to note that mandated reporters may also report suspected abuse outside the scope of their professional practice, as permissive reporters (Geiderman & Marco, 2020).

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KEY CONCEPTS FOR NURSE MANDATED REPORTERS

The registered nurse is contextually involved in the dynamics of dependent adult abuse merely by the professional responsibility as a mandated reporter and an advocate for patients. Some of the key concepts involved within the profession of nursing include:

• Nurses must maintain updated knowledge of signs and symptoms of suspected dependent adult abuse.
• Nurses must maintain updated knowledge of laws pertaining to dependent adult abuse.
• Nurses have a legal responsibility to report suspected abuse of dependent adults.
• Nurses must be vigilant and sensitive to the potential for abuse in the frail and vulnerable adult.
• Nurses must assess subtle signs of abuse.
• Nurses must proceed with a full assessment, including determination of safety of the victim. 
• Nurses must participate in the prevention and early recognition of potential abuse. 

(Registered Nursing, 2020; Touhy & Jett, 2016)

These same concepts can be applied by all mandated reporters.

What Is the Abuse Reporting Process?

IMMEDIATE PROTECTION CONTEXT

If urgent protection is believed necessary for a dependent adult, a reporter should immediately call 911 or law enforcement. The law enforcement personnel receiving this information will then report to the designated state agency (Registered Nursing, 2020).

COMMUNITY CONTEXT

Mandated reporters who suspect elder abuse or dependent adult abuse within the community generally must immediately make an oral report via an Adult Protective Services or elder abuse hotline or an online reporting system. Reporters who are a staff member or employee of a care facility must generally also notify the person in charge at the facility. A written report is usually required by the mandated reporter within a specified timeframe after the oral report (Samuels, 2020).

(See also “Resources” at the end of this blog for a sample report form.)

HEALTHCARE FACILITY CONTEXT

If abuse occurs in afacility, the reporter must immediately notify the person in charge, who must then notify the state’s Long-Term Care Ombudsman Program within a designated timeframe (ACL, 2018). This program is established in all states under the Older Americans Act, which is administered by the Administration on Aging. Local ombudsmen work with and on behalf of residents in hundreds of communities throughout the country. 

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SELF-REPORTING ABUSE

Some victims of abuse may be able to self-report if they are provided with an opportunity to do so. Unfortunately, however, the rate of self-reporting abuse is low due to fear, futility, and/or embarrassment. Healthcare professionals can suggest the following actions to those who wish to self-report abuse:

• Call 911 if you are in immediate danger.
• Speak up; if unhappy with your care, tell someone you know and trust; ask that person to report the abuse, neglect, or substandard care to your state’s abuse hotline or Long-Term Care Ombudsman’s office; or make the call yourself.
• Report to the local Adult Protective Services agency.

(Yon et al., 2019)

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PROTECTIVE INTERVENTIONS 

If older adult or dependent adult abuse is suspected, the healthcare professional should intervene as follows:

• Separate the adult from the suspected abuser for assessment
• Summon law enforcement if the elder is in immediate danger
• If there is no immediate danger, report the suspected abuse according to state laws and organizational policies and procedures concerning the reporting of older adult or dependent adult abuse
• Conduct a thorough screening and physical and mental health assessment

(Phelan, 2018)

Following a report, the local or state Adult Protective Services intervenes to conduct an investigation and provide services to abused, neglected, or exploited older and dependent adults. If the dependent adult is unable to be protected by Adult Protective Services, the court may intervene and take actions such as:

• Authorize or order the provision of protective services
• Prohibit a caregiver from interfering with the provision of protective services to the dependent adult
• Appoint conservatorship to an individual to assume responsibility for custody and control of the victim’s property
• Assign guardianship, granting another individual the authority to make personal and healthcare decisions for a dependent who is incapacitated
• Assign power of attorney to another individual to act on the dependent’s behalf regarding issues such as healthcare or financial management 

(IAC, 2020a)

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RIGHT TO SELF DETERMINATION

All adults have a right to self-determination. This means that the dependent adult can refuse services unless a court determines that the person is not competent to make decisions or is threatening his or her own life or that of others (EAPU, n.d.). 

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CONCLUSION

Healthcare professionals have an ethical, moral, and legal responsibility to understand and address the complexities of older adult and dependent adult abuse. Community service agencies, care facilities, clinics, and other healthcare centers are ideal places to embed the frameworks presented here for assessing and identifying vulnerable adults who are at risk for such abuse.

Nurses and other professionals serve as advocates for all those in their care, including the most vulnerable. It is through education and interdisciplinary teamwork that mandated reporters can provide a compassionate and quick response to suspected abuse in order to protect the safety and well-being of the dependent adults within our communities and facilities.

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RESOURCES

Adult Protective Services map (NAPSA)

Elder abuse and elder financial exploitation statutes

Elder Abuse Suspicion Index (EASI)

Elder Locator Helpline (to self-report abuse): 1-800-677-1116

How to Find a Long-Term Care Ombudsman Program

National Adult Protective Services Association

National Center on Elder Abuse

Suspected dependent adult abuse report (sample form) (Iowa Department of Human Services)

REFERENCES

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Administration for Community Living (ACL). (2018). Long-term care ombudsman program. https://acl.gov/programs/protecting-rights-and-preventing-abuse/long-term-care-ombudsman-program

Boltz M, Capezuti E, Fulmer T, & Zwicker D. 2020). Evidence-based geriatric nursing protocols for best practices (6th ed.). Springer Publishing Co.

Burston G. (1975). Letter: granny-battering. British Medical Journal, 3, 592. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1674523/pdf/brmedj01463-0050b.pdf

Center on Victimization and Safety (CVS). (2020). Violence against people with disabilities occurs at alarming rates. https://www.endabusepwd.org/problem/alarming-rates/

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Elder Abuse Prevention Unit (EAPU). (n.d.). Rights of older people. http://www.eapu.com.au/uploads/EAPU_general_resources/Rights_of_older_people-EAPU.pdf 

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Help Guide. (2019). Elder abuse and neglect. https://www.helpguide.org/articles/abuse/elder-abuse-and-neglect.htm

Iowa Administrative Code (IAC). (2020a). Chapter 235B: dependent adult abuse services—information registry. https://www.legis.iowa.gov/docs/ico/chapter/235B.pdf

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Law Insider. (2020). Definition of caretaker. https://www.lawinsider.com/dictionary/caretaker

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Sitkans Against Family Violence. (n.d.). What is vulnerable adult abuse? https://www.safv.org/vulnerable-adult-abuse

Touhy T & Jett K. (2016). Common legal and ethical issues. Ch. 31 in Ebersole & Hess, Toward healthy aging: human needs and nursing response. Elsevier. 

US Legal. (2020). Dependent adult law and legal definition. https://definitions.uslegal.com/d/dependent-adult/

Yon Y, Mikton C, Gassoumis ZD, & Wilber KH. (2019). The prevalence of self-reported elder abuse among older women in community settings: a systematic review and meta-analysis. Trauma Violence Abuse, 20(2), 245–59.