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Psychological abuse and its characteristic correlates among elderly Taiwanese
Archives of Gerontology and Geriatrics 42 (2006) 307–318 www.elsevier.com/locate/archger
Psychological abuse and its characteristic correlates among elderly Taiwanese Jing-Jy Wang * Department of Nursing, Fooyin University, 151 Chinh-Hsuen Road, Ta-Liao Hsiang, Kaohsiung Hsien 831, Taiwan ROC Received 22 March 2005; received in revised form 15 August 2005; accepted 17 August 2005 Available online 7 October 2005
Abstract This study examined the prevalence of psychological abuse and identified individual characteristics associated with different levels of psychological abuse in a group of randomly selected elderly Taiwanese. A cross-sectional design was performed that utilized a descriptive-correlational approach. Data for this study were gathered from several communities in southern Taiwan. The sample comprised 195 elderly Taiwanese aged 60 years or older, capable of verbal communication, and partially dependent on a caregiver. The Psychological Elder Abuse Scale (PEAS), the Short Portable Mental State Questionnaire (SPMSQ), and the Barthel’s Index were used for data collection. The findings demonstrated that the PEAS score range was 0–24 (mean 6.32 4.6). Moreover, 44 subjects (22.6%) had scores of ten or greater. The most frequently reported indicators in the PEAS were ‘‘wishes to see family members unfulfilled’’ and ‘‘economic dependence on others’’. The analytical results also showed that the SPMSQ and Barthel’s Index scores were strongly related to the PEAS score ( p < 0.001), indicating psychological abuse appeared higher among elderly people with lower cognitive and physical functioning. The findings of this study are crucial in developing a national system for protecting the elderly, and a continuing educational plan is required for enforcing communication between caregivers and elders. # 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Psychological elder abuse; Cognitive functioning; Physical functioning
1. Introduction According to the Department of Economic and Social Affairs of the United Nations, the older population is itself aging, with the 80 years or older segment now having become the * Tel.: +886 7 7811151x601; fax: +886 7 7836719. E-mail address: [email protected]. 0167-4943/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2005.08.006
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fastest growing sector of the older population. Although abuse and neglect of the elderly is not a new phenomenon, the literature only began candidly discussing this subject as a social problem in the 1970s both in eastern and western countries (Choi and Mayer, 2000; Jamuna, 2003). Importantly, the problem is likely to grow in the future, with predicted rapid growth of the elderly population worldwide, who perhaps face the highest risk of abuse and neglect. Based on a review of the previous literature, although most discussions of abuse of the elderly have discussed physical abuse, which frequently leaves visible scars, bruises, or broke bones, numerous discussions have also included emotional or psychological abuse, which inflicts anguish, pain, or distress through verbal aggression, threats, intimidation, insults, humiliation, and harassment, and can be both intentional or unintentional (Choi and Mayer, 2000). Abuse, regardless of its form, is largely a hidden problem since both those abused and the perpetrators frequently feel ashamed and thus hide the incidents from investigators. However, most studies from developed countries have found that the most common types of maltreatment of the elderly are neglect and psychological or emotional abuse (Soeda and Araki, 1999; Goergen, 2001; Vida et al., 2002). In Taiwan, physical abuse of elders is socially unacceptable and, since 2002, elderly protective services have been provided in accordance with the Elderly Welfare Protection Law (Ministry of Interior, 2002). However, special attention should be drawn to the more common but harder to identify ‘‘psychological abuse of elders’’, as discussed by Choi and Mayer (2000). However, cases of psychological abuse of the elderly are being missed because only cases of visible physical abuse are typically reported to the relevant governmental agencies. Psychological abuse can only be identified by observing day-today interactions. As Johnson (1995) stated, psychological abuse may be especially difficult to define because it lacks concrete behavioral criteria. Several reasons exist for the paucity of empirical research on psychological abuse of the elderly in Taiwan. First, most governmental officials only considered the detection of obvious physical abuse. Second, researchers feared that if their research revealed evidence of abuse of the elderly in domestic or institutional care, their work would be perceived as accusing family or staff caregivers of emotional mistreatment of their charges. Third, elderly Taiwanese who have been abused may be reluctant to report such abuse because of being dependent on their abuser (mostly their own children) for their basic survival. Furthermore, some abused elderly people may fear removal from their homes or being institutionalized, whereas others fear abandonment or subsequent reprisals. Because little literature exists examining the level of psychological abuse and its related factors among elderly Taiwanese, this study attempts to achieve two objectives: (1) to examine the prevalence of psychological abuse of the elderly in Taiwan, (2) to identify personal characteristics associated with abuse. 1.1. Prevalence Studies in the United States showed that roughly 3.2–10% of adults aged 65 years and older had experienced all types of abuse (Pillemer and Finkelhor, 1988; Podnieks et al., 1990; Jones et al., 1997). Moreover, Jones et al. (1997) reported a figure of 68% of elderly adults having been psychologically abused. Another investigation reported that 81% of institutional staff claimed to have witnessed psychological abuse (Pillemer and Moore,
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1989). Furthermore, a 4–16% prevalence of abuse or neglect was found in Canada, with 1.4–6% being chronic verbal aggression (Podnieks et al., 1990; Vida et al., 2002). Psychological abuse towards elderly residents appeared common among Canadian and American nursing care staff, and up to 36–40% of staff admitted psychologically abusing residents (Pillemer and Finkelhor, 1988; Pillemer and Moore, 1989; Beaulieu, 1992). In European countries, Hydle (1993) reported a 1–8% prevalence of abuse by close relatives from a investigation carried out in Denmark, Finland, and Sweden. Moreover, in the Netherlands, Comijs et al. (1998) reported a prevalence of 5.6% prevalence in a random sample of 1797 elderly persons, as well as a 3.2% prevalence of verbal aggression. In Ireland, a 3–5% prevalence of elderly abuse was found (O’Neill et al., 1990; O’Loughlin and Duggan, 1998). In Germany, Hirseh and Brendebach (1999) found a 5-year abuse prevalence of 10% via a postal questionnaire sample of elderly living in Bonn, generally psychological and financial abuse. Additionally, Goergen (2001) reported that 79% of caregivers had abused or neglected a resident at least once during the previous months, and 66% of them had witnessed victimization of residents by colleagues. Furthermore, a Swedish study found that 11% of the nursing staff were aware of situations of abuse of the elderly, and 2% admitted having themselves been abusive towards elderly residents (Saveman et al., 1999). Additionally, in New Zealand, Weatherall (2001) discovered that 92% of health care managers identify at least one resident who had been subjected to abuse during the last year, generally psychological abuse. In Asian countries such as Japan, Tyan (1994) reported a prevalence of abuse of the elderly of approximately 4%. To summarize, abuse of the elderly in developed countries has been reported in 1–10% prevalence of communities of elderly people, with psychological abuse being the most common type. However, accurate figures do not exist for the developing world. In Taiwan, a governmental administration report demonstrated that around 10% of adults aged 65 years and older had experienced abuse, and 15% worried about being abused (Lo et al., 2001), but forms of abuse were not specified. However, in 2001, total abuse of the elderly referrals received by governmental agencies were below 1000 cases for the whole of Taiwan, which is clearly an under-estimate (Ministry of Interior, 2001). Therefore, besides reports received by individual local governments, the only reliable sources of evidence are crime records, journalistic or news reports, social welfare records, and case studies. Data regarding this subject was not systematically collected from Taiwan. 1.2. Characteristic correlates Some of the key factors related to residential abuse of the elderly include the residential setting environment, the staff characteristics, and the resident characteristics (including cognitive impairments and communication difficulties). Most western studies found that the indicators of frailty and dependency among the elderly were significant predictors of mistreatment (Coyne et al., 1993; Lachs et al., 1997; Comijs et al., 1999; Saveman et al., 1999; Soeda and Araki, 1999). Restated, older age, impairment of activities of daily living (ADLs), and cognitive deficits are associated with increased vulnerability to mistreatment. The two studies by Soeda and Araki (1999) demonstrated that 42.4 and 57.6% of abused elderly individuals are demented, indicating that the demented elders are abused more than the normal elders. Additionally, their work found that between 72 and 81% of abused
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elderly people are moderately to severely dependent on their caregivers. The other aspect of this problem is that a high proportion of individuals with cognitive impairment are abusive towards their caregivers (Kitchen et al., 2002). Personal characteristics identified in the literature to be prevalent among victims of abuse include female gender, minority status, living arrangement, family relationship, and socioeconomic status. Saveman et al. (1999) reported that two thirds of victims of abuse were women, and moreover the average age of victims of abuse was 81 years, and most such victims had more than one handicap/ disability, for example dementia, mobility disorders, or behavioral disorders. In Japan, daughters-in-law have been identified as the main perpetrators of elderly abuse. Meanwhile, among the abused, over 70% are women and the majority are aged over 80 years old. Vida et al. (2002) found that patients living with non-spouse family, friends, or others were considerably more likely to have suffered abuse than were those living with their own spouse or in a supervised setting. Matthias and Benjamin (2003) found that family ties played a significant role in abuse of the elderly. In Canada, ecological studies suggest that communities with high rates of referral for cases of abuse of the elderly tend to display lower socioeconomic status (Vida et al., 2002). In Taiwan, Chung and Jang (2000) analyzed the characteristics of 85 elderly people referred as victims of abuse from the Taipei City Domestic Violence Protection Center, and found that female sex, age 75 years and older, being widowed, living at home with adult children and grandchildren, poor health, economic dependency, and impaired physical and functional ability were significantly correlated to abuse of the elderly. 1.3. Effect of abuse on psychological health Reported correlates of and risk factors for abuse of the elderly are complex and vary with investigation objectives, types of abuse, samples and methods. Several studies had confirmed that the abuse was markedly attributed to the stress associated with caregiving and poor relationships between caregivers and the abused (Soeda and Araki, 1999; Vida et al., 2002). Regarding the psychological effects of maltreatment, some studies found that abused elderly individuals displayed significantly higher rates of depression than nonabused elders (Bristowe and Collins, 1989; Pillemer and Prescott, 1989). Other consequences of psychological abuse include helplessness, posttraumatic stress disorder, or feelings of guilt, shame, and fear (Wolf, 1997). Therefore, preventive programs should be initiated to assist elderly people at risk of abuse.
2. Subjects and methods A cross-sectional design utilizing the descriptive-correlational approach, the face-toface administration of study instruments and direct observation were used for this study. 2.1. Setting and sampling The data was collected by random sampling. Data for this study were obtained from several communities located in Kaohsiung and PingDong County. The sample comprised
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99 institutionalized (50.8%) and 96 domestic (49.2%) adults aged 60 years or older, capable of verbal communication, and partially dependent on a caregiver. 2.2. Instruments The Psychological Elder Abuse Scale (PEAS) (Wang et al., 2005) was developed by the investigator previous to this study for assessing level of psychological abuse of elders, because no such instruments are available for use in Taiwan. This instrument was mainly developed in Chinese. The PEAS is a 32-item scale based on a yes/no response format, which is user-friendly for older adults. The PEAS was relatively easy to administer, and took just 10 min. The total psychological abuse scores of the subjects were calculated as the sum of all items answered in the affirmative, with a higher score indicating greater psychological abuse. A cut-off point of 10 or above suggests a greater likelihood of psychological abuse. The expert content validity index (CVI) for the PEAS was 0.92. Furthermore, the test–retest reliability of the PEAS was established, with the percentage agreement between two interviewers ranging from a high of 100% for seven indicators to a low of 79% for one indicator. Most indicators had significant Kappa values, exceeding 0.60. A Short Portable Mental State Questionnaire (SPMSQ) (Pfeiffer, 1975) with high validity and test–retest reliability was used. This was a 10-item questionnaire designed to measure several intellectual domains, including general information, orientation, short and long-term memory, and problem solving. The total score of the SPMSQ ranged from 0 to 10. A total score of eight and above represented intact cognitive functioning; 6–7 denoted mild cognitive impairment; 3–5 indicated moderate cognitive impairment; and 0–2 represented severe cognitive impairment. The Chinese version of the SPMSQ was validated in several studies, and the Cronbach’s alpha of the SPMSQ Chinese version was 0.70 (Chi and Boey, 1993; Chou, 2002). The Barthel’s Index (Mahoney and Barthel, 1965) was a highly validated and widespread instrument for assessing disability in activities of daily living (ADLs). This instrument includes 10 tasks of self-care and physical functioning ability. The total score of the Barthel’s Index ranged from 0 to 100. A total score of 100 represented total independence; 91–99 denoted mild dependence; 61–90 indicated moderate dependence; 21–60 represented severe dependence; and 0–20 denoted total dependence. A Chinese version of the Barthel’s scale was established earlier by Dai et al. (1995). 2.3. Data collection and analysis Study sites included several community institutions and domestic homes. Residents from all study sites who met the study criteria were recruited as potential subjects. The researcher randomly selected potential subjects from the study sites. Then, an institutional and home visit was made for each subject. Before the visit, the purpose of the study was explained and the consent form signed. Following subjects were recruited, structured faceto-face interviews and direct observation were used to administer the study instruments. Data was collected between January 2002 and June 2003. A total of 195 subjects completed the study. The PEAS was administered to each participant together with the SPMSQ and the Barthel’s index and the collection of demographic information. Data entry and analysis
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was performed using the SPSS 12.0 statistical software package. Mean, standard deviation, frequency, percentage, and Pearson’s correlation were used for data analysis.
3. Results 3.1. Demographic characteristics The sample comprised 88 males (45.1%) and 107 females (54.9%), with ages ranging from 60 to 96 years (mean 77.9 7.6). Among the subjects, 44.1% were illiterate, and only 10 had completed a college education. Most of the participants were widowed (50.8%); 39.5% were married. Most of the subjects were born in Taiwan (75.4%), and the remainder were immigrants from the Chinese mainland. The average number of chronic diseases per subject was 2.2 1.6 (S.D.) (range 0–7). About 61% of the subjects had a reasonable income. Of the 96 elderly subjects living at home, 46 were cared for by their children, 26 by spouses, 12 by in-laws, and the rest by paid-employment or other means, and 52% lived with their own children or grandchildren. Table 1 lists the demographic characteristics of the subjects. 3.2. Prevalence of elder psychological abuse The PEAS score range for the 195 subjects was 0–24 (mean 6.32 4.6). Moreover, the distribution of the overall scores was positively skewed. Forty-four subjects (22.6%) had scores of 10 or above. Regarding the 32 indicators, 62.6% of the subjects reported ‘‘wishes to see relatives unfulfilled’’, 61% reported having ‘‘Economic dependence on others’’, 44.1% reported having ‘‘Poor sleep for unknown reasons’’, and 40.5% reported being ‘‘Left alone involuntarily’’. Additionally, between 25 and 31% of the subjects reported ‘‘Excessive dependence on caregiver’’, ‘‘Low self-esteem’’, ‘‘privacy not respected’’, and ‘‘Feeling emotionally confused, dispirited and anxious’’. The above eight indicators were most frequently reported by the study subjects (Table 2). 3.3. Association between level of abuse and personal characteristics The mean PEAS for the institutionalized subjects was 5.83 4.9, compared to 6.83 4.2 for the domestic subjects, revealing no significant difference (t = 1.53, p = 0.12). Pearson correlation analysis revealed no significant correlation between the PEAS and subject age, educational level, and number of children. However, number of chronic diseases was significantly related to the PEAS (r = 0.23, p = 0.001), indicating that individuals with chronic disease may experience more psychological abuse from their caregivers. Chi-square test also indicated that subjects’ social economic status significantly influenced level of psychological abuse ( p = 0.005). Additionally, the correlation between overall SPMSQ and the PEAS score was 0.32 ( p < 0.001), indicating that experience of psychological abuse increased with subject cognitive impairment. Furthermore, subject dependence status, as indicated by the Barthel’s index, was also significantly related to the PEAS (r = 0.362, p < 0.001), indicating that the level of psychological abuse increased with the functional dependence of individuals.
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Table 1 Demographic characteristics of the subjects (N = 195) Variables
Frequency
Percentage
Gender Male Female
88 107
45.1 54.9
Age (year) 60–75 75–85 Over 85
76 86 33
39.0 44.1 16.9
Education (year) 0 1–5 6–9 9–12 Over 12
86 26 55 18 10
44.1 13.3 28.2 9.2 5.1
Marital status Married Widowed Single Divorced/separated
77 99 16 3
39.5 50.8 8.2 1.5
Primary caregiver Institutionalized Children Spouse In-law Paid-employment and other
99 46 26 12 12
50.8 23.6 13.3 6.2 6.2
Living arrangement Institutionalized Alone With spouse With children/grandchildren With friends/relatives
99 16 24 49 7
50.8 8.2 12.3 25.1 3.6
Number of chronic diseases 0 1–3 4
24 140 31
12.3 71.8 15.9
Income status Adequate Fair Not adequate
44 120 31
22.6 61.5 15.9
4. Discussion The wide range of abuse scores (0–24) obtained on the PEAS was expected because individual subjective experience of abuse is idiosyncratic, and health practitioners must be aware that individual subjects do not necessarily experience all indicators of abuse. The
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Table 2 Frequency and percentage of abuse for each of the items on the PEAS (N = 195) #
Indicators
Frequency
Percentage
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Left alone involuntarily Personal belongings used without permission Angry at caregiver Dependent on others economically Wish to see relatives unfulfilled Poor sleep for unknown reasons Inability to make own decisions No response to alert of health problems Irrelevant answers to questions or unresponsive Facial expression of dissatisfaction towards caregiver Unexplained problems with verbal expression or language Privacy not respected Verbal description of abuse situation Nightmares Feeling emotionally confused, dispirited and anxious Isolation and withdrawal from social activities Unnecessary suspicions and ideation of being harmed Feelings of shame, powerlessness and loss of dignity Destroyed own belongings Fear of specific persons or events Unexplained irritability Low self-esteem Eating difficulties Unreasonably inflexible viewpoint Unexplained ideation of harm and murder of others Take pleasure in blaming others Taking improper medication for unknown reasons Excessive dependence on caregiver Dissatisfied with current conditions Unreasonable demands Timidity and fearfulness Sudden loss of trust in an acquaintance
79 17 32 119 122 86 63 27 21 25 19 50 11 41 49 34 21 30 5 12 10 49 20 35 3 36 29 61 33 18 37 39
40.5 8.7 16.4 61.0 62.6 44.1 32.3 13.8 10.8 12.8 9.7 25.6 5.6 21.0 25.1 17.4 10.8 15.4 2.6 6.2 5.1 25.1 10.3 17.9 1.5 18.5 14.9 31.3 16.9 9.2 19.0 20.0
findings indicated that 22.6% of the subjects had PEAS of 10 or higher, indicating a higher prevalence of elder psychological abuse than did Taiwanese government reports, which reported a prevalence of abuse of the elderly of around 10% (Lo et al., 2001). In fact, prevalence and incidence data from different self-report studies or governmental reports in Taiwan are difficult to compare because of differences in instruments and samples. Although, psychological abuse rate varied from nation to nation and from study to study, using only cases report to governmental agencies may cause underestimation of victims. Therefore, clinicians and health care workers must recognize that cases of psychological abuse of the elderly are being largely missed. Therefore, better outreach and screening program has to be established and exercised. ‘‘Wishes to see relatives unfulfilled’’ and ‘‘economic dependence on others’’ were the two indicators most frequently reported by subjects in this study. Traditional Chinese culture considers filial piety a strong social norm, and this piety included an obligation to care for parents and visit them frequently after leaving home. Unfortunately, the values and
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attitudes of the younger generation have changed as a result of recent revolutions in social and family structure, and consequently young couples with children who move to live away from their aging parents are increasingly less likely to visit their aging parents frequently. From this perspective it is not surprising that unfulfilled expectations to see their adult children is the most frequently reported indicator of psychological abuse of the elderly. Consequently, children should make an effort to visit their elderly parents more frequently. On the other hand, studies suggested an especially high association between abuse and physical and economic dependence of the elderly (Vida et al., 2002; Jamuna, 2003). If adult children face a higher financial burden to care for their elderly parents, then the possibility of abuse is increased. Other frequently reported indicators were primarily associated with the relationship between caregivers and the elderly (excessive dependence on caregiver, being left alone involuntarily) and the autonomy of the elderly individual (lack of respect for privacy, inability to make their own decisions). This finding is similar to the findings of an earlier study by Soeda and Araki (1999), which viewed the stress associated with caregiving and the poor relationship between caregivers and elderly individuals as the most common causes of abuse. Wood and Stephens (2003) stated that elderly people are frequently left unsupervised both in residential and home case settings. In Taiwan, older people may rely on powerful others such as health providers or family members to make decisions on their behalf, thus decreasing their self-efficacy. However, respect for the decision making and privacy of elderly people can avoid unintentionally hurting the psyche of patients. Although the level of psychological abuse of the elderly did not differ significantly between the institutional and the domestic subjects in this study, the domestic subjects exhibited a higher mean score than the institutionalized elderly. This phenomenon can be explained by the fact that in a domestic setting, caregiving is difficult to supervise and monitor in Taiwan. The findings of this study also indicated that individuals with chronic diseases experienced more psychological abuse from their caregivers, a phenomenon supported by several studies indicating that people who are more physically dependent on caregivers or who demand significant attention report more abuse (Saveman et al., 1999; Soeda and Araki, 1999; Jamuna, 2003). For example, Saveman et al. (1999) noted that most abused persons exhibited multiple handicaps/disabilities. The above studies confirmed that the level of frailty and dependency of the elderly is a significant predictor of maltreatment of the elderly. The significant relationships shown between the PEAS and the measures of cognitive status and functional activity in daily living supported are similar to previous findings (Coyne et al., 1993; Lachs et al., 1997; Comijs et al., 1999; Saveman et al., 1999; Soeda and Araki, 1999). Restated, impairments affecting activities of daily living (ADLs) and cognitive deficits are associated with increased vulnerability of elders to mistreatment. Therefore, management and prevention programs relating to abuse of the elderly should target specific personal characteristics that are associated with such abuse.
5. Conclusions This study demonstrates that psychological abuse of the elderly is common among elderly Taiwanese in community setting, and that interventional services should develop
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multidisciplinary expertise and resources for dealing with such invisible abuse. Additionally, caution against oversimplification of psychological abuse as a unitary problem should be activated. Nevertheless, attention should also be paid to the personal characteristics of the elderly, because the cognitive and physical function of the elderly was closely associated with level of abuse. The contextual factors related to psychological abuse of the elderly must be monitored to prevent abuse. The findings of this study can provide a crucial component for designing a nationwide system for protecting the elderly, and a continuing educational plan to enforce communication mode between caregivers and elders will be needed. Health practitioners are also responsible for educating the public about maltreatment of the elderly, including educating family caregivers, home health aids and institutional nurse aids. O’Brien and Smock (2003) stated that the ‘‘prevention of abuse and neglect represents a daunting task with a constantly growing population of dependent older adults imposing an increasing demand on caregivers and on social and health services’’ (p. 296). Formal support system resources must be made available from the governmental health services. Most importantly, understanding and respecting the rights of older people is crucial for preventing psychological abuse of the elderly. 5.1. Limitations and future research The findings of this study may not be generalizable to larger populations because the study data was gathered from a geographically limited area in southern Taiwan. The other limitation involved instrument issue. The PEAS partly relied upon self-report of indicators by caregivers, making it impossible to know whether respondents would have reacted in exactly the same way in a real-life situation. Despite the growing awareness of abuse of the elderly, risk factors associated with caregivers, for example stress and burnout, depression and anxiety, environmental hazards, and financial difficulties and crises should be studied. Intervention strategies should be designed and the efficacy of these strategies should be estimated.
Acknowledgement The authors would like to thank the National Science Council of the Republic of China, Taiwan for financially supporting this research under Contract No. NSC 92-2314-B-242003.
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Tyan, C., 1994. Elderly welfare services study: elder abuse investigation. Presented at 1994 Elderly Intervention Conference (abstract 262), Tokyo, Japan. Vida, S., Monks, R.C., Rosiers, P.D., 2002. Prevalence and correlates of elder abuse and neglect in a geriatric psychiatry. Can. J. Psychiatry 47, 459–467. Wang, J., Hsu, Y., Chen, K., Tseng, H., 2005. Development and testing of the indicators to screening Elder Subtle Psychological Abuse for older Taiwanese adults. Presented at 23rd Quadrennial International Council of Nurses Congress (abstract # C.0400.C), Taipei, Taiwan. Weatherall, M., 2001. Elder abuse: a survey of mangers of residential care facilities in Wellington. N. Z. J. Elder Abuse Neglect 13, 91–98. Wolf, R., 1997. Elder abuse and neglect: causes and consequences. J. Geriatr. Psychiatry 30, 153–174. Wood, S., Stephens, M., 2003. Vulnerability to elder abuse and neglect in assisted living facilities. Gerontologist 43, 753–757.
Psychological abuse and its characteristic correlates among elderly Taiwanese Jing-Jy Wang * Department of Nursing, Fooyin University, 151 Chinh-Hsuen Road, Ta-Liao Hsiang, Kaohsiung Hsien 831, Taiwan ROC Received 22 March 2005; received in revised form 15 August 2005; accepted 17 August 2005 Available online 7 October 2005
Abstract This study examined the prevalence of psychological abuse and identified individual characteristics associated with different levels of psychological abuse in a group of randomly selected elderly Taiwanese. A cross-sectional design was performed that utilized a descriptive-correlational approach. Data for this study were gathered from several communities in southern Taiwan. The sample comprised 195 elderly Taiwanese aged 60 years or older, capable of verbal communication, and partially dependent on a caregiver. The Psychological Elder Abuse Scale (PEAS), the Short Portable Mental State Questionnaire (SPMSQ), and the Barthel’s Index were used for data collection. The findings demonstrated that the PEAS score range was 0–24 (mean 6.32 4.6). Moreover, 44 subjects (22.6%) had scores of ten or greater. The most frequently reported indicators in the PEAS were ‘‘wishes to see family members unfulfilled’’ and ‘‘economic dependence on others’’. The analytical results also showed that the SPMSQ and Barthel’s Index scores were strongly related to the PEAS score ( p < 0.001), indicating psychological abuse appeared higher among elderly people with lower cognitive and physical functioning. The findings of this study are crucial in developing a national system for protecting the elderly, and a continuing educational plan is required for enforcing communication between caregivers and elders. # 2005 Elsevier Ireland Ltd. All rights reserved. Keywords: Psychological elder abuse; Cognitive functioning; Physical functioning
1. Introduction According to the Department of Economic and Social Affairs of the United Nations, the older population is itself aging, with the 80 years or older segment now having become the * Tel.: +886 7 7811151x601; fax: +886 7 7836719. E-mail address: [email protected]. 0167-4943/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.archger.2005.08.006
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fastest growing sector of the older population. Although abuse and neglect of the elderly is not a new phenomenon, the literature only began candidly discussing this subject as a social problem in the 1970s both in eastern and western countries (Choi and Mayer, 2000; Jamuna, 2003). Importantly, the problem is likely to grow in the future, with predicted rapid growth of the elderly population worldwide, who perhaps face the highest risk of abuse and neglect. Based on a review of the previous literature, although most discussions of abuse of the elderly have discussed physical abuse, which frequently leaves visible scars, bruises, or broke bones, numerous discussions have also included emotional or psychological abuse, which inflicts anguish, pain, or distress through verbal aggression, threats, intimidation, insults, humiliation, and harassment, and can be both intentional or unintentional (Choi and Mayer, 2000). Abuse, regardless of its form, is largely a hidden problem since both those abused and the perpetrators frequently feel ashamed and thus hide the incidents from investigators. However, most studies from developed countries have found that the most common types of maltreatment of the elderly are neglect and psychological or emotional abuse (Soeda and Araki, 1999; Goergen, 2001; Vida et al., 2002). In Taiwan, physical abuse of elders is socially unacceptable and, since 2002, elderly protective services have been provided in accordance with the Elderly Welfare Protection Law (Ministry of Interior, 2002). However, special attention should be drawn to the more common but harder to identify ‘‘psychological abuse of elders’’, as discussed by Choi and Mayer (2000). However, cases of psychological abuse of the elderly are being missed because only cases of visible physical abuse are typically reported to the relevant governmental agencies. Psychological abuse can only be identified by observing day-today interactions. As Johnson (1995) stated, psychological abuse may be especially difficult to define because it lacks concrete behavioral criteria. Several reasons exist for the paucity of empirical research on psychological abuse of the elderly in Taiwan. First, most governmental officials only considered the detection of obvious physical abuse. Second, researchers feared that if their research revealed evidence of abuse of the elderly in domestic or institutional care, their work would be perceived as accusing family or staff caregivers of emotional mistreatment of their charges. Third, elderly Taiwanese who have been abused may be reluctant to report such abuse because of being dependent on their abuser (mostly their own children) for their basic survival. Furthermore, some abused elderly people may fear removal from their homes or being institutionalized, whereas others fear abandonment or subsequent reprisals. Because little literature exists examining the level of psychological abuse and its related factors among elderly Taiwanese, this study attempts to achieve two objectives: (1) to examine the prevalence of psychological abuse of the elderly in Taiwan, (2) to identify personal characteristics associated with abuse. 1.1. Prevalence Studies in the United States showed that roughly 3.2–10% of adults aged 65 years and older had experienced all types of abuse (Pillemer and Finkelhor, 1988; Podnieks et al., 1990; Jones et al., 1997). Moreover, Jones et al. (1997) reported a figure of 68% of elderly adults having been psychologically abused. Another investigation reported that 81% of institutional staff claimed to have witnessed psychological abuse (Pillemer and Moore,
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1989). Furthermore, a 4–16% prevalence of abuse or neglect was found in Canada, with 1.4–6% being chronic verbal aggression (Podnieks et al., 1990; Vida et al., 2002). Psychological abuse towards elderly residents appeared common among Canadian and American nursing care staff, and up to 36–40% of staff admitted psychologically abusing residents (Pillemer and Finkelhor, 1988; Pillemer and Moore, 1989; Beaulieu, 1992). In European countries, Hydle (1993) reported a 1–8% prevalence of abuse by close relatives from a investigation carried out in Denmark, Finland, and Sweden. Moreover, in the Netherlands, Comijs et al. (1998) reported a prevalence of 5.6% prevalence in a random sample of 1797 elderly persons, as well as a 3.2% prevalence of verbal aggression. In Ireland, a 3–5% prevalence of elderly abuse was found (O’Neill et al., 1990; O’Loughlin and Duggan, 1998). In Germany, Hirseh and Brendebach (1999) found a 5-year abuse prevalence of 10% via a postal questionnaire sample of elderly living in Bonn, generally psychological and financial abuse. Additionally, Goergen (2001) reported that 79% of caregivers had abused or neglected a resident at least once during the previous months, and 66% of them had witnessed victimization of residents by colleagues. Furthermore, a Swedish study found that 11% of the nursing staff were aware of situations of abuse of the elderly, and 2% admitted having themselves been abusive towards elderly residents (Saveman et al., 1999). Additionally, in New Zealand, Weatherall (2001) discovered that 92% of health care managers identify at least one resident who had been subjected to abuse during the last year, generally psychological abuse. In Asian countries such as Japan, Tyan (1994) reported a prevalence of abuse of the elderly of approximately 4%. To summarize, abuse of the elderly in developed countries has been reported in 1–10% prevalence of communities of elderly people, with psychological abuse being the most common type. However, accurate figures do not exist for the developing world. In Taiwan, a governmental administration report demonstrated that around 10% of adults aged 65 years and older had experienced abuse, and 15% worried about being abused (Lo et al., 2001), but forms of abuse were not specified. However, in 2001, total abuse of the elderly referrals received by governmental agencies were below 1000 cases for the whole of Taiwan, which is clearly an under-estimate (Ministry of Interior, 2001). Therefore, besides reports received by individual local governments, the only reliable sources of evidence are crime records, journalistic or news reports, social welfare records, and case studies. Data regarding this subject was not systematically collected from Taiwan. 1.2. Characteristic correlates Some of the key factors related to residential abuse of the elderly include the residential setting environment, the staff characteristics, and the resident characteristics (including cognitive impairments and communication difficulties). Most western studies found that the indicators of frailty and dependency among the elderly were significant predictors of mistreatment (Coyne et al., 1993; Lachs et al., 1997; Comijs et al., 1999; Saveman et al., 1999; Soeda and Araki, 1999). Restated, older age, impairment of activities of daily living (ADLs), and cognitive deficits are associated with increased vulnerability to mistreatment. The two studies by Soeda and Araki (1999) demonstrated that 42.4 and 57.6% of abused elderly individuals are demented, indicating that the demented elders are abused more than the normal elders. Additionally, their work found that between 72 and 81% of abused
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elderly people are moderately to severely dependent on their caregivers. The other aspect of this problem is that a high proportion of individuals with cognitive impairment are abusive towards their caregivers (Kitchen et al., 2002). Personal characteristics identified in the literature to be prevalent among victims of abuse include female gender, minority status, living arrangement, family relationship, and socioeconomic status. Saveman et al. (1999) reported that two thirds of victims of abuse were women, and moreover the average age of victims of abuse was 81 years, and most such victims had more than one handicap/ disability, for example dementia, mobility disorders, or behavioral disorders. In Japan, daughters-in-law have been identified as the main perpetrators of elderly abuse. Meanwhile, among the abused, over 70% are women and the majority are aged over 80 years old. Vida et al. (2002) found that patients living with non-spouse family, friends, or others were considerably more likely to have suffered abuse than were those living with their own spouse or in a supervised setting. Matthias and Benjamin (2003) found that family ties played a significant role in abuse of the elderly. In Canada, ecological studies suggest that communities with high rates of referral for cases of abuse of the elderly tend to display lower socioeconomic status (Vida et al., 2002). In Taiwan, Chung and Jang (2000) analyzed the characteristics of 85 elderly people referred as victims of abuse from the Taipei City Domestic Violence Protection Center, and found that female sex, age 75 years and older, being widowed, living at home with adult children and grandchildren, poor health, economic dependency, and impaired physical and functional ability were significantly correlated to abuse of the elderly. 1.3. Effect of abuse on psychological health Reported correlates of and risk factors for abuse of the elderly are complex and vary with investigation objectives, types of abuse, samples and methods. Several studies had confirmed that the abuse was markedly attributed to the stress associated with caregiving and poor relationships between caregivers and the abused (Soeda and Araki, 1999; Vida et al., 2002). Regarding the psychological effects of maltreatment, some studies found that abused elderly individuals displayed significantly higher rates of depression than nonabused elders (Bristowe and Collins, 1989; Pillemer and Prescott, 1989). Other consequences of psychological abuse include helplessness, posttraumatic stress disorder, or feelings of guilt, shame, and fear (Wolf, 1997). Therefore, preventive programs should be initiated to assist elderly people at risk of abuse.
2. Subjects and methods A cross-sectional design utilizing the descriptive-correlational approach, the face-toface administration of study instruments and direct observation were used for this study. 2.1. Setting and sampling The data was collected by random sampling. Data for this study were obtained from several communities located in Kaohsiung and PingDong County. The sample comprised
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99 institutionalized (50.8%) and 96 domestic (49.2%) adults aged 60 years or older, capable of verbal communication, and partially dependent on a caregiver. 2.2. Instruments The Psychological Elder Abuse Scale (PEAS) (Wang et al., 2005) was developed by the investigator previous to this study for assessing level of psychological abuse of elders, because no such instruments are available for use in Taiwan. This instrument was mainly developed in Chinese. The PEAS is a 32-item scale based on a yes/no response format, which is user-friendly for older adults. The PEAS was relatively easy to administer, and took just 10 min. The total psychological abuse scores of the subjects were calculated as the sum of all items answered in the affirmative, with a higher score indicating greater psychological abuse. A cut-off point of 10 or above suggests a greater likelihood of psychological abuse. The expert content validity index (CVI) for the PEAS was 0.92. Furthermore, the test–retest reliability of the PEAS was established, with the percentage agreement between two interviewers ranging from a high of 100% for seven indicators to a low of 79% for one indicator. Most indicators had significant Kappa values, exceeding 0.60. A Short Portable Mental State Questionnaire (SPMSQ) (Pfeiffer, 1975) with high validity and test–retest reliability was used. This was a 10-item questionnaire designed to measure several intellectual domains, including general information, orientation, short and long-term memory, and problem solving. The total score of the SPMSQ ranged from 0 to 10. A total score of eight and above represented intact cognitive functioning; 6–7 denoted mild cognitive impairment; 3–5 indicated moderate cognitive impairment; and 0–2 represented severe cognitive impairment. The Chinese version of the SPMSQ was validated in several studies, and the Cronbach’s alpha of the SPMSQ Chinese version was 0.70 (Chi and Boey, 1993; Chou, 2002). The Barthel’s Index (Mahoney and Barthel, 1965) was a highly validated and widespread instrument for assessing disability in activities of daily living (ADLs). This instrument includes 10 tasks of self-care and physical functioning ability. The total score of the Barthel’s Index ranged from 0 to 100. A total score of 100 represented total independence; 91–99 denoted mild dependence; 61–90 indicated moderate dependence; 21–60 represented severe dependence; and 0–20 denoted total dependence. A Chinese version of the Barthel’s scale was established earlier by Dai et al. (1995). 2.3. Data collection and analysis Study sites included several community institutions and domestic homes. Residents from all study sites who met the study criteria were recruited as potential subjects. The researcher randomly selected potential subjects from the study sites. Then, an institutional and home visit was made for each subject. Before the visit, the purpose of the study was explained and the consent form signed. Following subjects were recruited, structured faceto-face interviews and direct observation were used to administer the study instruments. Data was collected between January 2002 and June 2003. A total of 195 subjects completed the study. The PEAS was administered to each participant together with the SPMSQ and the Barthel’s index and the collection of demographic information. Data entry and analysis
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was performed using the SPSS 12.0 statistical software package. Mean, standard deviation, frequency, percentage, and Pearson’s correlation were used for data analysis.
3. Results 3.1. Demographic characteristics The sample comprised 88 males (45.1%) and 107 females (54.9%), with ages ranging from 60 to 96 years (mean 77.9 7.6). Among the subjects, 44.1% were illiterate, and only 10 had completed a college education. Most of the participants were widowed (50.8%); 39.5% were married. Most of the subjects were born in Taiwan (75.4%), and the remainder were immigrants from the Chinese mainland. The average number of chronic diseases per subject was 2.2 1.6 (S.D.) (range 0–7). About 61% of the subjects had a reasonable income. Of the 96 elderly subjects living at home, 46 were cared for by their children, 26 by spouses, 12 by in-laws, and the rest by paid-employment or other means, and 52% lived with their own children or grandchildren. Table 1 lists the demographic characteristics of the subjects. 3.2. Prevalence of elder psychological abuse The PEAS score range for the 195 subjects was 0–24 (mean 6.32 4.6). Moreover, the distribution of the overall scores was positively skewed. Forty-four subjects (22.6%) had scores of 10 or above. Regarding the 32 indicators, 62.6% of the subjects reported ‘‘wishes to see relatives unfulfilled’’, 61% reported having ‘‘Economic dependence on others’’, 44.1% reported having ‘‘Poor sleep for unknown reasons’’, and 40.5% reported being ‘‘Left alone involuntarily’’. Additionally, between 25 and 31% of the subjects reported ‘‘Excessive dependence on caregiver’’, ‘‘Low self-esteem’’, ‘‘privacy not respected’’, and ‘‘Feeling emotionally confused, dispirited and anxious’’. The above eight indicators were most frequently reported by the study subjects (Table 2). 3.3. Association between level of abuse and personal characteristics The mean PEAS for the institutionalized subjects was 5.83 4.9, compared to 6.83 4.2 for the domestic subjects, revealing no significant difference (t = 1.53, p = 0.12). Pearson correlation analysis revealed no significant correlation between the PEAS and subject age, educational level, and number of children. However, number of chronic diseases was significantly related to the PEAS (r = 0.23, p = 0.001), indicating that individuals with chronic disease may experience more psychological abuse from their caregivers. Chi-square test also indicated that subjects’ social economic status significantly influenced level of psychological abuse ( p = 0.005). Additionally, the correlation between overall SPMSQ and the PEAS score was 0.32 ( p < 0.001), indicating that experience of psychological abuse increased with subject cognitive impairment. Furthermore, subject dependence status, as indicated by the Barthel’s index, was also significantly related to the PEAS (r = 0.362, p < 0.001), indicating that the level of psychological abuse increased with the functional dependence of individuals.
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Table 1 Demographic characteristics of the subjects (N = 195) Variables
Frequency
Percentage
Gender Male Female
88 107
45.1 54.9
Age (year) 60–75 75–85 Over 85
76 86 33
39.0 44.1 16.9
Education (year) 0 1–5 6–9 9–12 Over 12
86 26 55 18 10
44.1 13.3 28.2 9.2 5.1
Marital status Married Widowed Single Divorced/separated
77 99 16 3
39.5 50.8 8.2 1.5
Primary caregiver Institutionalized Children Spouse In-law Paid-employment and other
99 46 26 12 12
50.8 23.6 13.3 6.2 6.2
Living arrangement Institutionalized Alone With spouse With children/grandchildren With friends/relatives
99 16 24 49 7
50.8 8.2 12.3 25.1 3.6
Number of chronic diseases 0 1–3 4
24 140 31
12.3 71.8 15.9
Income status Adequate Fair Not adequate
44 120 31
22.6 61.5 15.9
4. Discussion The wide range of abuse scores (0–24) obtained on the PEAS was expected because individual subjective experience of abuse is idiosyncratic, and health practitioners must be aware that individual subjects do not necessarily experience all indicators of abuse. The
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Table 2 Frequency and percentage of abuse for each of the items on the PEAS (N = 195) #
Indicators
Frequency
Percentage
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32
Left alone involuntarily Personal belongings used without permission Angry at caregiver Dependent on others economically Wish to see relatives unfulfilled Poor sleep for unknown reasons Inability to make own decisions No response to alert of health problems Irrelevant answers to questions or unresponsive Facial expression of dissatisfaction towards caregiver Unexplained problems with verbal expression or language Privacy not respected Verbal description of abuse situation Nightmares Feeling emotionally confused, dispirited and anxious Isolation and withdrawal from social activities Unnecessary suspicions and ideation of being harmed Feelings of shame, powerlessness and loss of dignity Destroyed own belongings Fear of specific persons or events Unexplained irritability Low self-esteem Eating difficulties Unreasonably inflexible viewpoint Unexplained ideation of harm and murder of others Take pleasure in blaming others Taking improper medication for unknown reasons Excessive dependence on caregiver Dissatisfied with current conditions Unreasonable demands Timidity and fearfulness Sudden loss of trust in an acquaintance
79 17 32 119 122 86 63 27 21 25 19 50 11 41 49 34 21 30 5 12 10 49 20 35 3 36 29 61 33 18 37 39
40.5 8.7 16.4 61.0 62.6 44.1 32.3 13.8 10.8 12.8 9.7 25.6 5.6 21.0 25.1 17.4 10.8 15.4 2.6 6.2 5.1 25.1 10.3 17.9 1.5 18.5 14.9 31.3 16.9 9.2 19.0 20.0
findings indicated that 22.6% of the subjects had PEAS of 10 or higher, indicating a higher prevalence of elder psychological abuse than did Taiwanese government reports, which reported a prevalence of abuse of the elderly of around 10% (Lo et al., 2001). In fact, prevalence and incidence data from different self-report studies or governmental reports in Taiwan are difficult to compare because of differences in instruments and samples. Although, psychological abuse rate varied from nation to nation and from study to study, using only cases report to governmental agencies may cause underestimation of victims. Therefore, clinicians and health care workers must recognize that cases of psychological abuse of the elderly are being largely missed. Therefore, better outreach and screening program has to be established and exercised. ‘‘Wishes to see relatives unfulfilled’’ and ‘‘economic dependence on others’’ were the two indicators most frequently reported by subjects in this study. Traditional Chinese culture considers filial piety a strong social norm, and this piety included an obligation to care for parents and visit them frequently after leaving home. Unfortunately, the values and
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attitudes of the younger generation have changed as a result of recent revolutions in social and family structure, and consequently young couples with children who move to live away from their aging parents are increasingly less likely to visit their aging parents frequently. From this perspective it is not surprising that unfulfilled expectations to see their adult children is the most frequently reported indicator of psychological abuse of the elderly. Consequently, children should make an effort to visit their elderly parents more frequently. On the other hand, studies suggested an especially high association between abuse and physical and economic dependence of the elderly (Vida et al., 2002; Jamuna, 2003). If adult children face a higher financial burden to care for their elderly parents, then the possibility of abuse is increased. Other frequently reported indicators were primarily associated with the relationship between caregivers and the elderly (excessive dependence on caregiver, being left alone involuntarily) and the autonomy of the elderly individual (lack of respect for privacy, inability to make their own decisions). This finding is similar to the findings of an earlier study by Soeda and Araki (1999), which viewed the stress associated with caregiving and the poor relationship between caregivers and elderly individuals as the most common causes of abuse. Wood and Stephens (2003) stated that elderly people are frequently left unsupervised both in residential and home case settings. In Taiwan, older people may rely on powerful others such as health providers or family members to make decisions on their behalf, thus decreasing their self-efficacy. However, respect for the decision making and privacy of elderly people can avoid unintentionally hurting the psyche of patients. Although the level of psychological abuse of the elderly did not differ significantly between the institutional and the domestic subjects in this study, the domestic subjects exhibited a higher mean score than the institutionalized elderly. This phenomenon can be explained by the fact that in a domestic setting, caregiving is difficult to supervise and monitor in Taiwan. The findings of this study also indicated that individuals with chronic diseases experienced more psychological abuse from their caregivers, a phenomenon supported by several studies indicating that people who are more physically dependent on caregivers or who demand significant attention report more abuse (Saveman et al., 1999; Soeda and Araki, 1999; Jamuna, 2003). For example, Saveman et al. (1999) noted that most abused persons exhibited multiple handicaps/disabilities. The above studies confirmed that the level of frailty and dependency of the elderly is a significant predictor of maltreatment of the elderly. The significant relationships shown between the PEAS and the measures of cognitive status and functional activity in daily living supported are similar to previous findings (Coyne et al., 1993; Lachs et al., 1997; Comijs et al., 1999; Saveman et al., 1999; Soeda and Araki, 1999). Restated, impairments affecting activities of daily living (ADLs) and cognitive deficits are associated with increased vulnerability of elders to mistreatment. Therefore, management and prevention programs relating to abuse of the elderly should target specific personal characteristics that are associated with such abuse.
5. Conclusions This study demonstrates that psychological abuse of the elderly is common among elderly Taiwanese in community setting, and that interventional services should develop
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multidisciplinary expertise and resources for dealing with such invisible abuse. Additionally, caution against oversimplification of psychological abuse as a unitary problem should be activated. Nevertheless, attention should also be paid to the personal characteristics of the elderly, because the cognitive and physical function of the elderly was closely associated with level of abuse. The contextual factors related to psychological abuse of the elderly must be monitored to prevent abuse. The findings of this study can provide a crucial component for designing a nationwide system for protecting the elderly, and a continuing educational plan to enforce communication mode between caregivers and elders will be needed. Health practitioners are also responsible for educating the public about maltreatment of the elderly, including educating family caregivers, home health aids and institutional nurse aids. O’Brien and Smock (2003) stated that the ‘‘prevention of abuse and neglect represents a daunting task with a constantly growing population of dependent older adults imposing an increasing demand on caregivers and on social and health services’’ (p. 296). Formal support system resources must be made available from the governmental health services. Most importantly, understanding and respecting the rights of older people is crucial for preventing psychological abuse of the elderly. 5.1. Limitations and future research The findings of this study may not be generalizable to larger populations because the study data was gathered from a geographically limited area in southern Taiwan. The other limitation involved instrument issue. The PEAS partly relied upon self-report of indicators by caregivers, making it impossible to know whether respondents would have reacted in exactly the same way in a real-life situation. Despite the growing awareness of abuse of the elderly, risk factors associated with caregivers, for example stress and burnout, depression and anxiety, environmental hazards, and financial difficulties and crises should be studied. Intervention strategies should be designed and the efficacy of these strategies should be estimated.
Acknowledgement The authors would like to thank the National Science Council of the Republic of China, Taiwan for financially supporting this research under Contract No. NSC 92-2314-B-242003.
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Tyan, C., 1994. Elderly welfare services study: elder abuse investigation. Presented at 1994 Elderly Intervention Conference (abstract 262), Tokyo, Japan. Vida, S., Monks, R.C., Rosiers, P.D., 2002. Prevalence and correlates of elder abuse and neglect in a geriatric psychiatry. Can. J. Psychiatry 47, 459–467. Wang, J., Hsu, Y., Chen, K., Tseng, H., 2005. Development and testing of the indicators to screening Elder Subtle Psychological Abuse for older Taiwanese adults. Presented at 23rd Quadrennial International Council of Nurses Congress (abstract # C.0400.C), Taipei, Taiwan. Weatherall, M., 2001. Elder abuse: a survey of mangers of residential care facilities in Wellington. N. Z. J. Elder Abuse Neglect 13, 91–98. Wolf, R., 1997. Elder abuse and neglect: causes and consequences. J. Geriatr. Psychiatry 30, 153–174. Wood, S., Stephens, M., 2003. Vulnerability to elder abuse and neglect in assisted living facilities. Gerontologist 43, 753–757.