Elder Abuse among Outpatient Department Attendees in a Tertiary Care Hospital in Sri Lanka

Objectives Abuse of older people is a hidden problem. Some believe that it is less in Asian societies as the extended family is a protective factor. The real extent of the problem however, is not researched adequately in Sri Lanka. Methods A cross sectional descriptive study was conducted at the North Colombo Teaching Hospital on 530 consecutive adults above 60 years of age attending the outpatient department. The Hwalek-Sengstock elder abuse screening test with modifications to address socio-cultural differences was administered. A brief demographic questionnaire and questions on past and present abuse were also included. Results Out of 530 elders studied, 32 (6%) were above 80 years of age and the mean age was 68.5 years. Male to female ratio was 1:2. Abuse, either physical, psychological, verbal or neglect was reported by 239 (45%) elders. Physical abuse was reported by 5.6%. The screening test revealed that the study population was vulnerable to psychological and financial abuse. Total overall rate of abuse was 38.5%. Loneliness was reported by 26%. Of the caregivers, 22% were financially dependent on the elders. Having more than three children was a risk factor for psychological and financial abuse and being single was a risk factor for psychological abuse. Conclusions Physical, emotional and financial abuse of elders were reported in our study population. A limitation of this study was that it studied elders who sought treatment at a tertiary care hospital. Community studies will be needed to establish the true prevalence of elder abuse.


Introduction
Abuse of older people is a hidden problem in any society or culture.Elders are frightened, ashamed or embarrassed to report such events even though they are aware that it is not sanctioned by society.Asian societies have many socio-cultural and religious practices based on the extended family concept.These values include care of the older generation by the younger generation.
In Asian societies, it is common for older persons to live with their son or daughter or even a niece or nephew.Elders living alone or in a care home for elders is considered shameful.Globalization, emergence of the nuclear family and migration of younger family members have changed these values and practices.In this backdrop elder abuse could be a problem.
The proportion of older people in the world is increasing [1].Population projections for Sri Lanka too show similar trends and by 2031 about 22% of the Sri Lankan population is expected to be aged over 60 years [2].According to population projections for 2011-2016 life expectancy of Sri Lankan females at birth is 77.2 years and for males 69.2 years [3].Elder abuse can become a significant problem because of the increase in life expectancy.
Elder abuse first appeared in medical literature as "battered granny syndrome" [4].The standard definition of elder abuse according to the World Health Organisation (WHO) 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" [5].United Nations also acknowledges elder abuse in principle 17 which states that "Older persons should be able to live in dignity and security and be free of exploitation and physical or mental abuse".Research into elder abuse highlighted the problem in high income countries in the 1980s and 90s [6][7][8][9].In Sri Lanka, there are but a handful of studies and case reports [10][11][12].
The objective of this study was to identify elder abuse among out patient department attendees over 60 years of age in a tertiary care hospital, using a culturally adapted interviewer administered tool.

Methods
A cross sectional descriptive study was conducted at the North Colombo Teaching Hospital, out-patient-Papers department on 530 adults over 60 years of age who gave informed consent.Patients were recruited consecutively.We adopted the WHO definition of elder abuse.Physical abuse was defined as the presence of at least a single episode of hitting, slapping or kicking by the care-givers.Sexual abuse was defined as inappropriate touching of private parts of the body.Financial abuse was defined as using an elder's money without expressed consent.Psychological abuse was defined as the presence of loneliness or sadness and verbal abuse was defined as derogatory remarks made about the elderly person.
The study was conducted using an interviewer administered questionnaire consisting of three sections.The first section contained demographic details, the second section consisted of the screening test of elder abuse, Hwalek-Sengstock Elder Abuse Screening Test (H/S EAST) and the third section consisted of question on current or past abuse.The screening test used in this study (H/S EAST) was adapted for a Sri Lankan population [13].The modified version was assessed for face and content validity among fifty elderly people.
Data were collected by trained pre-intern medical officers after obtaining informed written consent.Those with a mini-mental state examination score of 23 or less were excluded from the study, as they may not have the capacity to give informed consent, and to complete the questionnaire.The data were analysed using Statistical Package for Social Sciences (SPSS-version 14).Chi square tests were used to assess statistical significance.Approval for the study was obtained from the Ethics Review Committee of the Faculty of Medicine, University of Kelaniya.

Results
The age range of the participants was 60 years to 93 years with a mean of 68.5 years.The male to female ratio was 1:1.9.The majority were Sinhalese living in the Gampaha District as North Colombo Teaching Hospital is the main teaching hospital in the District.Race and religious distribution reflected the expected population trends (Table 1).Majority of elders were married and only 5% were either divorced or never married.The study group included 46 (9%) professionals, 122 (23%) skilled workers and 149 (28%) unskilled workers.However, only 84 (16%) were still gainfully employed.The group that was never employed (40%) mainly included housewives.Helping with domestic work, leisure activity and religious activity were the commonest ways of spending the day.The majority (88%) had a monthly income more than Sri Lankan Rupees 5000.The majority (68%) stated that they were financially supported by their children.The spouse supported 90 (17%) participants and 60 (11%) received a pension.Only 19 (3.5%) stated that they received money from social services (Table 1).Thirty two (6%) did not have children while 120 (22%) had more than 5 children and 226 (43%) had 1-3 children.The majority of elders 429 (81%) lived with children, while 272 (51%) lived with the spouse.Sixty four (12%) lived alone with the spouse, while 17 (3%) lived with relatives or friends and 27 (5%) lived alone.Ninety six (18%) stated that less than 3 persons were living in their home while 165 (31%) had more than 5 persons in the house.Alcohol consumption was reported by 103 (19%) and all were males.A similar number (18%) smoked tobacco.
According to H/S EAST, 204 (38.5%) of our study population was at high risk of being abused, neglected or exploited (Table 2).A positive answer to three or more questions indicated high risk of abuse.Response of "no" to questions 7, 8, 14 and 16, a response of "someone else" to question 1 and a response of "yes" to all others was taken as indications of being "abused."The H/S EAST showed that elders were more vulnerable to financial and psychological abuse than physical abuse.Violation of personal rights or indication of physical abuse was present in 6% while individual rights such as the right to practice their religion as they wished and the right to free movement were preserved.
The third section of the questionnaire on current and past abuse showed that some form of abuse, either physical, psychological, verbal or neglect was present in Papers 239 (45%) of elders.Fourteen (2.6%) elders had been hit, slapped or kicked by the caregivers while five persons received medical attention for injuries.However, only three made a complaint to the police against the caregiver.None of the elders in our sample were abused sexually.All elders who were physically abused underwent verbal abuse too.
Severe loneliness or sadness was stated by 136 (26%) persons.Twenty six (5%) were ignored by carers, while 53 (10%) experienced derogatory remarks.Seventeen (3%) stated that their health needs such as poor vision, hearing, dental hygiene etc. were not attended to.Six (1%) stated that they had been left alone without any food while two people stated that they had been denied access to medical care.One hundred and sixteen (22%) caregivers were dependent on the income from the elders they were caring for.Thirteen (2.6%) elders claimed that their property or money was forcefully taken away by caregivers.
We also studied the relationship of current or past abuse and the nature of the families (Table 3).Those psychologically abused in comparison to the non-abused, had 3 or more children (p<0.000) and lived in a house belonged to the elderly person (p=0.011).Physical abuse was more significant when the spouse was not living (p=0.001) and the legal ownership of the house was with children or others (p=0.027).Financial abuse was associated with having 3 or more children (p<0.001).

Discussion
Our study found that nearly half of elders over 60 years of age attending an out-patient department alleged some form of abuse.Psychological abuse was the commonest form of abuse, followed by financial exploitation.Physical abuse was reported only by a small proportion.Elder abuse appears to be a significant problem and it is possible that there is significant under-reporting.
Risk of elder abuse is more than the reported prevalence rates [14,15].The 2002 WHO report on world violence estimated a prevalence rate of 4% to 6% among older people which includes physical, psychological and financial abuse, and neglect.These were based on results from five high income countries [16].Cooper et al in their systematic review based on 49 studies around the world estimate the prevalence rate of elder abuse as more than 6%.A quarter of vulnerable adults and a third of family carers report being involved in significant abuse [17].
The prevalence of elder abuse and the types of abuse vary in different regions of the world [18][19][20][21][22][23][24][25][26].Canada reports higher rates of financial abuse, whereas the United Kingdom and the Netherlands report higher rates of verbal abuse [18][19][20].Australia reports higher psychological abuse [21].The first National Survey on elder abuse and neglect in Israel conducted during 2004-2005 reported that 18.4% of the respondents were exposed to some form of abuse during the 12 months preceding the interview.Verbal abuse and financial exploitation were the commonest forms of abuse [22].Asian societies such as India, China, Singapore and Japan have reported higher rates of elder abuse compared to high income countries in the West.The rates varied between 14% in India to 36% in China [23][24][25][26].Perera et al in their study on prevalence of elder abuse among elderly residents in the Galle Medical Officer Hospital based studies in Asia report findings similar to ours.A study on elder abuse among elders from India seeking prosthetic rehabilitation for missing teeth reported some form of abuse in 43% of elders [27].A cross-sectional study in a major urban medical center in Nanjing, China in 2007 report that 35% of participants screened positive for elder abuse and neglect [28].Financial abuse and exploitation in the Indian and Chinese studies were in the 20% to 25% range as in our study.In all three studies, physical abuse was less than 3%.
The high percentage of financial abuse seen in our study may be associated with Asian cultural practices as well as poverty.The study showed that the elderly parents spent their own money for family needs.Loneliness was the commonest psychological abuse reported in our study.This is unfortunate as most older people expect to live with their children and grandchildren.Perhaps the changing socio-economic realities have resulted in young families adopting a nuclear family concept excluding the older adults.Those having more than three children were at risk of psychological and financial abuse.This is contrary to the expectation that larger families with more children would be protective for elders as they would have more people to care for them.
The main limitation of this study is that it was a hospital based study and the findings cannot be generalised to the community.Those who do not access hospital services and those who are not ambulant would not have been sampled.The study also excluded those with dementia and cognitive impairment.The above mentioned groups may be more vulnerable to abuse.Even though the questionnaire was adapted to suit our culture it may have had shortcomings.The response to interviewer based questionnaire would depend on the rapport between the interviewer and the elderly person.

Conclusions
Physical, emotional and financial abuse were reported by the elderly in our sample.The medical community should take a more active role in the detection of elder abuse as elders visit doctors frequently.Greater awareness of this issue is necessary in all strata of society to prevent this.

Table 3 . Factors associated with elder abuse
[12] area in Sri Lanka report physical abuse in 9.8% of elderly females and 4.1% of elderly males; emotional abuse in 28.3% of females and 20.6% of males; financial abuse in 18.5% of females and 33.5% of males; neglect in 85% of females and 75.3% of males[12].Although the prevalence rate of elder abuse in the Galle MOH area cannot be taken as the prevalence rate for Sri Lanka, it shows a similar rate to other Asian countries.