It's an ugly subject. It shouldn't exist. It's one of those taboo issues we like to sweep under the rug, ignore, and pretend doesn't happen. Unfortunately, abuse of the elderly, like abuse of women or children, is a fact of life which might be increasing throughout the world.

"Abuse takes one of four forms," explained professor of social work, Howie Litwin. "There is physical abuse, the 'battered grandma syndrome,' which includes blows, burns or even restraints, such as tying a patient to his chair or gagging him."

There is also psychological abuse, which includes threatening, shaming or frightening an elderly person. The threat of abandoning an older person or sending him to an old aged home, can be a form of abuse. The third kind of abuse is material abuse. This refers to extortion, exploitation or deceit, for example, cheating an old man out of his rights or getting him to invest in bogus projects. Finally, the fourth form of abuse is neglect, both passive and active--forgetting to bathe or feed a dependent patient, administering the wrong medicine and withholding heat in the winter if he's freezing. These are all forms psychological abuse.

Abuse against the elderly is not easily revealed.

Some elderly abused people are afraid to admit the extent of their suffering or are embarrassed to let strangers know especially when a child or spouse is the aggressor. Some believe that they "have it coming to them." Others take a fatalistic approach ("Who cares anyway," or "What good will it do to complain."). Even if the victim complains, his story is not always understood or believed. "He's paranoid" or "He's a bit demented" are labels easily attributed to the distraught or incoherent elderly person.

Professionals are also loath to "rock the boat." In the emergency ward battered grannies are often returned to their homes by overworked staff who don't want to "get involved," aren't sure that there's something suspicious about the broken bones or black and blue marks, and don't want to get "stuck" with an aging patient who has nowhere to go. Moreover, the police claim their hands are tied if there is no complaint lodged by a victim. Yet anyone who discovers a case of abuse against the elderly and does nothing about it, is actually assisting the continuation of a criminal act.

Abuse of the elderly is not limited to the home. Unfortunately, more and more cases of abuse are coming to light in institutions. Here too, there are examples of physical aggression against inmates, cases of extortion when a staff member demands or hints at a tip. But much more common are the instances of neglect. Incontinent nursing patients who aren't changed or turned regularly in bed and so develop painful pressure sores are at one end of the spectrum, whereas residents wheeled into an activity room and left there facing a blank wall throughout the program are at the other end.

The staff in many nursing homes are overworked and underpaid and thus develop a low patience and frustration threshold. They can easily "forget" to answer a patient's call for help, or, even worse, turn on him in anger and shout, "You're a real pest, you know. Why are you always ringing the bell!" It is often difficult to pin responsibility on a particular aide as there are changing shifts every day and many family members, even if they are in the picture, are loath to complain. After all they have few options and are even afraid of reprisals if they report their suspicions of neglect or abuse to the director. The fear that the director might say, "If you don't like it here, you can always take your parent out," prevents family members from expressing criticism.

The elderly do not initially perceive some forms of abuse as such themselves. Widows are often relieved of their savings by smooth-talking exploiters who promise them marriage, companionship and everlasting devotion -- which lasts as long as there is still money in the bank.

"White angels" often come into the lives of lonely and dependent old people, running errands for them, doing favors, and gradually becoming indispensable. Not surprisingly these one-time strangers later appear in the wills of their victims, and sometimes, even before the wills are read, acquire rights to the property or money of the old people they assist "out of the goodness of their hearts." These cases of exploitation are difficult to prosecute because the elderly are often willing to "buy" companionship, cooperating fully and knowingly with the extortionist.

The most repulsive form remains physical violence. It appears in all socio-economic groups. There are certain generalities that one can make about the nature of the abused and the abusers in this age group. Most abusers were themselves brutalized, either as children or as wives, and learned to hit rather than communicate from the very parents or husband they now mistreat. Furthermore, the aggressor and the victim generally live together. Many of the abusers suffer from psychiatric illness, are substance abusers, and are overwhelmed by financial or family problems. The onus of caring for a dependent, often an elderly invalid, who has constant demands and does not let the caregiver sleep, is itself a source of pent-up frustration and stress which can lead to abuse.

The correct approach to abuse, according to the experts on the subject, is to give attention to the needs of the aggressor, as well as to those of the victim. "Whereas we cannot condone attack on a defenseless old person, resolution of the problem requires more than blaming the offender," said one gerontologist. "The perpetuator is as much a victim of unfortunate circumstances as the object of his abuse, and indeed, many abusers are horrified at their behavior but seem unable to help themselves. They are often under a great deal of stress, either due to life crisis or the worry and unbending weight of caring for their dependent relative.

"Crimes without villains" is how many experts refer to the phenomenon of elderly abuse in the home. Professionals must intervene on three levels:

1.) Crisis intervention must provide immediate protective measures, e.g. shelters or protected housing for the elderly at risk;

2.) Counseling for the abuser to help them gain self awareness and learn means of control;

3.) Alleviation of common family and social problems that may accelerate family tension and lead to abuse in the home. This means obtaining assistance from formal and informal networks and discovering what rights and services exist to alleviate the pressure.

Thus, even as society must protect the abused and make arrangements that will enhance their lives and care in the future, in most cases those who abuse are themselves tormented and miserable and in need of professional assistance and counseling. Greater awareness of the problem and increased sensitivity to both the victims and their tormentors should bring about a change in this most odious social situation and will lead, hopefully, to a decrease in abuse.