Introduction

There is scant evidence on elder abuse, one of the most hidden and frequent forms of family violence. According to the Centers for Disease Control and Prevention (CDC), elder abuse is an intentional act, or failure to act, by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult.¹

Social changes due to urbanism, acculturation, and fading of values and traditional beliefs have led to some challenges in family relationships, including domestic elder abuse. Elder abuse is not a new issue, but it has recently been raised as a main public health and a widespread, growing social problem worldwide. Elder abuse is targeted intentionally or unintentionally at the elderly and making them injured and annoyed.²

The World Health Organization (WHO) has reported the rate of elder abuse in domestic settings in developed countries to be 4%-6% if physical, psychological and financial abuse, and neglect are all included.³

A recently published paper reported an aggregate prevalence of 4.6% of elder abuse in New York state households, the United States in 2009.⁴ A systematic review of prevalence and risk factors for elder abuse in Asia reported the prevalence ranging from 0.22 per 1000 to 62%, across Asia.⁵ Despite the WHO’s emphasis on international awareness of detection and prevention of elder abuse incidence, unfortunately developing countries have not yet taken necessary measures to systematically gather the relevant data. However, there is much evidence on elder abuse incidence in these countries.⁶ A study on the prevalence of elder abuse in Gorgan and Aq-Qala cities, northern Iran in 2013 reported the total frequency of elder abuse to be 63.3%.⁷

Some studies, however, have indicated that many cases of elder abuse are not detected and only 1/10 cases of elder abuse is reported.³ Newton reported that actual figures show 67% of the abuse occurs in the elders’ own homes.⁸ Because abuses in the homes are usually not reported, the rate of hidden elder abuse is likely to be higher than the reported figures. This problem is under-reported in many communities because the victims rarely report or seek out assistance.

Several abuse type patterns have been reported in different studies. In a study by Buka and Sookhoo,⁹ psychological abuse was the highest at 38.9% with sexual and societal types at the lowest level, 1.9% and 1.5%, respectively. In Manoochehri et al¹⁰ study, emotional abuse was the most prevalent (84.8%) subscale followed by neglect (68.3%), financial abuse (40.1%), and sexual abuse (35.2%). Furthermore, Heravi-Karimoei et al¹¹ study on different types of elder abuse reported that most of the elderly were victims of emotional neglect, psychological abuse, and care neglect and the least number of them were victims of rejection and physical abuse.

Elder abuse can lead to declined self-esteem, hopelessness, insufficiency, mental problems, and inability.¹² Abuse at any degrees may decline the elderly health and safety.¹³ Regarding the significance of elder abuse and the elderly’s health as well as inconsistent findings of different studies and no large study of elder abuse in Iran, the present study was conducted to determine the status of elder abuse in the elderly population of Yazd in 2014-2015.

Materials and Methods

Results

Discussion

In the present study, the mean score of elder abuse was obtained 11. 84 (SD: 12.70) of a total score of 100, representing the low level of domestic elder abuse, but 79.6% of the studied elderly experienced at least on type of abuse. Manoochehri et al¹⁰ study in 2008 indicated that the prevalence of at least one type of family elder abuse as 87. 8 %. It was reported 25. 9 % in Heravi-Karimoei et al¹⁴ study in Tehran and 10.5%-25% in Karimi and Elahi study in Ahwaz.¹⁶ The prevalence of abuse has been obtained 4%-10% in the United States,¹⁷ 14% in India,¹⁸ 36% in China,¹⁹ 3%-5% in Ireland,²⁰ and 3%-10% in Australia, Canada, and England.²¹ Pillemer and Finkelhor²² estimated the prevalence of elder abuse in Boston, the United States to be 32/1000 people and Cooper et al²³ reported the total prevalence of domestic elder abuse to be 6%. The data on elder abuse are inconsistent because of differences in methods of the studies, non-probability sampling, no consensus on elder abuse concept, use of inappropriate instruments, and the problems related to gathering of reliable data. Therefore, it is difficult to compare the findings of different studies.²⁴ However, if we cannot say that the elder abuse is more prevalent in the studied community, we may easily say that the problem is as common as other communities.

Of the subscales of elder abuse, emotional neglect (mean: 40.51) and physical abuse (mean: 1.60) were the most and least reported abuse type. Similarly, Heravi-Karimoei et al¹¹ found emotional abuse to be the most reported subscale and physical abuse the least reported subscale. Manoochehri et al¹⁰ study on the rate and types of domestic elder abuse in the elderly going to parks in Tehran demonstrated that most of the elderly were victims of emotional abuse and neglect and least of them victims of physical abuse. In Zandi and Fadaei²⁵ study on the abused elderly referring police stations, prosecutors, courts, and offices of lawyers and consultants for criminal complaint, financial abuse was reported to be the most prevalent subscale. Nowrouzi²⁶ study on elder abuse rate and associated family factors among the elderly admitted to Tehran nursing houses found emotional neglect and physical abuse to be the most and least frequent abuse in the studied population. Karimi and Elahi¹⁶ found neglect followed by financial abuse and psychological abuse to be the most frequent types of abuse in the elderly living in Ahwaz including those in nursing houses. Some other studies^27-36 also reported similar findings in elder abuse types. All these studies highlight the significance of emotional domain for the elderly. Clearly, emotional abuse is more common elder abuse type and emotional support which comprises sympathy, attention, kindness, and interest, could play an important role in improving the quality of life and health among the elderly.

Abuse scores were significantly related to elder’s age, education level, living status and insurance status. In Keyghobadi et al²⁸ study no significant relation was observed between abuse and education level, living conditions, income source, and suffering from chronic diseases. Heravi-Karimoei et al¹¹ demonstrated that abuse was significantly associated with gender, insurance, occupation, adequate financial sources, age, and number of children. In Nori et al²⁷ study there was a significant association of elder abuse with income level and marital status. Karimi and Elahi¹⁶ derived a significant association between abuse and age in the elderly. More clearly, older participants were more predisposed to abuse.

In the present study, regarding gender, there was no difference in elder abuse between men and women, which is consistent with Heravi-Karimoei et al¹¹ and inconsistent with Gil et al.³⁷ According to National Center on elder abuse report, most abused elderly in the United States are women.³⁸ The inconsistency of the findings could be explained by the culture, customs, and religion in Yazd community by which women and men are treated equally and women are not considered subservient.

Regarding education level, abuse score was lower in educated people than the illiterate and those with elementary school education, consistent with Gil et al.³⁷ This finding represents that education contributes positively to living a healthy life in the elderly. High educated people develop mental disorders and chronic diseases less frequently³⁹ and hence are less predisposed to abuse, because acquisition of chronic and mental diseases and dementia could be one of the risk factors for being abused.

Regarding living status, mean abuse score was lower in elderly who were living with their spouses than those who were not, which is consistent with Nori et al.²⁷ As one of the potential risks to the elderly health is loneliness and seclusion, it is necessary to provide a supporting living environment and even rehabilitation services for them. The married elderly enjoy a strong support, spouse, which contributes considerably to preventing abuse in them. In most cases of abuse, the abused people are single. Losing spouse means losing emotional, mental, caring, and also financial support. The single elderly tend to face abuse in one of the subscales, particularly emotional, authority deprivation, and financial.

Regarding insurance, the findings, as expected, indicated that the elder abuse was lower in the insured elders. Since the educated, independent elders are usually insured, they are less likely to be abused.

As expected, consistent with some other studies,^16,32,40,41 a significant association was seen between elder abuse and acquisition of some diseases and problems. In other words, the elderly with chronic diseases had a lower quality of life than healthy elderly and hence were dependent on relatives’ help most of the time, making them more predisposed to abuse. These diseases may lead to elder abuse per se.

The limitations of this study include using self-reported questionnaire that are subject to response bias. Moreover, the study was conducted in Yazd province, Iran, which is famous as a traditional and religious community that respects the elders much more strictly than people in other provinces and the results cannot be generalized to the whole country. This study also was limited to urban areas and the results cannot be generalized to rural areas. Finally‏, due to non-experimental nature of the study, no causal inferences may be drawn.

Conclusion

Despite a low rate of domestic elder abuse, a large proportion of the elders experience some type(s) of abuse. Emotional neglect is the most frequently seen elder abuse type despite emphasis on respect for the elderly in Iran. Regarding the significance of affective domain in healthy ageing, raising the awareness and sensitivity of people and the related organizations is recommended to take effective measures to prevent elder abuse.

Ethical approval

The study was approved by the institutional review board at Shahid Sadoughi University of Medical Sciences. Moreover, participation in the study was voluntary and oral informed consent was taken from the participants for participation in the study after the study aims were explained for them before the interviews.

Competing interests

Authors declare that they have no competing interest.

Authors contributions

MSHMA and RP H, designed and implemented the study and wrote the paper. DA, participated in data analysis and ZA, participated in the study design.

Acknowledgments

The authors thank all respectful elders who participated in this study and their families. This paper was derived from a research project (grant no. 3415) funded by the Elderly Health Research Center, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

References

1. CDC. Elder Abuse: Definitions. Available from: http://www.cdc.gov/violenceprevention/elderabuse/definitions.html.
2. Taylor DK, Bachuwa G, Evans J, Jackson-Johnson V. Assessing barriers to the identification of elder abuse and neglect: a communitywide survey of primary care physicians. J Natl Med Assoc. 2006 ;98(3):403.
3. Krug EG, Mercy JA, Dahlberg LL, Zwi AB, eds. World report on violence and health. Geneva: World Health Organization; 2002. p. 129.
4. Burnes D, Pillemer K, Caccamise PL, Mason A, Henderson CR, 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(9):1906-12. doi: 10.1111/jgs.13601. [Crossref]
5. Yan E, Chan KL, Tiwari A. A systematic review of prevalence and risk factors for elder abuse in Asia. Trauma Violence Abuse 2015;16(2):199-219. doi: 10.1177/1524838014555033. [Crossref]
6. Levin SP. Discussing screening for elder abuse at primary health care level. Geneva: World Health Organization: 2008. Available from: www.who.int/ageing/publications/Discussing_Elder_Abuseweb.pdf.
7. Nassiri H, Heravi Karimooi M, Jouybari L, Sanagoo A, Chehrehgosha M. The prevalence of elder abuse in Gorgan and Aq-Qala cities, Iran in 2013. Iranian Journal of Ageing 2016;10 (4):162-173. [Persian].
8. Newton JP. Abuse in the elderly: a perennial problem. Gerontology 2005;22(1):1-2. doi: 10.1111/j.1741-2358.2005.00055.x. [Crossref]
9. Buka P, Sookhoo D. Current legal responses to elder abuse. Int J Older People Nurs 2006;1(4):194-200. doi: 10.1111/j.1748-3743.2006.00029.x. [Crossref]
10. Manoochehri H, Ghorbi B, Hosseini M, NasiriOskuyei N, Karbakhsh M. Degree and types of domestic abuse in the elderly referring to parks of Tehran. Journal of Nursing & Midwifery 2009;18(63): 39-45. [Persian].
11. Heravi-Karimoei M, Reje N, Foroughan M, Montazeri A. Elderly abuse rates within family among members of senior social clubs in Tehran. Iranian Journal of Ageing 2012;6(4):37-50. [Persian].
12. Criner JA. The Nurses role in preventing abuse of elderly patient. Rehabil Nurs 1994;19(5):277-97. doi: 10.1002/j.2048-7940.1994.tb00822.x. [Crossref]
13. Khoshbin S, Ghousi A, Frahani A, Motalagh ME. Guideline of promote healthy lifestyles in the elderly, nutrition and physical activity. 1st ed. Tehran: Office of Elderly Health, Office of Family Health and Population; 2007. [Persian].
14. Heravi-Karimooi M, Rejeh N, Montazeri A. Health-related quality of life among abused and non-abused elderly people: a comparative study. Payesh 2013;12:479-88. [Persian].
15. Heravi-Karimooi M, Anoosheh M, Foroughan M, Sheykhi M, Hajizadeh E. Designing and determining psychometric properties of the Domestic Elder Abuse Questionnaire. Iranian Journal of Ageing 2010;5(1):7-21. [Persian].
16. Karimi M, Elahi N. Elderly abuse in Ahwaz city and its relationship with individual and social characteristics. Iranian Journal of Ageing 2008;3(7):42–6. [Persian].
17. Penhale B. Older women, domestic violence, and elder abuse: a review of commonalities, differences, and shared approaches. J Elder Abuse Negl 2003;15(3/4):163-183. doi: 10.1300/J084v15n03_10. [Crossref]
18. Chokkanathan S, Lee AEY. Elder mistreatment in urban India: A community based study. J Elder Abuse Negl 2005;17(2): 45-61. doi: 10.1300/J084v17n02_03. [Crossref]
19. Dong X, Simon MA, Gorbien M. Elder abuse and neglect in an urban chinese population. J Elder Abuse Negl 2007; 19(3-4):79-96. doi: 10.1300/J084v19n03_05. [Crossref]
20. O’Neill D, McCormack P, Walsh T, Coakley D. Elder abuse. Irish Journal of Medicine Sciences 1990;159:48-9. doi: 10.1007/BF02937248. [Crossref]
21. United Nations. Elder abuse widespread and unreported says new report by Secretary-General. Second World Assembly on Ageing. 2002. Available from: http://www.globalaging.org/waa2/articles/elderabuse.htm.
22. Pillemer K, Finkelhor D. The Prevalence of Elder Abuse: A Random Sample Survey. Gerontologist 1988;28(1):51-7.doi:10.1093/geront/28.1.51. [Crossref]
23. Cooper C, Katona C, Finne-Soveri H, Topinkova E, Carpenter GI, Livingston G. Indicators of elder abuse: a cross national comparison of psychiatric morbidity and other determinants in the Ad-HOC study. Am J Geriatr Psychiatry 2006;14(6):489-7. doi: 10.1097/01.JGP.0000192498.18316.b6. [Crossref]
24. Tatara T. Elder Abuse in the United States: An Issue Paper. Washington DC: National Aging Resource Center on Elder Abuse (NABCEA); 1990.
25. Zandi F, Fadaei F. Victimization of elderly. Proceeding of the Second congress of Analysis of Geriatrics Issues in Iran. Tehran: Andisheh Kohan; 2008. [Persian].
26. Nowrouzi S. Assessment of Elder Abuse in Tehran. [Dissertation]. Tehran: University of Social Welfare and Rehabilitation Sciences; 2009. [Persian].
27. Nori A, Rajabi A, Esmailzadeh F. Prevalence of elder misbehavior in northern Iran (2012). J Gorgan Univ Med Sci 2015;16(4):93-8. [Persian].
28. Keyghobadi F, Moghaddam Hosseini V, Keyghobadi F, Rakhshani MH. Prevalence of Elder Abuse against women and Associated Factors. J Mazandaran Univ Med Sci 2014; 24(117): 125-132. [Persian].
29. Compton SA, Flanagan P, Gregg W. Elder abuse in people with dementia in Northern Ireland: prevalence and predictors in cases referred to a psychiatry of old age service. Int J Geriatr Psychiatry 1997;12(6):632-5.
30. Dong X. Elder abuse and neglect in an urban Chinese population. J Elder Abuse Negl 2007;19(3):79-96. doi: 10.1300/J084v19n03_05. [Crossref]
31. Yan E, Tang CS. Proclivity to elder abuse: A community study on Hong Kong Chinese. J Interpers Violence 2003;18(9):999-1017. doi: 10.1177/0886260503254461. [Crossref]
32. 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(2):292-7. doi: 10.2105/AJPH.2009.163089. [Crossref]
33. Comijs HC, Pot AM, Smit JH, Bouter LM, Jonker C. Elder abuse in the community: prevalence and consequences. J Am Geriatr Soc 1998;46(7):885-8.
34. Luoma ML, Koivusilta M, Lang G, Enzenhofer E, De Donder L, Verté D, et al. Prevalence Study of Abuse and Violence against Older Women. Results of a Multi-cultural Survey in Austria, Belgium, Finland, Lithuania, and Portugal (European Report of the AVOW Project). Finland: National Institute for Health and Welfare (THL); 2011.
35. Tsukada N, Saito Y, Tatara T. Japanese older people’s perceptions of “elder abuse”. J Elder Abuse Negl 2001;13(1):71-89. doi: 10.1300/J084v13n01_04. [Crossref]
36. Oh J, Kimb H S, Martinsb D, Kimc H. A study of elder abuse in Korea. Int J Nurs Stud 2006;43(2):203-14. doi: 10.1016/j.ijnurstu.2005.03.005. [Crossref]
37. Gil AP, Kislaya I, Santos AJ, Nunes B, Nicolau R, Fernandes AA. Elder abuse in Portugal: findings from the first national prevalence study. J Elder Abuse Negl 2015;27(3):174-95. doi: 10.1080/08946566.2014.953659. [Crossref]
38. National Center on Elder Abuse. World Elder Abuse Awareness Day. Available from: http://www.ncea.aoa.gov/Get_Involved/Awareness/WEAAD/index.aspx.
39. Wiglesworth A, Mosqueda L, Mulnard R, Liao S, Gibbs L, Fitzgerald W.Screening for abuse and neglect of people with dementia. J Am Geriatr Soc 2010;58(3):493-500. doi: 10.1111/j.1532-5415.2010.02737.x. [Crossref]
40. Ghodousi A, Maghsoodloo S, Hoseini SM. Forensic aspect of elder abuse: risk factors and characteristics. J Res Med Sci 2011;16(12):1598-604.
41. Phua DH, Ng TW, Seow E. Epidemiology of suspected elderly mistreatment in Singapore. Singapore Med J 2008;49(10):765-73.