Frequency and risk factors of the elder abuse in the

university hospital and health insurance attendees in

Ismailia city. Egypt.

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

ABSTRACT
Background: Elder abuse (EA) is associated with physical and mental
health problems, including physical injuries, depression, poor control of
chronic diseases, and functional disability. This study attempts to assess
the frequency, risk factors, types and consequences of the elder abuse in
Egypt.
Subjects and methods: This is a descriptive study; the study was
carried out at Suez Canal university hospital and health insurance
outpatient clinics in Ismailia city, Egypt. One hundred eighty eight
elders were included in this study. A semi structured questionnaire
was developed from World report on violence and health 2002
with some modifications to be suitable to our culture.
Results: The mean age of the studied elders was 67.86 years ±6.87. The
study showed that 61.2% were males, while 38.8% were females. The
majority of abused elders were 60-69 years old and this represents 66.1%.
The pension was the basic source of income for 95.2%. More than half
(52.7%) had insufficient income. The frequency of abused elders was
13.8% (26 elders). There was statistical significance relationship between
elder abuse and pre retirement occupation, presence of partner, thinking
of living at residential home and the significant factor was found by the
logistic regression affecting the abuse among the studied variables was
income insufficiency (P<0.05). The most frequent perpetrators were
siblings (84.6%), followed by daughter-in-law (23.1%). The emotional
abuse was the most frequent type (88.5%) of abused elders. The major
risk factor was financial difficulties (88.5%). The major consequences of
elder abuse were; depressive symptoms, and re-experiencing events; 84%
and 69.2% respectively.
:Conclusion
Elder abuse is a growing problem in Egypt. It is a complex phenomenon
that involves multiple risk factors and found in a variety of types. Higher
proportion of abused elderly people suffers from depressive symptoms
.and psychological distress
Introduction: World health organization (WHO) considered that the
age of 65 is the beginning of aging, but in Egypt, the age of 60 is still the
beginning of aging according to the retirement age for most people (1).
Concerns around elder abuse are increasing. International prevalence
estimates of elder abuse in community settings (including neglect by
caregiver, physical, psychological and financial abuse) from Canada,
Finland, the Netherlands, the United kingdom and the United states of
America range from 4-6% (2). The more recent study in the Republic of
Korea found a corresponding figure of 6.3% (3), while in Israel an
estimate of 18.4% has been reported with the majority of abuse involving
neglect ((4). Elder abuse has been defined as a single or repeated act, or
lack of appropriate action occurring within any relationship when there is
an expectation of trust, which causes harm or distress to an older person
(5). Elder abuse can take many forms including physical, psychological
and sexual abuse, financial exploitation, scapegoat, neglect and self
neglect, medication abuse, abandonment, and marginalization of older
people in institution or social and economic policies ((2). Abuse by
systems –the dehumanizing treatment older people is liable to suffer at
health clinics and pension offices, and marginalization by the government
(6). Substantial evidence exists for the following risk factors of elder
abuse; Shared living situation with abuser, likely due to an increased
opportunity for contact, dementia, social isolation, pathologic
characteristics of perpetrators such as mental illness and alcohol misuse
(7). For older people, the consequences of abuse can be especially
serious. Older people are physically weaker and more vulnerable than
younger adults, their bones are more brittle and convalescence takes
longer. Even a relatively minor injury can cause serious and permanent
damage. Many older people survive on limited incomes, so that the loss
of even a small sum of money can have a significant impact. They may
be isolated, lonely or troubled by illness, in which case they are more
vulnerable as targets for fraudulent schemes (2). The role of the family
physician in identifying abuse is critical. The vast majority of older
people visit their physician at least once a year, and he often has a long
standing relation-ship with their patient and the patient’s family, and
knows their background. Also, the family physician should have detailed
medical records for the patient and be well aware of both present and past
medical problems, current medication and the patient’s social situation.
They are therefore ideally placed to identify elder abuse (8). This study
attempts to assess the frequency, risk factors, types and consequences of
the elder abuse in Egypt.
Subjects and methods:
This is a descriptive study to assess the frequency, risk factors,
types and consequences of elder abuse in Egypt. The study was
carried out at Suez Canal University and health insurance hospitals
outpatient clinics in Ismailia city, Egypt. To our knowledge there
are no published findings concerning this phenomenon in Egypt, so
we carried out a pilot study on 49 attendees in university and health
insurance hospitals and found that the frequency was 14.2% (7/ 49)
then we used this figure as a basis to calculate the required sample
size. The following equation was used.
N= (Z/∆)2 P(1-P) (9). One hundred eighty eight elders were
determined as our sample size.
A semi structured questionnaire was used to investigate: Elder's
Socio- economic demographic data, the risk factors of the elder
abuse, the types of the elder abuse and the consequences of elder
abuse.
Results were represented in tables and graphs. Data analysis was
based on estimating the percentage of discrete data. Appropriate
statistical tests were used according to the type of data (e.g. Chi
square test and logistic regression analysis) and these data was
analyzed using computerized statistical software which was
Medcalc 10.0.1. The level of significance considered statistically
significant at p<0.05.
Results:
One hundred and eighty eight elders were included in this study; the
majority of studied elders were 60-69 years old and this represented
66.1%, while 27.2% were 70-79 years old, and 6.7% were ≥ 80 years old.
The mean age of the studied elders was 67.86 years ±6.87. Regarding
gender, it was found that more than half 61.2% were males, while 38.8%
were females. The majority of elders were from urban area (81.9%). Most
of them (66.5%) were married, (31.91%) were widows, (1.06%) were
divorced, and one was single (0.53%). About 35.1% of elders were
Employees, 31.4% were Workers, and 33.5% were non workers before
the retirement age.
The pension was the basic source of income for 95.2%. More than half
(52.7%) had insufficient income. The majority had low crowding index
(80.32%), tea and coffee drinking (77.12%). The majority of elders were
independent regarding self care (44.67%), while 23.4% of them received
care by their partners, 12.8% by their daughters, 8.5 % by daughter in
law, 10.1% by relatives and 0.53% had paid caregivers (Table 1).
Twenty six elders (13.8%) had elder abuse. The statistically significant
factor was found by the logistic regression affecting the abuse among the
studied variables was income insufficiency (Table 2). 84.6% of abused
elders were abused by their siblings, 23.1% were abused by their
daughter-in-law, and 7.7% by their wives, none of them were abused by
their husbands or their son-in-law (Figure 1). Emotional abuse was found
in 88.5%, Abandonment in 84.6%, Neglect in 57.7%, Verbal abuse in
53.8%, Economic abuse in 30.8%, and Physical abuse in 11.5% (Figure
2). The distribution of risk factors for abused elders; Financial difficulties
were found in 88.50%, social isolation in 84.60%, Cognitive impairment
in 80.80%, Living arrangement in 80.80%, life stressors in 61.50%,
Physical impairment in 61.50%, Economic dependency upon elder in
61.50%, Modernalization in 46.10%, uncomfortable home atmosphere in
34.60%, Poverty in 23.10%, Dependency on caregiver in 15.40%,
Substance abuse of caregiver in 7.7%, and Overburdened caregiver in
7.70% (Figure 3). The consequences of elder abuse were as follows; 84%
had depressive symptoms, 69.2% had re-experiencing events, 38.5% had
shame, 26.9% had isolation and loneliness, and both physical injury and
no consequences of elder abuse represents 7.7% (Figure 4).

Discussion:

The prevalence rate of elder abuse in our study was 13.8%, in comparison
to the prevalence of elder abuse in other studies; in a Korean study the
rate was 1.9- 4.2% in various types of abuse (3) , the rates in the USA
(0.19–2.2%) (10), who showed prevalence of elder abuse in USA varies
from 3% to 5%. This level of elder abuse in the current research was
different; this may due to difference in socioeconomic level and cultural
factors that may hide the abuse. In the current study those aged <80 years
were more likely to be abused than who aged ≥ 80 years, this result is
similar to the results from Korean study (3). The probable explanation is
that old persons as they age may learn helplessness from repeated abuse,
and become unable to perceive or express abuse situations accurately.
The current study found that older men equally experience abuse as
women, this result is near to the findings from other studies (10), which is
contrary to the findings from other studies where older men were more
likely to experience abuse than women (3) .This could be explained by
decreasing social perception of male role after the retirement age in these
societies.
The logistic regression analysis showed that the only statistically
significant factor affecting the abuse among the studied variables was
income insufficiency, so the abused elders were those with insufficient
income.
The most frequent perpetrators were siblings (84.6%), followed by
daughter-in-law (23.1%). Although this result is near to the findings from
Korean studies (3, 11, 12), it was different from a study done in other
country (13) in which a sister was the most frequent abuser in USA. This
difference may be due to the fact that the burden of caring for parents
rests upon the oldest son and his wife traditionally in Egypt.
The present research found that emotional abuse is the most frequent
type in 88.5% of elder. Similar to those found in Korean study (3). This
could be explained by similarity between the Korean traditional values to
Egyptian traditions.
Although the abuse rates by type vary in different studies, it is often
reported that psychological and physical abuse are the most frequent
types (10). In the current research, emotional abuse was the most frequent
type while physical abuse was the least prevalent one in 11.5%. This
result is similar to the results from studies by (3,11,12). Since the idea of
filial piety is still explicitly dominant in Egypt and other traditional
countries and physical harm to old people is taboo.

The economic situation of old persons seems to be a factor in elder abuse

as suggested by (14). It is possible that competent old people become the
subject of exploitation by adult children and may be abused by their
children for financial support. In the current research the majority of
abused elders were economically independent and take care for others
suggesting that they were more likely to be the objects of financial
exploitation.
The findings of this study regarding the distribution of risk factors for
elders abused group was as follow; Financial difficulties in 88.50%,
social isolation in 84.60%, Cognitive impairment in 80.80%, Living
arrangement(perpetrator living with victim, overcrowding) in 80.80%,
life stressors in 61.50%, Physical impairment in 61.50%, Economic
dependency upon elder in 61.50%, Modernalization in 46.10%,
uncomfortable home atmosphere in 34.60%, Poverty in 23.10%,
Dependency on caregiver in 15.40%, Substance abuse of caregiver in
7.7%, and Overburdened caregiver in 7.70%.
The current research found Poverty, life stressor Situational factors, such
as care giving stress and caregiver burden are risk factors similar to
other studies by (15, 16, 17).
Other risk factors like cognitive and physical impairment are similar to
other studies (18, 19, 20, 21). Other risk factors such as pathologic
characteristics of perpetrators like alcohol misuse are similar to findings
by (7).
Other studies also have shown that there is more likelihood of older
persons with physical and cognitive disability to be abused (16, 22).
We found that Social isolation represented a risk factor for elder abuse
which is similar to other studies (23, 24, 25).
 The research findings about Economic dependency upon elder
represents more frequent risk in 61.50%, than elder dependency on
caregiver, these findings were similar to findings by other study (26), this
may be explained by caregivers dependency usually on elderly parents for
housing and financial assistance.
This suggests that abuse is more likely to be triggered by the interplay of
several factors rather than by one single factor.
The current research found; 84% had depressive symptoms, 69.2% had
re-experiencing events, 38.5% had shame, 26.9% had isolation and
loneliness, and both physical injury and no consequences of elder abuse
represents 7.7%. These findings were similar to other studies (27, 28).
Conclusion:
Elder abuse is a growing problem in Egypt. It is a complex phenomenon
that involves multiple risk factors and found in a variety of types. Higher
proportion of abused elderly people suffers from depressive symptoms
and psychological distress.

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Legend of tables:
Table 1: Socio-demographic characteristics of studied elders (N=188)
Table 2: Logisic regression analysis for variables of the studied elders
Legend of figures:
Figure 1: The perpetrators (abusers) of abuse for the studied abused
elders
Figure 2: The types of abuse in the studied abused elders
Figure 3: The risk factors for elder abuse
Figure 4: The consequences of elder abuse
 Characteristics Frequency Percentage
(Age group ( in years
• 60-69 years 119 66.1%
• 70-79 years 49 27.2%
• ≥ 80 years 20 6.7%
Mean age ±SD 67.86 years ±6.87
Gender
• Male 115 61.2%
• Female 73 38.8%
Residence
• Urban 154 81.9%
• Rural 34 18.1%
Marital status
• Single 1 0.53%
• Married 125 66.5%
• Divorced 2 1.06%
• Widow 60 31.91%
Pre-retirement Occupation
• Employees 66 35.1%
• Workers 59 31.4%
• Non-workers 63 33.5%
Source of income
• Pension 179 95.2%
• Special income 3 1.6%
• Family support 6 3.2%
Income sufficiency
• Sufficient income 89 47.3%
• Insufficient income 99 52.7%
Crowding index
• Low 151 80.32%
• High 36 19.15%
• Living at residential home 1 0.53%
 Variable Coefficient Std.Error P
Age 0.1291 0.3477 0.7105
Crowding index 0.2899 0.6358 0.6484
Presence of disease 0.0287 0.4090 0.9441
Educational level 0.2416 0.1919 0.2080
Gender 0.02735- 0.8227 0.9735
Income sufficiency 1.1110 0.4680 *0.01761
Marital status 0.4928 0.6683 0.4609
Occupation 0.1221 0.5657 0.8292
Presence of partner 0.3300 1.3870 0.8119
Residence 0.3271 0.4340 0.4511
Source of income 0.4077- 0.6486 0.5296
Economic dependency 0.004472 0.2582 0.9862
Constant 7.0923-
 E lder abus er

90.00% 84.60%
80.00%
70.00%
60.00%
50.00%
40.00% E lder abus er
30.00% 23.10%
20.00%
10.00% 7.70%
0% 0% 0%
0.00%
W ife Hus band S iblings Daughter S on in others
in law law

88.50%
84.60%
90.00%
80.00%
70.00%
57.70% Emotional abuse
53.80%
60.00% Abandonment
50.00% Neglect
40.00% 30.80% Verbal abuse
Economic abuse
30.00%
Physical abuse
20.00% 11.50%

10.00%
0.00%
Types of abuse
90.00% Financial difficulties
80.00% social isolation
Cognitive difficulties
70.00%
Living arrangement
60.00% 80.80% life stressors
84.60%
88.50%

80.80%

Physical impairment
50.00%
Economic dependency upon elder
40.00% M odernalization
61.50%
61.50%
61.50% Psychopathology of family member
30.00%
Poverty

7.70%
7.70%
20.00% Dependency on caregiver
46.10%
34.60%

15.40%
10.00% 23.10% Substance abuse of caregiver
O verburdened caregiver
0.00%

90.00% 84.60%

80.00%
69.20%
70.00%
Depressive symptoms
60.00%
Reexperiencing events
50.00% Shame
38.50% Isolation & Loneness
40.00%
26.90% Physical injury
30.00%
No consequences
20.00%
7.70% 7.70%
10.00%

0.00%