Elder Abuse by Home Care Aides

Your parents are in their 80s or 90s and cannot take care of themselves anymore. They need a caregiver, but you cannot do it yourself. It would help if you got a caregiver, but aside from figuring out how to pay for this, you also worry about the potential risks of abuse.

Elder abuse by home care aides often goes unreported because the victims can no longer speak up or defend themselves. Sometimes, the victims trust the perpetrators and do not believe they are being exploited. Seniors who live alone are particularly vulnerable to risks of abuse, be it financial, physical, sexual, psychological, or neglect.

How to protect them from abuse? Here are the things to check, the signs to detect, and the actions to take when things go wrong.

Types of elder abuse

The most common types are:

• Financial abuse
• Physical abuse
• Sexual abuse
• Psychological or emotional abuse
• Neglect and abandonment

If you are considering hiring a caregiver for your frail loved ones, the first step is to shield them from potential abuse.

How to prevent elder abuse

• Get a genuine caregiver
• Take precautions
• Use value judgment

Get a genuine caregiver

Choosing a genuine caregiver can help you avoid the whole fiasco in the first place. Elder care can be taxing and lonely, so the people willing to do it must have good reasons and strong ethics.

Do:

• Choose one with the appropriate training, a valid state license, and reliable references.
• Thoroughly understand their duties and privileges as outlined in the contract.
• Observe their interaction with your senior. See if it’s a good personality fit.

Don’t:

• Hire a friend of a friend without checking their credentials
• Hire without a proper contract

Doing this already helps filter out the ones that may need to be corrected for this demanding job.

Types of home care aides

Let’s clarify the most common types of home care aides. Their responsibilities include a combination of these tasks.

Daily living tasks:

• Personal care: Eating, bathing, using the toilet, dental tasks, feeding, dressing, walking, medication, laundry, transport to outings and appointments.
• Errands: Shopping, meals, cleaning.

Medical tasks:

• monitor vital signs, infections
• record health patterns and behaviors
• conduct exercises. Offer walking assistance
• set up equipment
• administer meds and injections
• wound care, change dressings
• perform treatments: enemas, douches
• tube feedings
• clean catheters
• keep in close contact with healthcare providers and family

See the table below for a comparison of the commonly hired caregivers.

PCAs and HHAs are the most common home care aides because they are available at relatively affordable rates (about $13 to $18 per hour if hired directly). Their services lean towards domestic help and personal assistance, with some basic medical training.

Hire a PCA if your loved ones need help with daily tasks while their health conditions have stabilized and they take regular medications.

Hire an HHA if your loved ones need daily help with tasks and have unstable conditions that need monitoring. Thanks to their primary medical training, a home health aide is likely the most common choice for seniors aging in place.

The other three – CNAs, LPNs, and RNs – are medical professionals. These nursing jobs are more common in institutions and less common (read ‘affordable’) for seniors living at home.

Hire a CNA if your loved one has debilitating conditions that need regular medical assistance. You may need to hire an extra hand for housekeeping and errands to avoid over-burdening your CNA.

LPNs and RNs are nurses who primarily work in institutions. Hiring them per hour at home usually incurs prohibitive costs. Consider them only when the patient needs specialized care.

Take precautions

Before the caregiver starts working for you, do:

• Secure valuables, financial documents, and essential information.
• Put your loved ones’ phone numbers on the national Do Not Call registry.
• Block all phone numbers except an approved list of callers. Consider cutting off the landlines.
• Block all junk emails from their inbox. Set up a rigorous filter to allow only emails from approved senders.
• Secure your power of attorney if you are their adult children, and keep the paperwork.
• Hire more than one aide, with alternating shifts
• Know your rights and responsibilities as an employer of home care aides.

Once you have hired a caregiver, do:

• Closely monitor bank accounts and phone bills.
• Make unannounced visits. If unable to do so, ask a family friend or a neighbor. Isolated elders are more susceptible to abuse.
• Pay attention to unexplained changes.
• If other healthcare providers are involved, check in with them too.

Yes, this could be a lot if you are also shouldering other commitments. Or, you may have already done some of this. You know it pays off when there is no severe incidence.

Use value judgments

Are you a good judge of character? Your value judgment is crucial in preventing an abuser from entering your senior’s life.

However, do not beat yourself up if abuse happens, despite your best intention. None of us can predict the future, nor can we read minds.

With that said, here are things you could do to reduce the risk of hiring abusive caregivers.

Healthcare training

The more training a person has, the surer you can be that their ethical codes have been tested and proved with years of experience and reliable references.

With that said, professional training is not the only indication of one’s ethics. It also depends on the individuals, their life circumstances, and their moral standards.

For example, qualified nurses have the most capacity to do harm and hide it – a mistake in dosage, whether intentional or unintentional, can cause an emergency, which could be wrongly attributed to failing health rather than human errors.

Personality

A caregiver should be patient, dependable, agreeable, and supportive. They should have stamina, attention to detail, a mild temper, and a genuine willingness to help vulnerable people.

Watch out for caregivers who demonstrate dominance, anger, quick temper, inconsistency, or extreme emotions (too affectionate is as alarming as too cold).

If they do not inspire trust in you for some reason, they may not be the right choice.

Agency or self-hire?

Hiring a caregiver through an agency is substantially more expensive (around $35-$45/hour), but you don’t have to do the paperwork and background checks.

No agency can guarantee 100% that your loved ones will be safe from abuse – the risk factors include how the agency vets their aides or treat their aides.

Hiring a caregiver is cheaper ($13-$18/hour), but you must do all the administrative work. It includes writing and enforcing the contract.

In both cases, read the contract carefully to understand the expected duties and privileges clearly. On your visits, have a list of things to check against this list – make sure the aide performs them. Severe neglect or reduced service can constitute elder abuse.

Hire the right person for the proper needs

Make sure you hire the right person trained to care for the particular needs of your loved ones. Their services will be laid out in the employment contract, which will be helpful later on if abuse occurs. Doing more or less of what they are assigned to do without good reasons is often a sign that something is wrong (though, with no clear evidence, it may not amount to abuse).

For example, hiring a PCA to carry out intensive care for a dementia patient means asking for too much. The PCA isn’t trained for the job nor paid enough. If the PCA agrees to this, it is suspicious. Who would want to do a difficult job above their pay grade at minimum wage?

In this case, the PCA likely has a stronger motive to abuse to compensate for what they see as an unfair arrangement. They can also be opportunists who may take advantage of a vulnerable person.

Be compassionate: what’s a possible motive for abuse?

We could say that a person abuses just because they can. In many cases, this is true.

But thinking so doesn’t help you take proactive measures to prevent it.

Choosing a caregiver asks for more valuable judgment and compassion from you than choosing a hairdresser. The aide will attend to the most intimate needs of your loved ones, after all.

First, why would someone want to sign up for this job?

It’s low paid, has extended hours, few chances of advancement, lacking essential protection such as guarantees against harassment, discrimination, or workplace hazards. People whom do this have a limited chance of getting a job elsewhere, such as immigrants with poor English, criminal histories, or little education.

Another group is those who are starting a career in nursing. Doing this job earns them real-life experiences, which may count towards their professional development.

Second, why would a caregiver turn abusive?

Some caregivers did not start off being abusive or neglectful – they became abusive after long periods of stress. Caregiving is a stressful job in which the caregiver has to constantly pay attention to someone else’s wellbeing, sometimes prioritizing their patients’ wellbeing above their own. Therefore, prevent someone from turning ‘dark’ by giving them enough justified support. Avoid over-burdening them.

Make sure they are fairly compensated, have safe working conditions (as safe as you could make it), and are not forced to do anything more than what they sign up for.

If they have an alcohol or a drug problem, encourage them to seek help for themselves – and maybe consider not hiring them until they get it under control.

Happy and satisfied people tend not to abuse others. Don’t become part of the problem by pushing the reasonable limits of the hired caregivers.

Despite your best effort, abuse may still happen. Here is what to do if it does.

What to do when you suspect elder abuse?

Call the authorities

Call 911 if there is immediate harm to their life, body, or possessions.

In non-emergencies, report to these authorities:

• The local Adult Protection Service (APS)or the police.
• Find your state’s reporting numbers, government agencies, state law, and other resources regarding elder abuse from the National Center on Elder Abuse Listing of State Elder Abuse Hotlines.
• Refer to the Department of Justice for the National Elder Fraud Hotline and Eldercare locator helpline.

Investigate

You may start by asking the seniors about abuse, but be ready for these possible scenarios:

The elder is unaware that it happened 

Gather the suspicious signs (see below).

The elder is confused about how it happened

Ask them the questions in the sections below, but be prepared that they may need help to give clear or accurate answers.

The elder is too scared to report it

It could mean psychological abuse is also involved. Report to the local APS.

The senior believes that the caregiver means no harm or that it’s not that big of a problem.

This is tricky because the elder may not make it easy for you or anyone else to probe into this. Depending on your relationship with the elder, make your judgment about what you can do. If you are their adult children, do you have power of attorney? If you are not, it’s safest to report to the local APS.

The limit to asking your loved ones about abuse is that they may no longer be the best judge of their wellbeing.

In this case, stay with them for a day or two. Closely observe their interactions with the aide. Consider talking to their visitors, friends, neighbors, or other healthcare providers who have met them recently.

Pay close attention to sudden, recent changes to their routine and personality with no reasonable explanations.

Financial abuse

What constitutes financial abuse?

Scams, fraud, and coercion: when a home care aide tricks, scares or forces the senior into:

• giving them money
• making unnecessary purchases
• handing over control of assets and rights to property ownership.

Improper use: when a home care aide uses the senior’s money, property, or valuable resources without proper consent.

Older adults lost over $1 billion to scammers in 2021 alone, as reported by the Federal Trade Commission (FTC).

Financial abuse is the hardest to deal with when the senior trusts their aide and allows them to manage their money. It is especially suspicious when money management is not part of their duties. Even when it is, the aide should have access to only enough money for bills and daily necessities.

How to detect financial abuse?

Watch out for unexplained purchases, losses, or missing items:

• Belongings, precious items
• Cash withdrawals, transfers, or transactions are likely increasing over time.
• Unpaid bills, loans, and rent despite having enough money
• Warnings from landlords, creditors, and utility companies
• Reduced care, but the pay remains the same. Check with your agency, or refer to your original contract for a list of duties.

Unexplained or abrupt changes in important documents:

• Check for name changes, name addition, strange signatures in financial documents, bank statements, and land titles.
• Check their wills.
• Check their documents related to power of attorney.

In case the elder is of relatively clear mind and needs some encouragement to report the wrongdoings, ask these questions:

• Has anyone taken or spent your money without your permission?
• Has anyone forced, convinced, or misled you to give them something that belonged to you?
• Has anyone made you sign documents you didn’t understand?
• Has anyone pretended to be you to obtain goods or money?
• Has anyone stopped you from using your money?
• Has anyone kept information about your money from you?

Refer to the Department of Justice’s Financial Abuse Resource for more guidance.

Physical abuse

Any intentional act of causing bodily harm to the elder constitutes physical abuse.

Frequent, unannounced visits could deter the perpetrator from this type of abuse because wounds or pains do not go away quickly.

How to detect physical abuse? 

Watch out for:

• Visible marks: bruises, welts, lacerations, burns, rope marks, black eyes
• Untreated wounds: cuts, punctures, broken bones, sprains, dislocation. Ask the healthcare provider who treats their wounds why the treatment was delayed.
• Strange tooth loss or hair loss
• Broken personal items are worn on the body: eyeglasses, dentures, jewelry, or medical equipment.
• Over-medication or under-medication, with serious side effects.

Suspicious behaviors include:

• The caregiver explains the injuries poorly, and the story keeps changing.
• Inappropriate restraints or forced confinement. Likely hard to detect, but it may affect the elder’s behaviors.
• The elder’s sudden changes in behavior
• Suspicious pattern of hospitalization: frequent treatments for the same types of injuries or going to different facilities (to hide the pattern).

Like many physical abuse victims, the abused elders may cower or withdraw when approached by another person. Therefore, let them know you mean no harm, and gently ask them any questions below:

• Has anyone hit, kicked, bit, slapped, or thrown things at you?
• Has anyone shaken, pinched, or burned you?
• Has anyone pushed, shoved, or grabbed you?
• Has anyone held or tied you down or locked you in a room or building?
• Has anyone used a knife or gun on you?
• Has anyone not allowed you to go to the bathroom?
• Has anyone given you too much or too little medication?

Sexual abuse

Any sexual acts without consent constitute abuse. It includes forcing these acts upon the senior:

• Physical sex acts
• Touching
• Undressing or exposing themselves
• Taking pictures when partially dressed
• Watching pornography
• Talking in a sexual way

How to detect sexual abuse?

Watch out for:

• Bruises, cuts, pain, irritation, and bleeding around the breasts or genital area
• Blood found on sheets, linens, or the elder’s clothing
• Bloodied, stained, ripped clothing, especially underwear
• Unexplained sexually transmitted diseases
• Uncharacteristic sexual behaviors

Ask the senior these questions, but as with many sexual abuse victims, they would feel shame, fear, helplessness, and humiliation. It compels them to hide it from you unless you have their trust:

• Has anyone forced themselves on you?
• Has anyone sexually touched you?
• Has anyone forced you to touch them sexually?
• Has anyone forced you to expose yourself when you didn’t want to?
• Has anyone taken pictures of you with your clothes off?
• Has anyone talked to you in a sexual way that made you feel uncomfortable?
• Has anyone made you watch porn against your will?

Psychological or emotional abuse

This type of abuse can take many forms. It often goes with another kind of abuse.

Fear, distress, isolation, humiliation, etc., any acts intended to hurt a senior’s self-worth, dignity, sense of safety, and emotional wellbeing, may constitute psychological abuse. Here are a few common ones:

• Intimidation through yelling and threats
• Ridicule, blaming, scapegoating, gaslighting
• Ignoring

It could be hard to differentiate between abuse and the heavy toll of chronic illnesses and aging. In any case, observe both the senior and the caregiver.

How to detect psychological abuse?

Watch out for:

• Avoiding eye contact
• Changes in routine, especially sleeping, eating, socializing, and hobbies
• Significant weight gain or weight loss
• Isolated and unresponsive: sudden lack of all contact and participation
• Mood swings
• Personality change
• Depressed, withdrawn, scared, agitated, especially around a specific person
• Strange behaviors: rocking back and forth, sucking a thumb, nail-biting

While many of these signs could also signify a worsening mental illness, a genuine, non-abusive aide should express their concerns and report them to you or a healthcare provider.

If they don’t do this, observe the interactions between your loved one and the aide closely. A psychological abuser tends to have a certain air of dominance over the victim. Let your intuition tell you if there is something wrong.

Neglect & abandonment

It is when the home care aide fails to do their job, intentionally or unintentionally. This is the most common form of abuse.

However, before blaming everything on the aides, consider their duties and the support they receive.

Duties: are they being asked to do tasks above their training or pay grade? An HHA can monitor vital signs but not care for severe wounds (a task for CNAs) or run errands outside the house (a task for PCAs).

Support: if you hire them through an agency, is the agency treating them well? For example, if the agency gave the wrong address to their aide, causing the aide to arrive an hour late when they discovered the senior having fallen on their way to the toilet. In this case, it is not entirely fair to blame the aide for neglect.

With that said, neglect tends to be easier to detect.

How to detect neglect & abandonment?

Watch out for terrible living conditions and personal care:

• Low quality or quantity of essential supplies: water, food, meds, clothes
• Malnutrition, dehydration, and under-medication
• Poor personal hygiene
• Untreated injuries or infections: bedsores, sepsis.
• Unsafe or dirty living conditions: no heat, no running water, improper wiring, dirt, fleas, lice, soiled beddings, bad smells

Dangerous situations:

• Leaving the elder alone for a long time in a public place
• Letting the elder take care of themselves when they are unable to
• Abandoning their job

Questions to ask the senior: Has the aide stopped doing these things:

• Taking them to errands, regular events, or appointments?
• Help them with chores?
• Help them bathe or shower, get in and out of bed, get dressed, use the toilet?
• Help them take meds, get glasses and dentures?
• Help to pay bills or manage money?

Check these questions against the list of duties in the contract with the home care aide.

Abuse red flags versus normal aging: how to tell them apart?

Abuse victims are often fearful, anxious, and wary of others. They have problems with trust and sudden changes in behaviors and personality.

If your loved ones have these signs, they could be either victims of abuse or dealing with their illnesses.

When it’s abuse

To further ascertain abuse, observe the behaviors of the caregivers. Do they display these alarming issues?

Negativity:

• Unfairly criticize or express frequent frustration with family members or care providers
• Complain of exhaustion
• Get angry easily
• Display little or no kindness, compassion, or affection
• Act excessively or inappropriately affectionate

Control:

• Refuse or delay visits or social activities
• Resist outside assistance

Inconsistencies:

• Change the stories they tell about the same incidents
• Make seemingly out-of-context excuses
• Show poor caregiving abilities. Claiming care is adequate when it needs to improve

Personal problems:

• Abuse drugs or alcohol
• Money problems: having creditors or gangs looking for them.

When it’s normal aging

It is when the elders have a weak grip on reality, such as paranoia or delusion. They may claim to be abused by their caregivers, but this is closer to misunderstandings or unrealistic expectations.

For example, the elder may expect his HHA to fetch water immediately while the HHA is busy cleaning up the vomit resulting from his stomach upset. The failure to respond should be judged as a professional issue rather than an ethical faux pas.

Struggling with a severe illness or decreasing quality of life, the elders’ feelings of being wronged are justified. On the other side, this judgment is unfair to the caregiver whose actions (or inaction) do not necessarily constitute abuse.

Therefore, as a third party, exercise explicit judgments to determine whether you have an abuse case on your hands. Observe the signs, play detective, and know your seniors. Contact Adult Protection Service (link above) for support in determining the nature of an abuse case.

Prevent elder abuse with more family attention

It is incredibly disorienting and demeaning to be abused by someone you rely on for your daily wellbeing. The most common abusers are people a senior knows well: spouses, family, or close friends. Abuse by hiring caregivers is the second most common.

Seniors living in isolation are the most susceptible to abuse because the perpetrators think they can get away with it. Getting more involved in caring for your seniors is the best thing you can do to deter abusers. You could make a big difference in hiring the right person, getting your paperwork in order, and reporting to the local APS as soon as possible.

For support in the general care for your seniors aging in place, check out the advice from the AARP Foundation.