Global Prevalence of Elder Abuse: A Meta-analysis and Meta-regression

Abstract

Objective: Elder abuse is increasingly recognised as a global public health and social problem. There has been limited inter-study comparison of the prevalence and risk factors for elder abuse. This study aimed to estimate the pooled and subtype prevalence of elder abuse worldwide and identify significant associated risk factors.

Methods: We conducted a meta-analysis and meta-regression of 34 population-based and 17 non– population-based studies.

Results: The pooled prevalences of elder abuse were 10.0% (95% confidence interval, 5.2%-18.6%) and 34.3% (95% confidence interval, 22.9%-47.8%) in population-based studies and third party– or caregiver-reported studies, respectively. Being in a marital relationship was found to be a significant moderator using random-effects model.

Conclusions: This meta-analysis revealed that third parties or caregivers were more likely to report abuse than older abused adults. Subgroup analyses showed that females and those resident in non-western countries were more likely to be abused. Emotional abuse was the most prevalent elder abuse subtype and financial abuse was less commonly reported by third parties or caregivers. Heterogeneity in the prevalence was due to the high proportion of married older adults in the sample. Subgroup analysis showed that cultural factors, subtypes of abuse, and gender also contributed to heterogeneity in the pooled prevalence of elder abuse.

Introduction

Elder abuse was first brought to public attention in the 1970s,¹ with the emergence of phrases such as ‘granny battering'² and ‘granny bashing'³. It is associated with distress and increased mortality in older adults and contributes to caregivers' psychological morbidity.⁴ With the rise in the ageing population globally, there is an increase in the number of disabled older people with physical, mental, and financial vulnerability who may require more care and support. This places a burden on families and society. Mounting stress for caregivers in this transition of care may result in rising levels of abuse and neglect. The World Health Organization (WHO) defines elder abuse as “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 There are several widely accepted subtypes of elder abuse, which includes emotional, physical, financial, sexual, and neglect.⁶ The US National Center on Elder Abuse⁷ defines emotional or psychological abuse as “the infliction of anguish, pain, or distress through verbal or nonverbal acts”; financial or material exploitation as “the illegal or improper use of an older adult's funds, property, or assets”; neglect as “the refusal or failure to fulfil any part of a person's obligations or duties to an older adult”; physical abuse as “the use of physical force that can result in bodily injury, physical pain, or impairment”; and sexual abuse as “nonconsensual sexual contact of any kind with an older adult”. According to the WHO, the prevalence of elder abuse varies widely from 1% to 35%, influenced largely by the populations, settings, cultural backgrounds, definitions of abuse, and methodological measures.⁸ Based on previous studies, an estimated 1 to 2 million older adults in the US have been abused⁹ and this number is expected to increase when the global ageing population expands to nearly 2 billion in 2050.¹⁰ Nevertheless with elder abuse often viewed as a “hidden issue” or “family affair” that usually occurs in the privacy of the home, coupled with the lack of social and familial awareness, and limited access to institutional settings, the extent of this phenomenon is likely to be underreported.

Elder abuse is a pertinent social problem that affects one of the most vulnerable groups of citizens, significantly threatens the human dignity of older people, and limits their ability to lead a fulfilling life. There is a need to review this issue and reform existing services to protect their health and welfare. Nevertheless there remains a paucity of information on elder abuse.¹¹ We aimed to investigate the 618 Citations were identified using the search 588 Articles were selected for potential inclusion via 30 Articles were not written in English prevalence of elder abuse to help understand the magnitude of the problem. To the best of our knowledge, although there are published systematic reviews, there has been no meta-analysis on the aggregate prevalence of elder abuse. This paper attempted to establish the pooled prevalence of elder abuse across different countries with a meta-analytic abstract screening 423 Excluded 7 On self-neglect (not abuse) 21 Descriptive studies 26 Focused on screening methodology 369 Did not focus on prevalence or epidemiology approach, and through meta-regression and subgroup analyses to identify moderators and variables that explain the heterogeneity of prevalence. We hope the results of this study can help direct government policies, laws, and funding especially at this time when there is a worldwide phenomenon of greying populations.¹¹

Methods Study Selection

This study was done in accordance with the principles outlined in the Declaration of Helsinki. The following online databases were searched from inception to October 2013: PubMed (from 1966), EMBASE (from 1980), PsychINFO (from 1806), BIOSIS (from 1926), Science Direct (from 2006), and Cochrane CENTRAL (from 1993). The following search terms were used: “elder'* abuse OR mistreatment”, “elder'*abuse and prevalence”, “elder'* mistreatment and prevalence”, “elder'* physical abuse”, “elder'* physical mistreatment”, “elder'* AND emotional OR psychological OR verbal AND abuse”, “elder'* AND emotional OR psychological OR verbal AND mistreatment”, “elder'* financial OR material AND abuse OR elder'* exploitation”, “elder'* financial OR material AND mistreatment”, and “elder'* neglect, elder'*sexual abuse”, where * indicates truncation. In addition, systematic reviews of the prevalence of elder abuse were identified and their reference lists were hand-searched to further increase the number of relevant articles. Any disagreement between authors was resolved through consensus.

The search strategy and results are depicted in Figure 1. An initial 618 studies were identified. Of these, 165 were identified to be possibly relevant after abstract screening and papers were obtained and read. A total of 34 population- based studies and 17 non[-]population-based studies were included. A comprehensive literature search revealed the presence of 2 broad categories of papers on elder abuse — population-based and non[-]population-based studies, both of which reflect prevalence in a different manner. Population-based studies were defined by the following inclusion criteria: (a) the population size of elders in an area was defined and known, (b) the number of abused elders in that population was known. Third party[-] or caregiver- reported studies included subjects who were not older adults but third parties, such as relatives or health care workers who identified the presence of elder abuse from the third party point of view. For these studies, structured interviews or self-administered questionnaires were used. Participants were either asked if they had ever detected a case of elder abuse or were asked specific questions about the care they administered that amounted to abuse. In view of these 2 main types of elder abuse studies, we separated them into 2 groups and performed a meta-analysis separately.

Inclusion and Exclusion Criteria

We included primary studies that reported overall prevalence of elder abuse. Only English publications were considered. Articles were not limited by the year of publication. Population-based studies that recruited older adults aged [greater than or equal to] 60 years were included. Exclusion criteria included a poor or absent definition of elder abuse and lack of data to calculate effect size.

Data Abstraction

For the purpose of this meta-analysis, the following data were extracted: (1) publication details (title, author, year of publication, location of the study), (2) methodology (sampling method, measurement tools, method of data gathering, sample size, definition of ‘elder'), (3) sample characteristics (mean age, gender distribution, percentage of sample married), and (4) results (overall prevalence of elder abuse, prevalence of subtypes of abuse).

Statistical Analyses

Statistical analyses were computed with Comprehensive Meta-Analysis V.2.0 using random-effects models. Summary statistics included the pooled prevalence, 95% confidence interval (95% CI), and p value. Heterogeneity was tested with the Q statistic distributed as a χ² variate under the assumption of homogeneity of effect sizes. I² statistic was also included for between-study heterogeneity to evaluate the percentage of variability among effect estimates that could not be attributed to chance. τ² statistic was included to measure inter-study variance.

Due to significant heterogeneity, meta-regression analyses were further performed via mixed-effects regression to identify possible moderators that might have contributed to the heterogeneity of effect sizes. The univariate coefficient, Z values, and p values were reported in the meta-regression analysis. Subgroup analyses using a mixed-effects analysis were performed for categorical variables. Mixed-effects analysis used a random-effects model to combine and analyse studies within each subgroup while a fixed-effect model was used to combine the subgroups of various studies. Funnel plots and Egger's regression analyses were used to help detect the presence of publication bias.

One of the categorical variables for subgroup analysis was western versus non-western countries. Western countries were defined in this meta-analysis as countries that shared a similar culture derived from Europe and used a European language as the national language. This was considered as cultural beliefs would influence the prevalence of elder abuse.⁸ In this study, US, UK, the Netherlands, Brazil, Spain, Finland, Australia, Ireland, Canada, and Italy were classified as western countries, while Nigeria, India, Thailand, China, Israel, Turkey, Egypt, and Korea were classified as non-western countries.

Results Population-based Studies

In all, 34 population-based studies (Table 1^9,12-44) provided information about the pooled prevalence of elder abuse. These 34 studies included a total of 44,563,047 older adults. The pooled prevalence of elder abuse using the random-effects model was 10.0% (95% CI, 5.2%-18.6%, Q = 82,923, degrees of freedom [df] = 33, p [lesser than] 0.001, τ² = 4.499, I² = 100%). Figure 2 shows the forest plot generated for the pooled prevalence identified in the 34 population- based studies. As a result of the significant heterogeneity (I² = 100%, p [lesser than] 0.001), we performed meta-regression on specific demographic and abuse-related moderators and subgroup analyses on categorical variables.

A total of 7 moderators based on common risk factors of elder abuse according to the literature were included in the meta-regression. Of these, it was found that mean age (univariate coefficient [B] = [-]0.011, Z = [-]0.144, p = 0.89), proportion of females in the sample (B = 1.094, Z = 0.932, p = 0.35), proportion of sample living with others (B = 1.94, Z = 1.25, p = 0.21), proportion of perpetrators as adult children (B = 1.624, Z = 0.656, p = 0.51), proportion of perpetrators as spouses (B = 0.445, Z = 0.154, p = 0.88), and proportion of abused as females (B = [-]1.562, Z = [-]0.853, p = 0.40) were non-significant moderators and thus could not explain the heterogeneity of the population-based studies. Proportion of married older adults (B = 4.159, Z = 2.364, p = 0.02) in the sample was found to be a significant moderator and associated with heterogeneity in a positive direction. Subgroup analyses based on the mixed-effects analysis were performed on categorical variables including comparison between western versus non-western countries, subtypes of abuse, and gender. All 3 subgroup analyses were found to be statistically significant, and this suggested that the pooled prevalence of elder abuse among subgroups differed significantly. Table 2 illustrates the results for the subgroup analyses. Funnel plots and Egger's regression test were used to test for publication bias. There was significant publication bias in reporting pooled prevalence of elder abuse in population-based studies (intercept = 29.7, 95% CI = 14.7-44.8, t = 4.02, df = 32, p [lesser than] 0.001).

Third Party[-] or Caregiver-reported Studies

A total of 17 studies were included in this meta-analysis with a total of 4090 subjects (Table 3^15,45-60). The pooled prevalence of elder abuse using the random-effects model was 34.3% (95% CI, 22.9%-47.8%, Q = 820.5, df = 16, p [lesser than] 0.001, τ² = 1.342, I² = 98.1%) as illustrated in the forest plot in Figure 3.

Significant heterogeneity was found (τ² = 1.342, I² = 98.1%) and we performed meta-regression on specific demographic and abuse-related moderators and subgroup analysis on categorical variables. Two moderators were included in the meta-regression. Mean age of caregivers (B = [-]0.018, Z = [-]0.430, p = 0.67) and proportion of female caregivers (B = 1.706, Z = 0.528, p = 0.60) were non-significant moderators and thus could not explain the heterogeneity. Subgroup analysis based on the mixed-effects model was performed to compare the different subtypes of elder abuse. The pooled prevalence of different subtypes of elder abuse was found to be significantly different. Table 4 illustrates the results of subgroup analysis.

We also tested for the presence of publication bias using funnel plots and Egger's regression test. These tests did not show publication bias in the prevalence of elder abuse by third party[-] or caregiver-reported studies (intercept = [-]1.492, 95% CI = [-]9.46 to 6.48, t = 0.399, df = 15, p = 0.70).

Discussion

To the best of our knowledge, this is the first meta-analysis to estimate the pooled prevalence of elder abuse in studies conducted across the globe. The pooled prevalence of elder abuse in third party[-] or caregiver-reported studies (34.3%) was more than 3 times that reported in the population- based studies (10.0%). These differences could be due to several factors. Firstly, older adults might be unwilling to admit to being abused out of fear, especially if they are very dependent on the perpetrators.⁶ Secondly, both health care workers (in third party[-]reported studies) and older adults (in population-based studies) could be subject to recall bias. Older adults might be cognitively impaired or have memory disturbances and this might prevent them from remembering the events clearly.⁶ This might lead to underreporting of abuse. Health care workers might regret certain abusive actions towards the older adults and hence have better recall of such incidents. Thirdly, caregivers might feel guilty and thus be more willing to share when asked. Homer and Gilleard⁴⁵ reported that caregivers were able to share their difficulties when there was assurance of confidentiality and that interviewers were non-judgemental. Fourthly, third parties such as family doctors or geriatricians are usually experienced in looking after older adults and are more likely to identify elder abuse in third party[-] or caregiver-reported studies. Lastly, there was significant publication bias in population-based studies but not third party[-] or caregiver-reported studies. The publication bias suggested that some population-based studies were excluded. Bond and Butler⁶¹ reported that 1 in 5 to 1 in 14 cases of elder abuse go unreported. Studies that are retrospective in nature^9,12-14 tend to underestimate the prevalence of elder abuse. In addition, many population- based studies did not include older adults with cognitive impairment due to their difficulty in providing accurate information. The burden of care for this group of people is also much higher with an elevated risk of caregiver burnout. Exclusion of this vulnerable population could lead to underestimation of the pooled prevalence of elder abuse and contribute to publication bias.

In the subgroup analysis, there was a significant difference in the prevalence of elder abuse between western and non-western countries (Table 2b). Non-western countries revealed a 10.1% higher prevalence of abuse than that reported in western countries. Sooryanarayana et al⁶² stated that the concept of filial piety is very strong in East Asian cultures. In non-western culture, family structure is based on patriarchal and hierarchical models. There is a social and cultural expectation for adult children to care for the respected seniors in their family and this has become a tradition rather than a choice. As a result, adult children may be forced to look after their seniors rather than doing it voluntarily, and may lead to them abusing seniors to relieve stress and tension. This practice might have contributed to the 10.1% difference in abuse rates. In this meta-analysis, there was an over-representation of studies conducted in western countries. It is important to note that there are large ageing populations in China and India. If there were more primary studies conducted in non-western countries, the global prevalence of elder abuse might have been higher than the pooled prevalence reported in this meta-analysis.

The subgroup analysis of gender in elder abuse indicated that females were 6.1% more likely than males to be abused (17.0% for females vs. 10.9% for males). Women are more likely to be abused because they have a longer lifespan that is in turn associated with risk factors such as loss of independence in activities of daily living and cognitive impairment in old age. Women might also be more socially trained to endure abuse, especially those from the older generations. Elder abuse of women might be a continuation of intimate partner violence or other forms of violence into old age.⁶³

Subgroup analysis of the subtypes of elder abuse in population-based studies showed that emotional abuse was the most common, followed by financial abuse, neglect, physical abuse, and sexual abuse (Table 2a). Our findings are congruent with a systematic review performed by Sooryanarayana et al⁶² in which emotional abuse was the most common form of elder abuse. In contrast to subgroup analysis in population-based studies, subgroup analysis in third party[-] or caregiver-reported studies showed slightly different results (Table 4). Emotional abuse (71.5%) was the most prevalent subtype, followed by physical abuse, neglect, financial abuse, and then sexual abuse. Sexual abuse was the least common elder abuse subtype in population-based and third party[-] or caregiver-reported studies. Neglect and physical abuse were more common than financial abuse in third party[-] or caregiver-reported studies compared with population-based studies. This observation is explained by the fact that health care workers are more likely to participate in emotional and physical abuse and neglect rather than financial abuse.¹⁵ Johannesen and LoGiudice⁶⁴ reported that the risk factors among caregivers as perpetrators of elder abuse included caregiver burden and caregiver stress. These characteristics were more likely to be associated with physical and emotional abuse than financial abuse. In the US National Ombudsman Reporting System⁶⁵ that audited nursing facilities, financial abuse and sexual abuse were the second least common and least common type of elder abuse, respectively.

Meta-regression was performed to identify moderators that could explain significant heterogeneity in pooled prevalence of elder abuse in population-based and third party[-] or caregiver-reported studies. No moderator was significant except for the proportion of married older adults in the sample that contributed to heterogeneity in a positive direction. They may be more susceptible to elder abuse by a spouse or children as a result of caregiver stress. Johannesen and LoGiudice⁶⁴ reported that prolonged contact with older adults (e.g. staying in the same house) is a risk factor for elder abuse. Nonetheless, married older adults who have better social support and caregivers who do not suffer from burnout delay institutionalisation and associated elder abuse by third parties. Thus, the emotional health status of caregivers plays an important role in mediating elder abuse. Heterogeneity in the pooled prevalence was caused by differences in gender, cultural factors, and abuse subtype. Mean age of caregivers and proportion of females among caregivers were not significant moderators. This is in agreement with findings from Johannesen and LoGiudice.⁶⁴

Limitations

Although this study is one of the first meta-analyses of the pooled prevalence of elder abuse, there are several limitations. First, the significant heterogeneity of the pooled prevalence is the main limitation. Several important factors that could potentially influence the prevalence include: difference in definitions of the abuse, variations in study outcomes, and the time frame over which prevalence was assessed. Furthermore, several of the studies did not include the response rate that could affect the results as a moderator due to selection bias. In future, elder abuse studies should adopt a standard method to assess and define elder abuse.¹

Second, most studies included were cross-sectional studies. This limited the causality between risk factors and outcome of elder abuse. Third, the quality of the included studies was not assessed using the STROBE checklist. Fourth, only English language articles were sought from the database. This could have accounted for the smaller number of studies from non-western countries.

Conclusions

Our study is the first meta-analysis of the global prevalence of elder abuse. The following conclusions are derived from our study: (1) Third parties or caregivers tend to report a higher prevalence of elder abuse than older abused adults; (2) older adults living in non-western countries were more likely to be abused than those living in western countries; (3) female older adults were more likely to be abused than males; (4) emotional abuse was the most common subtype of elder abuse. Financial abuse was more common in population-based studies than in third party[-] or caregiver- reported studies; (5) meta-regression showed that the proportion of married older adults in the sample was the only significant moderator that contributed to the heterogeneity of pooled prevalence in elder abuse.

From this study, it is evident that elder abuse is a serious global problem that needs to be addressed at both society and government levels. Standardised screening tools are vital to tackle this mounting problem and enable meaningful comparisons among countries, after which we can learn from each other's experiences. Further research is also warranted to study the inherent characteristics of older adults and their caregivers, as well as ethnic and cultural ideologies that could influence abuse perceptions and outcomes.

Acknowledgement

We thank the Department of Psychological Medicine, National University Hospital, Singapore for the support in this study.

Declaration

All authors have disclosed no conflicts of interest.

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