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Abuse and Neglect in Older Men
Charles P
. Mouton MD, MS
a
, Melissa Talamantes MA
a
, Robert W.
Parker MD
a
, David V. Espino MD
a
& Toni P
. Miles MD, PhD
a
a
Department of Community and Family Medicine , University of
Texas Health Science Center at San Antonio , 7703 Floyd Curl Drive,
San Antonio, TX, 78229-7795, USA
Published online: 23 Sep 2008.
To cite this article: Charles P
. Mouton MD, MS , Melissa Talamantes MA , Robert W. Parker MD , David
V. Espino MD & Toni P
. Miles MD, PhD (2002) Abuse and Neglect in Older Men, Clinical Gerontologist,
24:3-4, 15-26, DOI: 10.1300/ J018v24n03_03
To link to this article: http:/ / dx.doi.org/ 10.1300/ J018v24n03_03
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2. Abuse and Neglect in Older Men
Charles P. Mouton, MD, MS
Melissa Talamantes, MA
Robert W. Parker, MD
David V. Espino, MD
Toni P. Miles, MD, PhD
ABSTRACT. Elder abuse and mistreatment is a growing national con-
cern. While victims and perpetrators are both men and women, much of
the focus has been on women. Reports of the gender distribution of elder
mistreatment conflict with some studies citing a greater prevalence in
males and others showing a female predominance. The article summa-
rizes the research on elder mistreatment, emphasizing the gender distri-
bution. Older men are more likely to be victims of neglect, particularly
abandonment. We use case vignettes to illustrate these major research
findings. We also present data from a series of focus group interviews
that included older men. The comments of the men about elder mistreat-
ment were analyzed and are presented in this article. Through these find-
ings we show that more research is needed to understand the similarities
and differences between male and female victims of elder abuse and mis-
treatment. [Article copies available for a fee from The Haworth Document Deliv-
ery Service: 1-800-HAWORTH. E-mail address: <getinfo@haworthpressinc.com>
Website: <http://www.HaworthPress.com> © 2001 by The Haworth Press, Inc. All
rights reserved.]
KEYWORDS. Aged, elder abuse, male
Charles P. Mouton, Melissa Talamantes, Robert W. Parker, David V. Espino and
Toni P. Miles are affiliated with the Department of Community and Family Medicine,
University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San
Antonio, TX 78229-7795.
Dr. Mouton is supported by NIA grant K08-AG-00822.
Clinical Gerontologist, Vol. 24(3/4) 2001
http://www.haworthpressinc.com/store/product.asp?sku=J018
 2001 by The Haworth Press, Inc. All rights reserved. 15
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3. INTRODUCTION
With adults in the United States living longer and more adults living into
older ages, elder mistreatment (EM) is becoming a growing national concern.
EM has been defined as one of several forms of domestic violence which in-
cludes child abuse and spousal abuse. The National Center on Elder Abuse
(NCEA) defines five types of elder mistreatment:
1. physical abuse, referring to the infliction of physical pain, injury, or
physical coercion, with at least one act of violence including beating,
slapping, hitting, burning, cutting, physical restraint use, or intentional
over-medication,
2. psychological abuse, including the infliction of mental anguish through
yelling, screaming, threatening, humiliation, infantilization, or provoca-
tion of intentional fear,
3. sexual abuse, defined as molestation or forced sexual actions,
4. financial/material exploitation, defined as the illegal exploitation of
monetary or material assets,
5. neglect, including the failure of a caregiver to meet care obligations
(NCEA).
Victims come from all ethnicities and socioeconomic backgrounds. Perpetra-
tors can be spouses, children, other relatives, professional caregivers or strang-
ers.
As for the gender distribution of EM, the data has been conflicting. Clas-
sically women are thought to experience elder abuse more than men (Tatara,
1993; Paveza, 1992). However, in a large population-based study, the per ca-
pita rate of male victims of EM was nearly double that of female victims
(Pillemer, 1988). Part of the gender discrepancy may be found in how cases of
EM are defined, how the perception of what constitutes abuse influences de-
tection, and how men are perceived in American culture, all of which lead to
under-reporting. In this article, we will review the national data on EM and
contrast the gender differences using a series of case reports and focus group
discussions.
Nationally, an estimated 3-6% adults over 65 years of age have been vic-
tims of EM (Lachs, 1998; AMA). According to the National Elder Abuse Inci-
dence Study (NEAIS), approximately 450,000 elderly persons in domestic
settings were abused and/or neglected during 1996 (NEAIS). Adding the el-
derly who experienced self-neglect, the number increases to approximately
551,000. In studies of long term care, twenty-three percent of elderly either
have been or still are victims of abuse (Homer, 1990).
Our oldest elders–those 80 years and over–are abused and neglected at two
to three times their proportion of the elderly population. In almost 90% of the el-
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4. der abuse and neglect incidents with a known perpetrator, the perpetrator is a
family member, and two-thirds of the perpetrators are adult children or
spouses. Victims of self-neglect are usually depressed, confused, or extremely
frail.
Several studies have suggested that female elders are abused at a higher rate
than males, after accounting for their larger proportion in the aging population.
The impression that women represent the majority of EM victims is an exten-
sion of the findings on spousal abuse. In spousal abuse, it is estimated that an-
nually 3 to 4 million women over 18 years old are new victims of domestic
violence (Barrier, 1998). Additionally 14%-25% of women seen at ambulatory
medical clinics and 20% of women seen in the emergency room have been
physically abused (Kahn, 1993). Violence seems to peak for women during
their childbearing years.
Among older women, female elders remain more likely to be the victims of
all categories of abuse except abandonment. Females made up about 57.6% of
the total national elderly population but in the NEAIS, women were the vic-
tims in 76.3% of emotional/psychological abuse, 71.4% of physical abuse,
63.0% of financial/material exploitation, and 60.0% of neglect, the most fre-
quent type of maltreatment. The majority of the victims of abandonment were
men (62.2%) while males made up 42.4% of the overall elderly population.
In the NEAIS overall, men were the perpetrators of abuse and neglect
52.5% of the time. Of the substantiated cases of abuse and neglect, males were
the most frequent perpetrators for abandonment (83.4%), physical abuse
(62.6%), emotional abuse (60.1%) and financial/material exploitation (59.0%).
Only in cases of neglect were women slightly more frequent (52.4%) perpetra-
tors than men. About three-fourths (77.4%) of domestic elder abuse perpetra-
tors in 1996 were white, and less than one-fifth (17.9%) were black. Other
minority groups accounted for only 2% of the perpetrators, while the race of
2.7% of perpetrators was unknown.
The percentages of females over 58% in any category may indicate that they
are over-represented. Neglect was the most frequent type of maltreatment, af-
fecting 48.7% of all victims of elder abuse. More than one-half (60.0%) of the
victims of neglect were female elders, while the remaining neglect victims
(40.0%) were male elders. Next, emotional/psychological abuse was the sec-
ond most frequent type, affecting 35.4% of the victims. Data show that about
three-quarters (76.3%) of the victims of this type of maltreatment were female
elders, while the remaining 23.7% were male elders. Emotional abuse is the
category of abuse in which women are most heavily over-represented com-
pared to their portion of the total elderly population (76.3% vs. 57.6%).
Financial/material exploitation was the third most frequent type involving
30.2% of the victims. Female elders were victims of financial/material exploi-
Mouton et al. 17
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5. tation somewhat more than their proportion of the elder population (63.0% vs.
57.6%), while male elders were victims of exploitation 37.0% of the time.
Physical abuse was the fourth most frequent type of elder maltreatment, ac-
counting for 25.6% of all victims. Over two-thirds (71.4%) of the victims of
physical abuse were female elders, while the remaining one-third (28.6%)
were male elders. Physical abuse is the second category in which women are
most over-represented as victims compared to overall population statistics
(71.4 vs. 57.6%). Abandonment only accounted for 3.6% of all victims of
abuse, but men were disproportionally represented compared with their pro-
portion of the elderly population (62.2 vs. 42.4%). Also, in a large popula-
tion-based study of EM which included neglect, older males were 52% of
those experiencing mistreatment. Other studies of EM reports do not show the
same male predominance.
The direct medical costs associated with EM injuries have been estimated to
add over 5.3 billion dollars to the nation’s annual health expenditures (Ham-
burger, 1992). EM is also associated with premature mortality in older adults.
Victims of EM had poorer survival than non-victims (9% vs 40%) with a risk
of death that is 3 times higher than non-victims (odds ratio for death 3.1)
CASE VIGNETTES
Case #1
Mr. TJ is an 82-year-old, non-Hispanic white male with mild hyperten-
sion who presents for evaluation of memory loss to the University Geri-
atrics Clinic with his son. Apparently, Mr. TJ had been an accountant
managing his own private firm until about two years ago when his
ex-wife discovered that he had been losing clients and the household
bills were going unpaid. In addition, he began to deny any problems or
bizarre behavior. His wife divorced him one year prior because of his bi-
zarre behavior. He subsequently lost the house due to foreclosure and
was on the street for about 8-10 months. TJ’s son located him and de-
cided to allow TJ to live with him. The son has seen the behavior and is
concerned about his memory. Apparently, TJ leaves early in the morn-
ing, stays out all day and returns home without knowing where he has
been. He has refused to shower, wear clean clothes, or keep his room
tidy. During the conversation, Mr. TJ and his son get in to verbal argu-
ment and his son indicates that “I just can’t take it anymore.”
With the “graying of America,” elder mistreatment is a growing national
problem with the potential of becoming an epidemic, especially among the
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6. frail and dependent elderly. There are currently 35,322,000 US adults 65 years
of age or older and it is estimated that there will be over 92 million by 2050.
Men currently make up 41% of this population. Over 85 years of age, the male
proportion drops to 29% (Kamarow, 1999).
As the populations ages, more older adults will be at risk for Alzheimer’s
disease. As the cognitive function of these Alzheimer’s patients deteriorates
and they become more dependent, their care becomes more demanding. Mr.
TJ’s son expressed some of the stress associated with this increase in caregiver
burden. Significant caregiver stress has been postulated as one model for EM.
As with Mr. TJ, approximately six out of ten substantiated elder abuse vic-
tims experienced some degree of confusion (31.6% were very confused, or
disoriented, and 27.9% were sometimes confused). This represents a high de-
gree of potential mental impairment among this group of abused elders, partic-
ularly when compared with the estimated 10% of the total national elderly
population suffering with some form of dementia. Many of these older adults
will be at risk for EM.
In evaluating Mr. TJ, discovering risk factors for EM are important. Victim
risk factors for EM include older age, nonwhite race, poverty, functional dis-
ability, and cognitive decline (Lachs, 1997). Other victim risk factors include
depression, living with another person, and lack of a confidant (Kleinschmidt,
1997; Pillemer, 1988). These risk factors in combination with caregiver stress
puts Mr. TJ at greater risk for EM.
Case #2
Mr. AG is a 78-year-old African American male with severe osteoarthritis
of both knees, hypertension, and congestive heart failure (NYHC stage
3). He is functionally impaired on a few Activities of Daily Living
(ADLs), namely bathing, dressing, and transferring. He is also impaired
on all the Instrumental Activities of Daily Living. He is cared by his wife
of 48 years, Ms. MG. Recently Ms. MG was found to have a large mid
epigastric mass subsequent determined to be pancreatic cancer. Three
months following the diagnosis of pancreatic cancer, Ms. MG died. Mr.
AG has no children or other family caregivers in the local area and re-
fuses to enter into an assisted living facility. Over the next three weeks,
Mr. AG lost 40 pounds of body weight, refused to eat or take his medica-
tion,wasshortofbreathandappeareddysphoricwithpoorpersonalhygiene.
Elders who are unable to care for themselves are more likely to suffer from
abuse and/or neglect. Approximately one-half (47.9%) of the substantiated in-
cidents of elder abuse involved elderly persons who were not able to care for
themselves, 28.7% were somewhat able to do so, and 22.9% were able to care
Mouton et al. 19
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7. for themselves (NEAIS). As in Mr. AG’s case, national estimates show that
14% of older adults have difficulties with one or more Activities of Daily Living.
For many older males, certain ADLs, such as meal preparation, have been
the purview of their spouses. As with Mr. AG, some older males expect that
such caring will continue for the rest of their lives. If their spouse precedes
them in death, many older males may be left without the necessary skills for in-
dependent living and become at risk for self-neglect. Mr. AG becomes one of
the older males who experience abandonment.
In addition, many older minority males still subscribe to a notion of filial
obligation. They feel the best and often the only person to care for them should
be their wife or daughter. Some older minority men become victims of neglect,
albeit self-inflicted, due to their refusal to allow for non-family caregiving.
Clinicians are often on the frontlines in recognizing self-neglect. Activating a
support network through various community groups to help with EM can im-
prove the chances for a beneficial outcome.
Another factor in Mr. AG’s situation may be depression. About 44% of all
substantiated abused elders were gauged to be depressed at some level, with
about 6% of them severely depressed. This compares with the estimated 15%
of all elders nationally who are depressed at any one time. One-third of sub-
stantiated elder abuse victims (35.4%) displayed no signs of depression.
Case #3
Mr. JG is an 89-year-old wheelchair bound Mexican American male
with a history of multiple cerebrovascular accidents, moderately severe
vascular dementia, left-sided spastic hemiplegia, and hypertension. He
has one son who provides most of the daily care and ADL support. He
has a homemaker for one hour three times a week. During the current of-
fice visit, Mr. JG and his son get into an argument about whether he is
taking his blood pressure medication. After asking Mr. JG’s son to step
outside the examination room, you question Mr. JG about any abuse. He
reveals that his son has shoved him on occasion and is constantly yelling
at him. He does not feel in any danger and is confident that he can pro-
tect himself. When you inform him that you think this is abuse and you
are legally required to report it, Mr. JG begs you not to report his son be-
cause his son already has two felony convictions and is worried that he
might be prosecuted. A third felony conviction would send him to prison
for life.
Beyond the overall problem of EM, mistreatment of older adults from mi-
nority populations is especially acute. In 1996, white elders were 84.0% of the
total elder population, while black elders comprised 8.3%, and Hispanic elders
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8. were 5.1%. Nationally, 16% of EM victims were older minorities, with His-
panic elderly accounting for 5.1% (Otiniano, 1999). While white elders were
the victims in eight out of ten reports for most types of maltreatment, black el-
ders were over-represented in neglect (17.2%), financial/material exploitation
(15.4%), and emotional/psychological abuse (14.1%). Hispanic elders and
those from other racial/ethnic groups were under-represented among victims
in all types of maltreatment. In Texas, Hispanic elders accounted for 20.6% of
cases reported to Adult Protective Services (APS) between 1991 and 1995
(Otiniano, 1999). In Connecticut, non-white elderly were twice as likely to be
reported to APS (Lachs, 1996).
The problem of EM in minority populations is complicated by the fact that
mutually acceptable behavior in relationships differs on the basis of age, cul-
tural, socioeconomic, or socioenvironmental factors. Most legal definitions of
abuse center on the majority population’s experiences and attitudes. Applying
that definition to minority populations surmises that the same conditions exist
within these groups (Moon, 1993; Fulmer, 1987). Moon found that African
Americans, Korean American, and Caucasians responded differently when
asked what constituted elder abuse (Moon, 1993).
FOCUS GROUP INTERVIEWS
In a recent focus group study on elder mistreatment in community-dwelling
elders, we found some interesting comments by men regarding a series of vi-
gnettes depicting stories of EM. These vignettes covered all types of mistreat-
ment defined by the NCEA as well as depicting different types of perpetrators
(male, female, spouse, son, daughter, non-family). The comments were gath-
ered as part of a series of focus group sessions on EM.
Responding to what defines abuse, male interviewees responded that verbal
abuse can be worse than physical violence.
. . . The silence treatment. I think that’s the worse that you can get. . . .
They say “I don’t want to talk to you anymore. . . .”
I had open heart surgery . . . the lady [caregiver] that took me, she cussed
at me. . . . I said to myself, how could she treat me like that. . . .
The lady [is the abuser] ‘cause she is the one who is coming in nagging
at the man all the time.
Responding to a vignette where a husband shoots his wife after finding her
cheating on him, older males responded that the female is the abuser and
seemed to downplay the male’s role in the shooting incident.
Mouton et al. 21
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9. She completely abused her husband right there [referring to his wife’s
infidelity] . . . by having done that on his own bed.
She had already known that he was going to do that . . . She had just
called . . . his bluff.
Responding to a vignette detailing a case of mistreatment where a male pa-
tient refused medication and a caregiver tried to “force feed” him his medicine,
the male interviewees observed that some individuals have the right to refuse
treatment.
. . . if he’s competent, then, by competency he knows the difference be-
tween right and wrong and he can make decisions in relation to himself. . . .
If he says, “I don’t want to. I’m not going to take it,” then you can’t force
it.
Another vignette detailed a case mistreatment where an older male resisted
taking a shower and was forced to take one. On the way back to bed, he was
dropped on the floor. Male interviewees seem to reverse their previous posi-
tion about the right to refuse treatment and are more accepting of forced care.
. . . they [should] tell him, you know, “We’re taking you to the shower,
whether you want to go or not, we’re taking you the shower . . .”
These responses indicated a difference depending on level of cognitive
function of the victim and whether the incident is related to medication or per-
sonal hygiene.
Overall, the men in these focus groups indicate that mistreatment of older
men is characterized by verbal and/or emotional abuse, as well as neglect.
These men also seemed to be more tolerant of physical abuse and the use of
force in matters of personal hygiene. The exception is the case of a competent
older male and his right to refuse treatment.
DISCUSSION
These vignettes include a variety of scenarios but the ones presented in this
manuscript focus on male interviewees’ responses to cases where a male was
perceived to be a victim of mistreatment. In another context, the problem of
abuse and neglect in older males can be viewed as part of the overall problem
of male abuse victims.
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10. Every year, 1,510,455 women and 834,732 men are victims of physical vio-
lence performed by an intimate according to a Nov. 1998 Department of Jus-
tice report on the National Violence Against Women Survey. Thus, every 37.8
seconds, somewhere in America a man is battered. The data also show that
men are more likely to have a knife used on them or to be threatened with a
knife, hit with an object, kicked, bitten or have something thrown at them.
Women are more likely to be beaten up, threatened with a gun, choked, victims
of drowning attempts, have their hair pulled or be pushed, grabbed or shoved
(Tjaden, 1998). If these figures endure as they mature, older males will be at
substantial risk for abuse as they are currently at greater risk of neglect.
More research is needed to better understand the problem of abuse and ne-
glect of older men. This research can be used to develop strategies to prevent
elder abuse and mistreatment and can be applied across the older population.
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