|Year : 2019 | Volume
| Issue : 2 | Page : 218-224
Prevalence of elder abuse and its association with psychiatric morbidity in a rural setting
Aseem Mehra1, Sandeep Grover1, Arun Agarwal2, Mohammad Bashar2, Ajit Avasthi1
1 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Community Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||25-Mar-2019|
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: The aim of this study was to evaluate the prevalence of elder abuse in a rural setting. In addition, the study aimed to evaluate the association of elder abuse with psychiatric morbidity and demographic factors. Methodology: A total of 125 elderly (age ≥55 years) were evaluated for psychiatric diagnosis as per the International Classification of Diseases, 10th revision (ICD-10) criteria by the qualified psychiatrist and were evaluated on Vulnerability to Abuse Screening Scale for elder abuse. Results: More than half (58.4%) of the participants had one psychiatric disorder, with depression being the most common. Elder abuse was seen in more than one-third (41.6%) of the study participants. Those with psychiatric morbidity had significantly higher prevalence of abuse. None of the demographic factors was associated with abuse. Conclusion: Elder abuse is highly prevalent in rural setting, especially among those with psychiatric morbidity. Implications: Considering the high prevalence of elder abuse, there is an urgent need to address the problem. Public awareness, education, and sensitization of people toward the abuse are need of the day.
Keywords: Abuse, depression, elderly
|How to cite this article:|
Mehra A, Grover S, Agarwal A, Bashar M, Avasthi A. Prevalence of elder abuse and its association with psychiatric morbidity in a rural setting. J Neurosci Rural Pract 2019;10:218-24
|How to cite this URL:|
Mehra A, Grover S, Agarwal A, Bashar M, Avasthi A. Prevalence of elder abuse and its association with psychiatric morbidity in a rural setting. J Neurosci Rural Pract [serial online] 2019 [cited 2019 May 19];10:218-24. Available from: http://www.ruralneuropractice.com/text.asp?2019/10/2/218/254686
| Introduction|| |
Elder abuse is not a new phenomenon and it has been reported since ancient times. However, it saw a resurgence in later half of the 20th Century, with the emergence of phrases like “granny battering” and “granny bashing.”,,, It was first described in scientific literature in 1975. Although many scientific or other societies tried to define the concept of abuse in elderly or mistreatment, there is a lack of consensus on the definition of elder abuse. One of the most accepted definition was developed by Action on Elder Abuse in the United Kingdom. This definition was later adopted by the International Network for the Prevention of Elder Abuse and according to this “Elder abuse is a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person.” The abuse can be seen in the form of physical abuse, psychological or emotional abuse, sexual abuse, financial abuse, and neglect. The elder abuse can be intentional or unintentional.,
Many studies have evaluated the prevalence of elder abuse across different countries. Studies from the United States of America (USA) suggest that about 10% of the elderly experience abuse; however, the figures for patients with dementia from the USA has been reported to be as high as 47.3%. Data from European countries suggest the prevalence of elder abuse to be 61.1% and that from countries such as Peru suggests a prevalence figure of 79.7%.
In terms of factors, associated with experience of elder abuse, available data suggest that elder abuse is more commonly experienced by females, those living in shared living situations, older subjects, and those with cognitive decline.,,,, Elder abuse has also been shown to be associated with self-neglect, social isolation, and financial problems.,,,, Apart from these factors, depression, loneliness, poor quality of life, poor physical health, living in rented housing, unemployment, and low socioeconomic profile are considered to be contributing factors.,, Abuse in elderly is most frequently perpetrated by family members, which could be due to the high rate of caregiver burnout, stress, substance use, financial problems, mental health problems, and family problems affecting the caregivers.,,,
According to the WHO, the prevalence of elder abuse varies widely from 1% to 35%, and is influenced by many factors such as settings, definitions, and methodological issues. Data from India suggest the prevalence of elder abuse to varies from 14% to 40%, with higher prevalence in cities., However, there is lack of data in terms of elder abuse in rural population. The present study aimed to evaluate the prevalence of elder abuse in a rural setting. In addition, the study aimed to evaluate the association of elder abuse with psychiatric morbidity and demographic factors.
| Methodology|| |
This cross-sectional study was carried out at the rural health clinic of village Kheri situated in the Panchkula district of Haryana, which falls in the catchment area of Community Clinic of Department of Community Medicine of Postgraduate Institute of Medical Education and Research, Chandigarh. The village has 288 families and the population is 1605. Out of this, 823 were male while the females count 782 here. The illiteracy rate for the village is reported to be 31%. Only 539 people of the village are involved in paid occupation, of which 78 are entirely dependent on agriculture.
For this study, elderly (age ≥55 years) people were identified by a female health worker and were explained about the study. Those who agreed to participate were brought to the rural health clinic along with their family members who were well versed with the patient's mental and physical health status. At the rural health clinic, they were interviewed in detail by the qualified psychiatrist well versed with the local language, dialect, traditions, and customs. The patients were recruited after obtaining written informed consent and approval was obtained from the Institute Ethics Committee. Patients, who were very sick, uncooperative, and had significant cognitive decline, had psychotic symptoms against family members and those who did not provide written informed consent were excluded from the study. The study sample comprised 125 patients.
Using a semi-structured interview, based on the available information from the patient, family members, and mental status examination, psychiatric diagnosis was made as per the International Classification of Diseases, 10th revision (ICD-10) criteria by the qualified psychiatrist, and if required, the patients were started on treatment. In addition, these patients were evaluated on Vulnerability to Abuse Screening Scale (VASS) by providing privacy.
Vulnerability to Abuse Screening Scale
This questionnaire has 12 items, with “yes” and “no” responses. It provides information on various forms of family abuse such as emotional, psychological, and verbal abuse., The items of the scales are further categorized into four factors, that is, vulnerability, dependence, dejection, and coercion. The vulnerability and coercion factors are reported to have high face validity for abuse and moderate-to-good construct validity. The dejection factor resembles a general measure of depression, whereas the dependence factor represents an indirect measure of vulnerability to abuse. Cronbach's alpha coefficients of various factors or domains of VASS vary from 0.31 to 0.74. For this study, VASS was translated into Hindi by following the methodology laid down by the World Health Organization.
| Results|| |
The mean age of the study population was 65.4 years (standard deviation [SD] = 6.4), and they had received formal education for a mean duration of 1.3 (SD = 2.9) years. About two-third of the study participants were female (n = 78; 62.4%) and married (n = 80; 64.0%) at the time of assessment. The majority of the people were not on paid employment (n = 111; 88.8%), were from lower socioeconomic status (n = 108; 86.4%), and more than three-fourth of the participants were living in a joint or extended families (n = 97; 77.6%) set up.
On semi-structured interview, 73 patients were diagnosed with a primary psychiatric diagnosis as per the ICD-10 criteria, with depressive disorder being the most common diagnosis, followed by somatoform disorder and anxiety spectrum disorders [Table 1]. Very few patients had more than one psychiatric disorder. More than half of the participants also had concomitant comorbid physical illnesses [Table 1].
As is evident from [Table 2], 41.6% of the elderly had a score of 6 or more on VASS, which is considered as a cutoff of the presence of abuse. The presence of elder abuse in various domains was considered to be present if the participant reported “yes” to at least one of the items. Accordingly, more than two-third of the elderly reported coercion and dejection, 60% reported experiencing dependence, and about half reported vulnerability to abuse.
Based on the presence or absence of elder abuse, the study sample was divided into two groups, i.e., those with and those without abuse. As shown in [Table 3], none of the demographic factors differed significantly between those with and without abuse. Among the clinical variables, those with abuse had significantly lower frequency of tobacco use/abuse and higher prevalence of psychotic symptoms.
|Table 3: Comparison of sociodemographic and clinical profile of those with and without elder abuse|
Click here to view
Further, when those with and without psychiatry morbidity were compared, as is evident from [Table 4] and [Table 5], those with psychiatric morbidity had higher scores in all the domains and also had higher prevalence of abuse in the domains of vulnerability, dejection, and coercion.
|Table 4: Comparison of abuse experienced by those with and without psychiatric morbidity|
Click here to view
|Table 5: Comparison of the presence or absence of abuse experienced by those with and without psychiatric morbidity|
Click here to view
When those with and without psychiatry morbidity were compared, those with psychiatric morbidity were significantly younger, were more often females, and were not using substances [Table 6].
|Table 6: Comparison of sociodemographic and clinic profile with psychiatric illness and those without psychiatric illness|
Click here to view
| Discussion|| |
Elder abuse is understood as a socially and culturally constructed phenomenon. Improving the understanding of this phenomenon can help in not only understanding the extent of the problem but also will help in understanding the risk factors. This understanding can help in increasing the awareness among the public, sensitizing the clinicians in recognizing the problem in the vulnerable people, and taking appropriate measures to stop abuse and prevent further abuse. The present study was a step in this direction. According to the findings of the present study, 41.6% of the elderly participants reported experiencing abuse. In terms of abuse as per the various domains of VASS, more than two-third of the elderly reported experiencing coercion and dejection, 60% reported experiencing dependence, and about half reported vulnerability to abuse. When one attempts to compare the findings of the present study with the existing literature, it is evident that prevalence of abuse is similar to the previous studies from India, which have reported it to be 40%, but is significantly higher than that reported in other studies, which have estimated the prevalence of elder abuse to be 14%. The findings of the present study are also comparable to that reported in European and other countries,,,, but are significantly higher than that reported in the from USA.,
The high prevalence indicates that there is an urgent need to recognize this problem and provide support to the vulnerable elderly. The Government of India has Law in the form of “Maintenance and Welfare of Parents and Senior Citizens Act, 2007,” which has provisions for maintenance and welfare of elderly. According to this law, it is a legal obligation for children and other heirs to provide maintenance to senior citizens and parents by providing monthly allowance. This act is thought to provide protection to the elderly from abuse, but till now, this has not been implemented by all the states in the country. Further, although some states have implemented the same, there are minimal efforts in the form of awareness campaigns to make elderly aware of existence of the law and their rights. Police is also not much aware of the law and hence fail to protect the elderly. Accordingly, there is a need to develop awareness campaigns to spread the message that the elderly can seek protection using the “Maintenance and Welfare of Parents and Senior Citizens Act.”
In terms of factors associated with abuse, the present study suggests that elder abuse was more common among those who had psychiatric morbidity. Previous studies from other parts of the world have also reported similar results.,, However, previous studies had mainly evaluated the relationship of abuse with dementia. In contrast, the present study has evaluated the association with any psychiatric morbidity. This finding suggests that elderly with psychiatric disorders are a vulnerable group to experience abuse. However, it is important to note that the present study was cross-sectional in nature and cannot provide information about cause and effect relationship between psychiatric morbidity and elder abuse. It can be hypothesized that it is quite possible that experience of abuse may lead to the development of psychiatric morbidity. However, it is also possible that elderly participants who develop psychiatric morbidity, may be neglected, because of lack of or poor contribution to the household. Future studies with longitudinal study design can possibly provide answer to the cause and effect relationship between elder abuse and psychiatric morbidity. However, considering the high prevalence of elder abuse among those with psychiatric disorders, it can be said that psychiatrists managing elderly patients should routinely inquire about the elder abuse and increase the awareness of the elderly about their rights.
The present study has certain limitations. This was a cross-sectional study. The study did not attempt to evaluate the perpetuators of elder abuse nor did the study evaluate the awareness of elderly about the existing law. Although the present study shows that elder abuse is more common among those who have psychiatric morbidity, no cause-effect relationship can be concluded. The study sample was recruited by purposive sampling, was relatively small, and was limited to rural setting. The study also did not evaluate other factors such as social support, self-esteem, living situation in terms of privacy, and sexual abuse faced by the elderly. However, the present study has certain strengths in the form of psychiatric diagnosis being made by a qualified psychiatrist rather than based on screening questionnaire and evaluation of abuse by a clinician by providing privacy to the patient.
| Conclusion|| |
The present study suggests that elder abuse is common in the Indian setting, especially among those with mental illnesses. Considering the high prevalence of elder abuse, there is an urgent need to address the problem. Public awareness, education, and sensitization of people toward the abuse are the need of the hour. There is also a need to improve the awareness of the clinicians dealing with geriatric patients. All such clinicians should screen the elderly for abuse and must make them aware about their rights. There is also a need to develop legal aid cells to provide legal aid to the elderly facing abuse in the hands of their children, other heirs, and significant others.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Mysyuk Y, Westendorp RG, Lindenberg J. Added value of elder abuse definitions: A review. Ageing Res Rev 2013;12:50-7.
Burston GR. Letter: Granny-battering. Br Med J 1975;3:592.
Baker AA. Granny-battering. Modern Geriatrics 1975;5:20-4.
Walshe-Brennan K. Granny bashing. Nurs Mirror 1977;145:32-4.
World Health Organization. The Toronto Declaration on the Global Prevention of Elder Abuse. Geneva: World Health Organization; 2002.
Hudson MF. Elder mistreatment: A taxonomy with definitions by Delphi. J Elder Abuse Neglect 1991;3:1-20.
Institute of Medicine. Confronting Chronic Neglect. The Education and Training of Health Professionals on Family Violence. Washington, DC: The National Academies Press; 2002.
Dong XQ. Elder abuse: Systematic review and implications for practice. J Am Geriatr Soc 2015;63:1214-38.
Cooper C, Selwood A, Livingston G. The prevalence of elder abuse and neglect: A systematic review. Age Ageing 2008;37:151-60.
Lachs MS, Williams C, O'Brien S, Hurst L, Horwitz R. Risk factors for reported elder abuse and neglect: A nine-year observational cohort study. Gerontologist 1997;37:469-74.
Paveza GJ, Cohen D, Eisdorfer C, Freels S, Semla T, Ashford JW, et al.
Severe family violence and Alzheimer's disease: Prevalence and risk factors. Gerontologist 1992;32:493-7.
Pillemer K, Finkelhor D. The prevalence of elder abuse: A random sample survey. Gerontologist 1988;28:51-7.
Burnes D, Pillemer K, Caccamise PL, Mason A, Henderson CR Jr., Berman J, et al.
Prevalence of and risk factors for elder abuse and neglect in the community: A population-based study. J Am Geriatr Soc 2015;63:1906-12.
Lachs MS, Williams CS, O'Brien S, Pillemer KA, Charlson ME. The mortality of elder mistreatment. JAMA 1998;280:428-32.
Cooper C, Katona C, Finne-Soveri H, Topinková E, Carpenter GI, Livingston G, et al.
Indicators of elder abuse: A crossnational comparison of psychiatric morbidity and other determinants in the ad-HOC study. Am J Geriatr Psychiatry 2006;14:489-97.
Lachs MS, Berkman L, Fulmer T, Horwitz RI. A prospective community-based pilot study of risk factors for the investigation of elder mistreatment. J Am Geriatr Soc 1994;42:169-73.
Buri H, Daly JM, Hartz AJ, Jogerst GJ. Factors associated with self-reported elder mistreatment in Iowa's frailest elders. Res Aging 2006;28:562-81.
Dong X, Simon MA, Odwazny R, Gorbien M. Depression and elder abuse and neglect among a community-dwelling Chinese elderly population. J Elder Abuse Negl 2008;20:25-41.
Dong X, Simon MA. Is greater social support a protective factor against elder mistreatment? Gerontology 2008;54:381-8.
O'Keefe M, Hills A, Doyle M, McCreadie C, Scholes S, Constantine R, et al
. UK Study of Abuse and Neglect of Older People: Prevalence Survey Report. London: National Centre for Social Research and King's College London; 2007.
World Health Organisation. European Report on Preventing Elder Maltreatment. Geneva: World Health Organisation; 2011.
Bond MC, Butler KH. Elder abuse and neglect: Definitions, epidemiology, and approaches to emergency department screening. Clin Geriatr Med 2013;29:257-73.
Yaffe MJ, Tazkarji B. Understanding elder abuse in family practice. Can Fam Physician 2012;58:1336-40, e695-8.
Krienert JL, Walsh JA, Turner M. Elderly in America: A descriptive study of elder abuse examining national incident-based reporting system (NIBRS) data, 2000-2005. J Elder Abuse Negl 2009;21:325-45.
Dong X. Elder abuse: Research, practice, and health policy. The 2012 GSA Maxwell Pollack award lecture. Gerontologist 2014;54:153-62.
Chokkanathan S, Lee AE. Elder mistreatment in urban India: A community based study. J Elder Abuse Negl 2005;17:45-61.
Mattoo KA, Shalabh K, Khan A. Geriatric forensics: A dentist's perspective and contribution to identify existence of elder abuse among his patients. J Forensic Dent Sci 2010;2:81-5.
] [Full text]
Schofield MJ, Reynolds R, Mishra G, Powers J, Dobson A. Vulnerability to abuse, perceived control and psychological stress among older women: Women's Health Australia study. J Appl Gerontol 2002;21:24-39.
Schofield MJ, Mishra GD. Validity of self-report screening scale for elder abuse: Women's Health Australia study. Gerontologist 2003;43:110-20.
World Health Organisation. Process of Translation and Adaptation of Instruments. Geneva: World Health Organization; 2002.
Abdel Rahman TT, El Gaafary MM. Elder mistreatment in a rural area in Egypt. Geriatr Gerontol Int 2012;12:532-7.
Ajdukovic M, Ogresta J, Rusac S. Family violence and health among elderly in Croatia. J Aggress Maltreat Trauma 2009;18:261-79.
Wu L, Chen H, Hu Y, Xiang H, Yu X, Zhang T, et al.
Prevalence and associated factors of elder mistreatment in a rural community in people's republic of China: A cross-sectional study. PLoS One 2012;7:e33857.
Fraga S, Lindert J, Barros H, Torres-González F, Ioannidi-Kapolou E, Melchiorre MG, et al.
Elder abuse and socioeconomic inequalities: A multilevel study in 7 European countries. Prev Med 2014;61:42-7.
Silva-Fhon JR, Del Rio-Suarez AD, Motta-Herrera SN, Fabricio-Wehbe SC, Partezani-Rodrigues RA. Domestic violence in older people living in the district of Breña, Peru. Rev Facultad Med 2015;63:367-75.
Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W, et al.
Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The national elder mistreatment study. Am J Public Health 2010;100:292-7.
Roepke-Buehler SK, Simon M, Dong X. Association between depressive symptoms, multiple dimensions of depression, and elder abuse: A cross-sectional, population-based analysis of older adults in urban Chicago. J Aging Health 2015;27:1003-25.
Amstadter AB, Cisler JM, McCauley JL, Hernandez MA, Muzzy W, Acierno R, et al.
Do incident and perpetrator characteristics of elder mistreatment differ by gender of the victim? Results from the national elder mistreatment study. J Elder Abuse Negl 2011;23:43-57.
Nisha C, Manjaly S, Kiran P, Mathew B, Kasturi A. Study on elder abuse and neglect among patients in a medical college hospital, Bangalore, India. J Elder Abuse Negl 2016;28:34-40.
Dyer CB, Pavlik VN, Murphy KP, Hyman DJ. The high prevalence of depression and dementia in elder abuse or neglect. J Am Geriatr Soc 2000;48:205-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]