Frequency and risk factors of the elder abuse in the university hospital and health insurance attendees in

Ismailia city. Egypt.

Maged sayed khattab, Magda Taha Fahmy, Hanan Abbas Elgammal, Enayat Mohamed Soltan. Family Medicine Department, Faculty of Medicine, Suez Canal University.

ABSTRACTBackground: Elder abuse (EA) is associated with physical and mental health problems, including physical injuries, depression, poor control of chronic diseases, and functional disability. This study attempts to assess the frequency, risk factors, types and consequences of the elder abuse in Egypt.

Subjects and methods: This is a descriptive study; the study was carried out at Suez Canal university hospital and health insurance outpatient clinics in Ismailia city, Egypt. One hundred eighty eight elders were included in this study. A semi structured questionnaire was developed from World report on violence and health 2002 with some modifications to be suitable to our culture.

Results: The mean age of the studied elders was 67.86 years ±6.87. The study showed that 61.2% were males, while 38.8% were females. The majority of abused elders were 60-69 years old and this represents 66.1%. The pension was the basic source of income for 95.2%. More than half (52.7%) had insufficient income. The frequency of abused elders was 13.8% (26 elders). There was statistical significance relationship between elder abuse and pre retirement occupation, presence of partner, thinking of living at residential home and the significant factor was found by the logistic regression affecting the abuse among the studied variables was income insufficiency (P<0.05). The most frequent perpetrators were siblings (84.6%), followed by daughter-in-law (23.1%). The emotional abuse was the most frequent type (88.5%) of abused elders. The major risk factor was financial difficulties (88.5%). The major consequences of elder abuse were; depressive symptoms, and re-experiencing events; 84% and 69.2% respectively.

Conclusion :Elder abuse is a growing problem in Egypt. It is a complex phenomenon that involves multiple risk factors and found in a variety of types. Higher proportion of abused elderly people suffers from depressive symptoms and psychological distress.

Introduction: World health organization (WHO) considered that the age of 65 is the beginning of aging, but in Egypt, the age of 60 is still the beginning of aging according to the retirement age for most people (1). Concerns around elder abuse are increasing. International prevalence estimates of elder abuse in community settings (including neglect by caregiver, physical, psychological and financial abuse) from Canada, Finland, the Netherlands, the United kingdom and the United states of America range from 4-6% (2). The more recent study in the Republic of Korea found a corresponding figure of 6.3% (3), while in Israel an estimate of 18.4% has been reported with the majority of abuse involving neglect ((4). Elder abuse has been defined as a single or repeated act, or lack of appropriate action occurring within any relationship when there is an expectation of trust, which causes harm or distress to an older person (5). Elder abuse can take many forms including physical, psychological and sexual abuse, financial exploitation, scapegoat, neglect and self neglect, medication abuse, abandonment, and marginalization of older people in institution or social and economic policies ((2). Abuse by systems –the dehumanizing treatment older people is liable to suffer at health clinics and pension offices, and marginalization by the government (6). Substantial evidence exists for the following risk factors of elder abuse; Shared living situation with abuser, likely due to an increased opportunity for contact, dementia, social isolation, pathologic characteristics of perpetrators such as mental illness and alcohol misuse (7). For older people, the consequences of abuse can be especially serious. Older people are physically weaker and more vulnerable than younger adults, their bones are more brittle and convalescence takes longer. Even a relatively minor injury can cause serious and permanent damage. Many older people survive on limited incomes, so that the loss of even a small sum of money can have a significant impact. They may be isolated, lonely or troubled by illness, in which case they are more vulnerable as targets for fraudulent schemes (2). The role of the family physician in identifying abuse is critical. The vast majority of older people visit their physician at least once a year, and he often has a long standing relation-ship with their patient and the patient’s family, and knows their background. Also, the family physician should have detailed medical records for the patient and be well aware of both present and past medical problems, current medication and the patient’s social situation. They are therefore ideally placed to identify elder abuse (8). This study attempts to assess the frequency, risk factors, types and consequences of the elder abuse in Egypt.Subjects and methods:

This is a descriptive study to assess the frequency, risk factors,

types and consequences of elder abuse in Egypt. The study was carried out at Suez Canal University and health insurance hospitals outpatient clinics in Ismailia city, Egypt. To our knowledge there are no published findings concerning this phenomenon in Egypt, so we carried out a pilot study on 49 attendees in university and health insurance hospitals and found that the frequency was 14.2% (7/ 49) then we used this figure as a basis to calculate the required sample size. The following equation was used.

N= (Z/∆)2 P(1-P) (9). One hundred eighty eight elders were determined as our sample size.

A semi structured questionnaire was used to investigate: Elder's Socio- economic demographic data, the risk factors of the elder abuse, the types of the elder abuse and the consequences of elder abuse.

Results were represented in tables and graphs. Data analysis was based on estimating the percentage of discrete data. Appropriate statistical tests were used according to the type of data (e.g. Chi square test and logistic regression analysis) and these data was analyzed using computerized statistical software which was Medcalc 10.0.1. The level of significance considered statistically significant at p<0.05.

Results:

One hundred and eighty eight elders were included in this study; the majority of studied elders were 60-69 years old and this represented 66.1%, while 27.2% were 70-79 years old, and 6.7% were ≥ 80 years old. The mean age of the studied elders was 67.86 years ±6.87. Regarding gender, it was found that more than half 61.2% were males, while 38.8% were females. The majority of elders were from urban area (81.9%). Most of them (66.5%) were married, (31.91%) were widows, (1.06%) were divorced, and one was single (0.53%). About 35.1% of elders were Employees, 31.4% were Workers, and 33.5% were non workers before the retirement age.The pension was the basic source of income for 95.2%. More than half (52.7%) had insufficient income. The majority had low crowding index (80.32%), tea and coffee drinking (77.12%). The majority of elders were independent regarding self care (44.67%), while 23.4% of them received care by their partners, 12.8% by their daughters, 8.5 % by daughter in law, 10.1% by relatives and 0.53% had paid caregivers (Table 1).Twenty six elders (13.8%) had elder abuse. The statistically significant factor was found by the logistic regression affecting the abuse among the studied variables was income insufficiency (Table 2). 84.6% of abused

elders were abused by their siblings, 23.1% were abused by their daughter-in-law, and 7.7% by their wives, none of them were abused by their husbands or their son-in-law (Figure 1). Emotional abuse was found in 88.5%, Abandonment in 84.6%, Neglect in 57.7%, Verbal abuse in 53.8%, Economic abuse in 30.8%, and Physical abuse in 11.5% (Figure 2). The distribution of risk factors for abused elders; Financial difficulties were found in 88.50%, social isolation in 84.60%, Cognitive impairment in 80.80%, Living arrangement in 80.80%, life stressors in 61.50%, Physical impairment in 61.50%, Economic dependency upon elder in 61.50%, Modernalization in 46.10%, uncomfortable home atmosphere in 34.60%, Poverty in 23.10%, Dependency on caregiver in 15.40%, Substance abuse of caregiver in 7.7%, and Overburdened caregiver in 7.70% (Figure 3). The consequences of elder abuse were as follows; 84% had depressive symptoms, 69.2% had re-experiencing events, 38.5% had shame, 26.9% had isolation and loneliness, and both physical injury and no consequences of elder abuse represents 7.7% (Figure 4).

Discussion:

The prevalence rate of elder abuse in our study was 13.8%, in comparison to the prevalence of elder abuse in other studies; in a Korean study the rate was 1.9- 4.2% in various types of abuse (3) , the rates in the USA (0.19–2.2%) (10), who showed prevalence of elder abuse in USA varies from 3% to 5%. This level of elder abuse in the current research was different; this may due to difference in socioeconomic level and cultural factors that may hide the abuse. In the current study those aged <80 years were more likely to be abused than who aged ≥ 80 years, this result is similar to the results from Korean study (3). The probable explanation is that old persons as they age may learn helplessness from repeated abuse, and become unable to perceive or express abuse situations accurately. The current study found that older men equally experience abuse as women, this result is near to the findings from other studies (10), which is contrary to the findings from other studies where older men were more likely to experience abuse than women (3) .This could be explained by decreasing social perception of male role after the retirement age in these societies.The logistic regression analysis showed that the only statistically significant factor affecting the abuse among the studied variables was income insufficiency, so the abused elders were those with insufficient income. The most frequent perpetrators were siblings (84.6%), followed by daughter-in-law (23.1%). Although this result is near to the findings from Korean studies (3, 11, 12), it was different from a study done in other

country (13) in which a sister was the most frequent abuser in USA. This difference may be due to the fact that the burden of caring for parents rests upon the oldest son and his wife traditionally in Egypt. The present research found that emotional abuse is the most frequent type in 88.5% of elder. Similar to those found in Korean study (3). This could be explained by similarity between the Korean traditional values to Egyptian traditions.Although the abuse rates by type vary in different studies, it is often reported that psychological and physical abuse are the most frequent types (10). In the current research, emotional abuse was the most frequent type while physical abuse was the least prevalent one in 11.5%. This result is similar to the results from studies by (3,11,12). Since the idea of filial piety is still explicitly dominant in Egypt and other traditional countries and physical harm to old people is taboo.

The economic situation of old persons seems to be a factor in elder abuse as suggested by (14). It is possible that competent old people become the subject of exploitation by adult children and may be abused by their children for financial support. In the current research the majority of abused elders were economically independent and take care for others suggesting that they were more likely to be the objects of financial exploitation. The findings of this study regarding the distribution of risk factors for elders abused group was as follow; Financial difficulties in 88.50%, social isolation in 84.60%, Cognitive impairment in 80.80%, Living arrangement(perpetrator living with victim, overcrowding) in 80.80%, life stressors in 61.50%, Physical impairment in 61.50%, Economic dependency upon elder in 61.50%, Modernalization in 46.10%, uncomfortable home atmosphere in 34.60%, Poverty in 23.10%, Dependency on caregiver in 15.40%, Substance abuse of caregiver in 7.7%, and Overburdened caregiver in 7.70%. The current research found Poverty, life stressor Situational factors, such as care giving stress and caregiver burden are risk factors similar to other studies by (15, 16, 17). Other risk factors like cognitive and physical impairment are similar to other studies (18, 19, 20, 21). Other risk factors such as pathologic characteristics of perpetrators like alcohol misuse are similar to findings by (7). Other studies also have shown that there is more likelihood of older persons with physical and cognitive disability to be abused (16, 22).We found that Social isolation represented a risk factor for elder abuse which is similar to other studies (23, 24, 25).

The research findings about Economic dependency upon elder represents more frequent risk in 61.50%, than elder dependency on caregiver, these findings were similar to findings by other study (26), this may be explained by caregivers dependency usually on elderly parents for housing and financial assistance.This suggests that abuse is more likely to be triggered by the interplay of several factors rather than by one single factor. The current research found; 84% had depressive symptoms, 69.2% had re-experiencing events, 38.5% had shame, 26.9% had isolation and loneliness, and both physical injury and no consequences of elder abuse represents 7.7%. These findings were similar to other studies (27, 28).Conclusion:Elder abuse is a growing problem in Egypt. It is a complex phenomenon that involves multiple risk factors and found in a variety of types. Higher proportion of abused elderly people suffers from depressive symptoms and psychological distress.

References

1-Sherif Y ( 2000) :Cooperative care for the elderly in Egypt. In: Elderly On Arabic World. The current status and future, Hellwan press, Cairo; 17-36.

2- Krug EG (2002) : World report on violence and health. Geneva, World Health Organization.

3-Jinjoo O, Hesook S, Martins D, Kim H (2006): A study of elder abuse in Korea. International Journal of Nursing studies; 43:203-14.4- Siegel-Itzkovich J (2005): A fifth of elderly people in Israel are abused. Br Med J; 330:493.5- Action on elder abuse (1995): What is elder abuse? London, ( http:// www. Elderabuse.org.uk/ documents/ leaflets/ what leaflet. PDF. Html, accessed 2 February 2006.6-Keikelame J, Ferreira M, Mpathekombi Y (2000): elder abuse in black townships on the Cape Flats. Cape Town,Human Sciences Research Council and University of Cape Town Centre for Gerontology.

7-Sellas M I (2006): Elder abuse. eMedicine. World Medical Library

June 19.

8- Kurrle SE (2004): Elder abuse .Australian Society for Geriatric Medicine. Position Statement No.1.Aust J Ageing; 23:38–41.

9-Ratain J and Hochberg M (1990): Clinical trials: A guide to understanding methodology and interpreting results. Arth Rheum: 33 : 131.

10-Pillemer K, and Finkelhor D (1988): Prevalence of elder abuse: a random sample survey. The Gerontologist; 28:51 –57.

11- Han DH (1996): A study of elder abuse. Doctor’s Thesis, Catholic University of Daegu. Korea.

12- Kim HS (1997): A study on the current situation of elder abuse. Master’s Thesis, Soongsil University, Korea.

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14-Douglass RL (1988): Domestic Mistreatment of the Elderly Towards Prevention. American Association of Retired Persons, Washington, DC.

15-Steinmetz SK (1983): Dependency, stress, and violence between middle-aged caregivers and their elderly parents. In: Kosberg, J.L. (Ed.), Abuse and Maltreatment of the Elderly. John Wright, Littleton, MA: 134–139.

16-Lachs MS, Pillemer K (1995): Abuse and neglect of elderly persons. The New England Journal of Medicine; 332 (7): 437–443.

17-O’Rourke M (1981): Elder abuse; the state of the art. Paper Prepared for the National Conference on the Abuse of Older Persons, Boston, MA: 23–25.

18-Kamel F (2002): Assessment Of An Attitude And Practice Of Family Caregivers Towards Abuse And Neglect Of Older Adults. Master Degree Thesis, Faculty of Nursing, Ain Shams University.

19-Hansberry MR, Chen E, Gorbien MJ (2005): Dementia and elder abuse. Clin Geriatr Med; 21:315–332.

20-Akaza K, Bunai Y, Tsujinaka M, et al (2003): Elder abuse and neglect: social problems revealed from 15 autopsy cases. Leg Med (Tokyo); 5:7–14.

21-Joshi S, and Flaherty J (2005): Elder abuse and neglect in long-term care. Clin Geriatr Med; 21:333–354.

22-Pillemer KA, and Suitor JJ (1992): Violence and violent feelings: what causes them among family caregivers? Journal of Gerontology; 47:S165 –S172.

23-Wolf RS, and Pillemer KA (1989): Helping elderly victims: the reality of elder abuse. New York, NY, Columbia University Press.

24-Phillips LR (1989): Theoretical explanations of elder abuse. In: Pillemer KA, Wolf RS, eds. Elder abuse: conflict in the family. Dover, MA, Auburn House: 197 –21.

25-Grafstrom M, Nordberg A, Winblad B (1994): Abuse is in the eye of the beholder. Scandinavian Journal of Social Medicine; 21:247 –255.

26-Pillemer KA (1989): Risk factors in elder abuse: results from a case –control study. In:Pillemer KA, Wolf RS, eds. Elder abuse: conflict in the family. Dover, MA, Auburn House: 239 –264.

27-Booth BK, Bruno AA, Marin R (1996): Psychological therapy with abused and neglected patients. In: Baumhover LA, Beall SC, eds. Abuse, neglect, and exploitation of older persons: strategies for assessment and intervention. Baltimore, MD, Health Professions Press: 185 –206.

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Legend of tables:Table 1: Socio-demographic characteristics of studied elders (N=188)Table 2: Logisic regression analysis for variables of the studied eldersLegend of figures: Figure 1: The perpetrators (abusers) of abuse for the studied abused elders Figure 2: The types of abuse in the studied abused eldersFigure 3: The risk factors for elder abuseFigure 4: The consequences of elder abuse

Characteristics Frequency Percentage Age group ( in years)

60-69 years 70-79 years ≥ 80 years

Mean age ±SD 67.86 years ±6.87

1194920

66.1%27.2%6.7%

Gender Male Female

11573

61.2%38.8%

Residence Urban Rural

15434

81.9%18.1%

Marital status Single Married Divorced Widow

1125

260

0.53%66.5%1.06%

31.91%Pre-retirement Occupation

Employees Workers Non-workers

665963

35.1%31.4%33.5%

Source of income Pension Special income Family support

17936

95.2%1.6%3.2%

Income sufficiency Sufficient income Insufficient income

8999

47.3%52.7%

Crowding index Low High Living at residential home

151361

80.32%19.15%0.53%

Variable Coefficient Std.Error PAge 0.1291 0.3477 0.7105

Crowding index 0.2899 0.6358 0.6484Presence of disease 0.0287 0.4090 0.9441

Educational level 0.2416 0.1919 0.2080Gender -0.02735 0.8227 0.9735

Income sufficiency 1.1110 0.4680 0.01761 *Marital status 0.4928 0.6683 0.4609

Occupation 0.1221 0.5657 0.8292Presence of partner 0.3300 1.3870 0.8119

Residence 0.3271 0.4340 0.4511Source of income -0.4077 0.6486 0.5296

Economic dependency 0.004472 0.2582 0.9862

Constant -7.0923    

7.70%0%

84.60%

23.10%

0% 0%0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Wife Husband Siblings Daughterin law

Son inlaw

others

Elder abuser

Elder abuser

88.50%84.60%

57.70%53.80%

30.80%

11.50%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Types of abuse

Emotional abuse

Abandonment

Neglect

Verbal abuse

Economic abuse

Physical abuse

88.5

0%

84.6

0%

80.8

0%

80.8

0%

61.5

0%

61.5

0%

61.5

0%

46.1

0%

34.6

0%

23.1

0%

15.4

0%

7.70

%

7.70

%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00% Financial difficultiessocial isolationCognitive difficultiesLiving arrangementlife stressorsPhysical impairmentEconomic dependency upon elderModernalizationPsychopathology of family memberPovertyDependency on caregiverSubstance abuse of caregiverOverburdened caregiver

84.60%

69.20%

38.50%

26.90%

7.70% 7.70%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

Depressive symptoms

Reexperiencing events

Shame

Isolation & Loneness

Physical injury

No consequences