Abuse within long-term care facilities occurs when the staff intentionally or unintentionally harm their residents, with elder abuse taking forms like verbal, physical, or psychological mistreatment. The consequences may range from trauma responses to depression and, in severe cases, even death. For those with loved ones facing malnourishment, dehydration, or other abuses in a nursing home or assisted living center, it’s important to familiarise yourself with these different forms of abuse. This knowledge empowers you to identify signs of mistreatment and provide necessary support to your elderly family member.
Internationally recognised as a significant and urgent issue, elder abuse demands attention from the general public, healthcare authorities, and policymakers. While acknowledging the occurrence of elder abuse in care settings, the authors express that it is an overstatement. No reliable prevalence studies have been conducted on mistreatment in old age homes or long-term care facilities, especially in India. Drawing on personal experiences, observations, and anecdotal evidence from around the world, the authors don’t deny the possibility that many elders in care, especially those with dementia, face neglect and abuse daily. Let’s closely examine this distressing and entirely unacceptable situation, urging for thorough studies on the nature and prevalence of neglect and abuse within long-term care settings. In this discussion, we focus specifically on the abuse occurring in care settings. But the authors want to tell the readers that these are isolated incidents and not a regular thing. We don’t want to generalise it.

  • Roshan J Mundapallil, Sowmya Lakshmi

The old lady on the phone seems to be very upset, and shouted at me. ‘This is second time I’m calling. Once again, your staff consumed all the chocolates my nephew brought. Shame on you people. Can’t you spare a few for my brother’. I was taken aback as I wasn’t informed about the events that led to her complaint. It took me a moment to regain composure, and I hesitantly asked, “Madam, what happened?”

She’s still in a very agitated mood.

“Are you Mr. Jacob, the person overseeing the ‘Old Age Home’? My brother, Vasudevan, is a resident there, and during my nephew’s visit, he brought some chocolates, but they weren’t distributed, not even one.”

I understand now. She dialled my number by mistake. As social gerontologists, we don’t handle daily operations. I clarified that there’s no patient named Vasudevan admitted to our Skilled Nursing Home. I outlined our protocol for food items brought by relatives, assuring her our staff doesn’t touch patient-intended chocolates. I suggested she verify her brother’s care facility. Pilfering patient food packages also falls under the category of “elder abuse.”

We quote a news from Australia which spoke of the universality of the issue. Bupa is Australia's biggest private elder care chain, but when it approached for re-accreditation, the authorities found more than 60 per cent of its care settings have substandard care and a sizeable chunk are putting the health and safety of the elderly at "serious risk". It was widely reported about one such facility, ‘Bupa Seaforth’, located along Sydney's northern beaches, with incidences of patients vanishing, many incidents of inmates assaulting one another, dying residents left hungry and in pain and poor end-of-life care. The accreditation audit paints a grim picture of life inside Bupa Seaforth, with families saying the facility is understaffed resulting in inferior care, and inexperienced and unskilled nursing assistants making matters worse.

Lately, 93-year-old Anantharaman wears a constant smile while singing his favorite PB Srinivas song, ‘Poojaikku Vantha Malarae Vaa.’ Since moving from an ‘old folks’ home to our skilled nursing facility, which he calls a “Punarjanma” (Second Life), Anantharaman expresses gratitude to Tirupathi Venketesa. Subramonian, realizing his maternal uncle faced mistreatment at the old age home, observed ongoing neglect during his regular visits. Acting as the local contact for Anantharaman, Subramonian, along with other family members, noticed inadequate dental care, infrequent showers, prolonged use of incontinence pads, and a lapse in prescribed medications. Resulting in bedsores, the family made the crucial decision to relocate him to our advantAGE.

Describing that ‘old age home’ as horrendous would be putting it lightly,” remarked Mr. Anantharaman’s nephew, Subramonian. “Inmates were left unattended, walking around, falling over, and calling out for help, yet no one bothered. The meals were disgraceful—never warmed up and mostly bland. The level of abuse and neglect surpassed even the most cynical expectations.” Faced with a dilemma about where and to whom to complain, they opted for a Google review. Upon the children’s arrival, they relocated him to our skilled nursing home, which costs the same but, according to the family, provides superior care. Subramonian expressed, “He’s being cared for so much better. The quality is fantastic, and we’re paying the same.”

Ms. Swetha Shree, a seasoned care home manager with a decade of experience in two facilities, asserts that the prevalent issues in most care facilities stem from ‘untrained staff’ and ‘understaffing.’ Disputing the claim of providing person-centered care by many managements, she stated, “If they truly embraced person-centered care, the issues plaguing many substandard care facilities wouldn’t persist,” emphasising her perspective as a Care Expert.

“What's important is actually understanding the health status of each individual and creating a care plan — what about the mental status and what about the chronic conditions — and many more things like evaluating the nutritional status, infection control and crisis management. Managing ADLs (Activities of Daily Living) like how they were helped to shower, use the restroom facilities , eat and use continence aids, as well as how medication was managed, how wounds were looked after and how pain was addressed. Most importantly, the manpower distribution and making sure that the ratio or the relationship of qualified nurses to assistant nurses should be appropriate for the mix of inmates of that particular care setting," she said.

Certain, old age homes in India, as commonly referred to, share a common descriptor – ‘appalling.’ Characterised by understaffing, deplorable working conditions, lack of regulation, and government apathy, our investigation affirms systemic neglect and abuse of elderly residents in these long-term care facilities. Care workers are aware, with collusion among care home management and administrators. Unfortunately, a significant number of family members of those facing neglect and abuse are also aware. Elder neglect and abuse persist in such care homes and, more distressingly, are often concealed by all stakeholders except the care recipients.

Knowing more about institutional elder abuse and the ways to prevent it is important. Here are a few key observations that fuel the persistence of institutional neglect and abuse:

1 ) Ageism Matters

Ageism remain widespread and many young people think elderly are useless; their lives don’t matter; our job is to warehouse them, not engage them with life. These negative myths impact the way we care for elderly people who live with chronic conditions in long-term care facilities.

2) Buying Cheapest Facility

For everything else quality matters but when it comes to selecting a care facility for parents, first priority is to look for the cheapest option. Who runs and how it runs is no concern. Don’t want to know the privacy policy, emergency protocol, crisis management, experience and qualifications of staffs and management etc,. The less you pay, quality suffers.

3 ) Callous leadership

The following is the scenario of a badly run senior care: The owner is a builder and does not have the basic knowledge of social gerontology or senior health. For him this is just another ‘business’ and the sad part he is that he is not willing to delegate management to professionals. He himself manages with one-hour visit in the evening, with the rest being left to a few untrained staff including some relatives from his village This “profit first” attitude is responsible for most of the issues that result in neglect and abuse. We strongly condemn such attitudes and such people are not fit to run care facilities as they risk the lives of those who have been entrusted to their care. Identifying shortcomings and fixing them is not an impossible task, but it takes vision, will, energy and commitment. If those kinds of people were in leadership positions now, what more can be expected: broken facilities full of shattered people.

4 ) Lack of gerontology understanding

Elder care requires gerontology understanding and training. The standard of care in any given facility is only as good as the front-line workers who deliver it. If care workers don’t have the requisite knowledge and skills to deal with the elders, neglect and abuse are inevitable. This job of caring elders with chronic conditions or sometimes bed ridden is very exhausting and tiresome. Only competent, compassionate, visionary leaders with a passion for ‘elder care’ can instil confidence and get the job done because the staff needs constant encouragement and support.

5 ) Low staff-to-resident ratios

To our surprise, our American friends told the Care home ratio is 1:8 which is unbelievable for us. Humanely impossible to do justice to the job. How can one care worker attend to the needs of eight to ten and do it to a reasonable standard? It’s not possible; we maintain almost one to one ratio. Care workers tend to be poorly trained and poorly paid, and overworked because of low staff to resident ratios; they are often unhappy, and unappreciated. It’s no wonder neglect and abuse are pervasive.

6 ) Hygiene matters

Good hygiene practices are a must in preventing the spread of illness, and keeping inmates healthy. Within a care home, good hygiene is essential as the immune system begins to weaken as we age and that’s why we consider proper hygiene as an important factor. When a care home compromise on good hygiene there are chances for the spread of germs and prove dangerous or fatal for residents who have existing health issues. Moreover, it is also important that care home staffs maintain a very high level of personal hygiene because of the often hands-on care required by residents. Management and staffs must ensure good personal hygiene to protect the inmates and others from many life threatening infections.

7 ) Nutrition and Hydration

If the facility has a person centre’s approach, nutrition and hygiene are well taken care of. Every caregiver must me taught about the need to promote adequate nutrition and hydration especially to the patients who have impaired mobility and intellectual deficits. Many dementia patients cannot demand food or water when they are hungry or thirsty. Older people in care homes will have a range of dietary needs. Residents who are reasonably functional and have a good appetite can enjoy a balanced healthy diet. In others case, the challenges are to ensure that meals, snacks and drinks provided meet dietary recommendations for this vulnerable group and are eaten and enjoyed. Appetising food, served in a positive and caring environment, that meets individual needs, is a key aspect of delivering high quality care.

8 ) Medication management

The quality standard covers managing medicines safely and effectively in care homes. Most so called ‘care homes’ gloss over this vital aspect. Medication management in elderly care has become a considerable part of the care work. It involves health care professionals, such as registered nurses, formally delegating their tasks to non-professionals, typically care workers. Most care workers have limited education or have seventh fail qualification and not able to understand the medications and it’s contraindications. Many a time, mix up, forgotten, over doses are common when dispensing. People in long-term care facilities are at increased risk of medication prescribing and administration errors. Polypharmacy and medication adherence in the elders are of significant public-health concerns worldwide and are an important focus of integrated care.

Spotting signs of abuse in older people

Recognising signs of abuse isn’t always straightforward. Victims might offer excuses for bruises, avoid social interactions, or exhibit memory lapses. Familiarising yourself with these signs is crucial, and if identified, gently express your concerns to the person you suspect is being abused. Delaying this conversation might prolong the abuse, so taking timely action is essential.

Behavioral indicators of abuse in an older individual encompass:
• becoming reserved and withdrawn
• displaying aggression or anger without apparent cause
• appearing unkempt, dirty, or experiencing unexplained weight loss
• abrupt shifts in character, such as expressions of helplessness, depression, or tearfulness
• observable physical signs, including bruises, wounds, fractures, or untreated injuries
• recurrence of the same injuries
• expressing reluctance to be alone or left with specific individuals
• exhibiting unusual lightheartedness while insisting that nothing is wrong

Moreover, their residence may feel unusually cold or unkempt, with noticeable signs of dirtiness or disorder, and items may be missing. Another indicator is a sudden financial shift, such as a reduced ability to cover regular expenses or accumulating debt. Be vigilant for any unusual or missing official and financial documents related to their finances. If you suspect someone is displaying signs of abuse, engage in a conversation to explore ways to offer assistance. Recognise that they may not be ready to discuss the issue immediately, especially if they’ve grown accustomed to explaining away injuries or personality changes. Despite potential discomfort, it’s crucial not to disregard your concerns, as doing so might allow the abuse to persist or worsen.

Assuming, incidence of abuse is a regular thing is wrong. In reality, the incidents of abuse are rare, but invoke such an emotional response that they quickly become the assumed status quo. This is damaging to the sector, when in fact the vast majority of people in care homes have overwhelmingly positive experiences. Across the country, thousands of hardworking, devoted and caring people get up each morning to work in a care home. The work they do is both physically and emotionally difficult, and usually not well paid. These workers don't go into the field for money or an easy ride but because they want to make a real difference in an individual's life, bringing happiness, comfort and quality of life to those they support.

The incidents of abuses reported in the media are of course shocking and certainly cannot be ignored, but it is not only unfair but unhelpful to brush all care staff with the same stroke. In reality, most residents flourish in care homes when compared with living on their own because they are part of a strong community and have access to 24/7 medical and emotional support from trained and professional staff.

Media often focus on isolated incidents. It’s crucial for them to highlight positive examples in social care to safeguard the interests of residents, families, the sector, and the public. By sharing stories of dedicated care, we can counteract fears that hinder older individuals from receiving the support they truly need in care homes. Additionally, as the sector’s reputation diminishes, it becomes challenging to advocate for residents and influence government policies on crucial matters like regulation and funding.


Negative perceptions primarily stem from a single source: the media. It’s essential for the media to avoid portraying the entire social care sector as substandard and abusive. Striking a balance is crucial, especially when it comes to sensational stories that can profoundly impact thousands of people nationwide. Accreditation and regulation may mitigate this trauma to some extent.