It is almost impossible to imagine a loving spouse or child striking out and abusing their partner or parent. It is a sad fact, however, that in the majority of cases a family member is the abuser. Abuse occurs in every setting and is just as common in affluent families as in poor families, in those with a high level of education or low, by spouses, children and friends, irrespective of age, sex or ethnicity. The second most common individual is someone hired to care for a dependent older person. Family members caring for a dependent older person are referred to as informal caregivers, and those who are hired are formal caregivers.

Physical violence, while horrifying, reflects only a small fraction of the problem. The patient may be slapped, dragged, pulled and scratched if he fails to follow instructions while bathing, dressing or using the toilet. Because of increased awareness and training, crimes against residents in nursing homes are less frequent.

Most abuse is emotional or psychological. A caregiver may yell, humiliate, insult or threaten. Neglect is a form of abuse. Failure to feed, groom, assist with toileting, allowing the patient to live in an unsanitary environment or failing to follow treatment plans are all forms of neglect. On occasion a caregiver may abandon the patient at a hospital, park or even railway station. Caregivers may take advantage of patients financially by writing checks, stealing social security checks, cash or belongings, or forging a signature.

Patients with Alzheimer's disease are particularly prone to abuse. Recently the British Medical Journal published a study that examined the prevalence and forms of abuse amongst caregivers of patients with Alzheimer's disease. A total of 52 percent of caregivers admitted to some form of abuse, the most common being screaming or yelling (26 percent), using a harsh tone or swearing (18 percent) or threatening to send the patient to a nursing home (4 percent). Only 1 percent reported physical abuse. Most caregivers who admitted to emotional abuse indicated that it occurred rarely. Caregivers who did abuse their loved one were remorseful and guilty, but felt provoked.

What causes abuse? Although stress from being a caregiver is a major risk factor for abuse, it is not the most common. Stressed individuals are more likely to abuse if they are depressed, receive no support from other family members or feel that being a caregiver is overwhelming and burdensome. Abuse is more common in spouses who have significant conflicts during their marriage. Men are more likely to abuse than women, as are those with low self-esteem, alcohol and drug dependency, or those who have been abused themselves. Abuse is more common if relatives are financially dependent on the person for whom they are caring.

As it can occur in every setting, it is important that close friends, family and physicians be on the look out for elder abuse. A problem should be suspected if bruises, scratches or fractures occur, if the patient complains that the caregiver has been emotionally abusive or if there are signs of neglect such as weight loss, poor grooming and failure to take medications.

Because of the breadth of the problem, every caregiver must be aware that they are at risk of being abusive. The more elder abuse is understood, the greater the public awareness and the more education, the better. Learn as much as possible about elder abuse and caregiving.

If possible, caregivers should not "go it alone." Insist that children, other siblings, grandchildren or friends help. Every caregiver should make sure that his or her needs are met and always consider respite care if possible. Look into adult day health care that provides the caregiver with time alone and an opportunity to take care of his or her own day-to-day tasks. Ask a relative to take over care for a weekend, or consider admission to a nursing home or residential facility for respite care. In many circumstances, this may be a benefit covered by Medicare or insurance.

And last but not least, join a caregiver support group. Rest assured there are many wise individuals who have experienced similar problems.

Taking care of a beloved spouse or parent, although very difficult, can be spiritually rewarding and a truly uplifting experience. This will only occur if you truly understand the task and seek the necessary support and love to make it work.

Dr. David Lipschitz is the author of the book "Breaking the Rules of Aging." To find out more about Dr. David Lipschitz and read features by other Creators Syndicate writers and cartoonists, visit the Creators Syndicate Web page at www.creators.com. More information is available at: DrDavidHealth.com.