Bette Davis once said old age ain't for sissies. She was right.

As though declining health, impending mortality and other challenges weren't hard enough, too often old age is also plagued by abuse, neglect and exploitation.

Science has extended our lives dramatically: In 1900, Americans' average life expectancy was 47. By 2000, it was 77, and it's still rising. But our energy and resources have been disproportionately focused on living longer rather than living better — a phenomenon called "the longevity paradox."

Even her fortune couldn't protect the late socialite and philanthropist Brooke Astor. Modern medicine helped her live to 105, but her friends and grandson assert that she languished with Alzheimer's on a reeking couch, subsisting on pureed peas and oatmeal because her son didn't pay for adequate care; the Manhattan district attorney has indicted him on charges of grand larceny for pilfering her assets.

Eight years of working on issues involving abuse of the elderly at the Department of Justice taught me that Astor's alleged plight in old age was common. Estimates of the prevalence of elder abuse vary wildly, but by some reports there could be up to 5 million cases a year, with 84 percent going unreported. All other factors being equal, victims of even relatively minor mistreatment are three times more likely to die prematurely than those who are not victimized.

Furthermore, our nation is in the midst of three seismic demographic shifts that will put seniors at even greater risk for mistreatment. Older people are living longer, until they're frailer and more vulnerable. They are increasingly alone in old age, given that families are smaller and more dispersed. And the pool of potential caregivers is shrinking.

Although elder abuse conjures visions of nightmarish nursing homes, the term encompasses a far broader spectrum of trouble, including physical and psychological abuse, neglect and financial exploitation. Practitioners report that most elder abuse occurs at home at the hands of family, and that the most frequent perpetrators are adult male relatives with mental health or substance abuse problems.

We are perhaps in greatest denial about elder sexual abuse. Take the case of "Miss Mary," 96. To get out of a nursing home, Miss Mary moved into the trailer home of her grandson and his wife. She cooked, cleaned and contributed part of her Social Security check to the household; they sold off her belongings and stole her burial payments. One night in 2004, when his wife was gone, Miss Mary's grandson raped and assaulted her for six hours, then threatened to kill her. Instead he fell asleep, and Miss Mary called 911.

Despite serious injuries and abundant evidence of the attack, her entire family took the grandson's side. But jurors convicted the grandson of sexual battery, for which he was sentenced to 40 years in prison. Until her death last year, Miss Mary lived in the place she had most wanted to avoid — a nursing home.

Neglect may sound more benign than abuse, but it usually lasts longer, is harder to prove and prosecute, and can be just as lethal.

When paramedics were called to the home of Blossom Deering, 68, in 2000, they found her kneeling on the ground. Her legs were crossed and stuck to the floor by a glue that had formed when her waste fused with cloth and newspaper. She had been there about two weeks, covered in huge pressure sores, many to the bone. Deering's infection was so severe that she died three days later.

A 51-year-old man was living in Deering's house rent-free in exchange for "helping" her. He had been writing checks to himself from her account. While she lay on the ground, he spent her money on gambling and shopping sprees. He claimed that, while she was on the floor, he had brought her food and that she had declined help, worried that she'd be taken from her home. Eventually he pleaded guilty to abuse and neglect of a dependent person and was sentenced to 10 years in prison.

Thirty percent of seriously ill elders surveyed have told researchers that they would rather die than go to a nursing home, a fear that drives many to remain in bad home situations. But while neglect of one person is tragic, systemic neglect by a facility or chain housing numerous residents can be catastrophic.

Between 1998 and 2001, nursing homes run by American Healthcare Management in St. Louis didn't have enough caregivers to help residents who couldn't feed themselves. Food trays returned to the kitchen untouched; residents became malnourished and dehydrated. They lay in their waste for hours, developing life-threatening bed sores. An 88-year-old wheelchair-bound woman was found with ants crawling all over her body. Another went without food for a week before being hospitalized. She died.

Facility owners may extract millions in profits, leaving insufficient funds for resident care. They are rarely held accountable, insulated by corporate structure and blaming facility staff. In 2006, however, federal prosecutors obtained a felony plea against AHM and its chief executive and co-owner, Robert Wachter, for conspiring to defraud Medicare and Medicaid by providing too few personnel to properly care for residents; defendants also agreed to pay $1.25 million in a 2005 civil settlement.

A 2002 government study concluded that more than half of the nation's nursing homes are understaffed at levels that harm residents. Nursing homes receive $80 billion from Medicare and Medicaid annually to care for 1.5 million residents. Another million Americans live in other long-term care facilities, and 10 million receive care at home, where oversight is sparse to nonexistent.

Yet not a single federal employee works on elder abuse issues full-time, an inattention that is all the more baffling given the approaching tsunami of 77 million aging baby boomers, and given that the population's fastest-growing segment, those 85 and older, are at greatest risk for mistreatment.

The same vacuum exists legislatively. Comprehensive legislation to combat child abuse and violence against women was enacted in 1974 and 1994 respectively, while the relatively uncontroversial Elder Justice Act has languished since 2002, despite the support of 225 organizations and 99 of 100 senators in two Congresses.

Why has there been no public outrage?

Perhaps the twin culprits of ageism and denial are to blame. Perhaps the constellation of phenomena — elders beaten by crack-addled nephews, going unfed in assisted-living facilities, impoverished by sending checks for mythical sweepstakes winnings — are so disparate that the problem lacks a coherent public identity. Perhaps elder abuse is seen as a family predicament rather than a national one.

The customs of aging are ancient and varied. At one end of the spectrum is the wise elder, cared for and revered by the community. At the other is the frail elder, consuming precious food, no longer able to contribute to the tribe's needs, shunted off on an ice floe. We take solace in believing we are not a nation that abandons our elders. But we overestimate our civility. Because in the end, we subject many of our old people to a plight as bad as, if not worse than, the ice floe.

Marie-Therese Connolly, a fellow at the Woodrow Wilson International Center for Scholars, is former coordinator of the Department of Justice's Elder Justice and Nursing Home Initiative.