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The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis

The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 58 European Journal of Public Health 25 Wahrendorf M, Blane D. Does labour market disadvantage help to explain why 34 LaCroix AZ, Guralnik JM, Berkman LF, et al. Maintaining mobility in late life. II. childhood circumstances are related to quality of life at older ages? Results from Smoking, alcohol consumption, physical activity, and body mass index. Am J SHARE. Aging Ment Health 2015;19:584–94. Epidemiol 1993; 37:858–69. 26 Wahrendorf M, Blane D, Bartley M, et al. Working conditions in mid-life and 35 Murtagh KN, Hubert HB. Gender differences in physical disability among an elderly mental health in older ages. Adv Life Course Res 2013;18:16–25. cohort. Am J Public Health 2004;94:1406–11. 36 Friedmann JM, Elasy T, Jensen GL. 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This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 IGO License (https://creativecommons.org/ licenses/by/3.0/igo/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. doi:10.1093/eurpub/cky093 Advance Access published on 5 June 2018 ......................................................................................................... The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis 1 1 2 1 1 Yongjie Yon , Maria Ramiro-Gonzalez , Christopher R. Mikton , Manfred Huber , Dinesh Sethi 1 WHO Regional Office for Europe, Copenhagen DR-2100, Denmark 2 WHO Headquarters, Geneva 1202, Switzerland Correspondence: Yongjie Yon, Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe, Marmorvej 51, Copenhagen DR-2100, Denmark, Tel: +45 (0) 45 33 69 32, Fax: +45 (0) 45 33 70 01, e-mail: yony@who.int Background: A recent study has shown that close to one in six older adults have experienced elder abuse in a community setting in the past year. It is thought that abuse in institutions is just as prevalent. Few systematic evidence of the scale of the problem exists in elder care facilities. The aim of this review is to conduct a systematic review and meta-analysis of the problem in institutional settings and to provide estimates of the prevalence of elder abuse in the past 12 months. Methods: Fourteen academic databases and other online platforms were systematically searched for studies on elder abuse. Additionally, 26 experts in the field were consulted to identify further studies. All studies were screened for inclusion criteria by two independent reviewers. Data were extracted, and meta-analysis was conducted. Self-reported data from older residents and staff were considered separately. Results: Nine studies met the inclusion criteria from an initial of 55 studies identified for review. Overall abuse estimates, based on staff reports, suggest that 64.2% of staff admitted to elder abuse in the past year. There were insufficient studies to calculate an overall prevalence estimate based on self-reported data from older residents. Prevalence estimates for abuse subtypes reported by older residents were highest for psychological abuse (33.4%), followed by physical (14.1%), financial (13.8%), neglect (11.6%), and sexual abuse (1.9%). Conclusions: The prevalence of elder abuse in institutions is high. Global action to improve surveillance and monitoring of institutional elder abuse is vital to inform policy action to prevent elder abuse. ......................................................................................................... Organization (WHO), elder abuse is defined as ‘a single, or Introduction repeated act, or lack of appropriate action, occurring within any lder abuse is an important public health issue with serious social, relationship where there is an expectation of trust which causes economic and health consequences. The global prevalence of past harm or distress to an older person’. Elder abuse can be categorized year elder abuse in the community settings is 15.7%, or approxi- according to: type of abuse—psychological, physical, sexual, and mately one in six older adults. According to the World Health financial abuse and neglect; type of abuser—family members, Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 The prevalence of elder abuse in institutional settings 59 informal and formal caregiver, or acquaintance; or setting in which institutional settings from existing literature and to identify gaps it occurs—in the community and in an institution. Within institu- for future research directions. tional settings, abuse can be broadly categorized into resident-to- resident abuse or staff-to-resident abuse. Methods Compared with research on other forms of interpersonal violence, elder abuse research, especially in institutions, is still in its infancy. Search strategy and selection criteria However, research has shown that elder abuse occurs in every This research, focused on institutional settings, was part of a larger country with nursing and residential facilities and anecdotal systematic review of studies examining the prevalence of elder abuse evidence suggests that abuse may be very prevalent. A survey of in all settings. The study conforms to the Preferred Reporting Items nursing home staff in the USA indicated that 40% of staff for Systematic reviews and Meta-Analysis – or PRISMA – guidelines admitted to committing psychological abuse in the past year and and has been registered with PROSPERO International Prospective 10% to committing physical abuse. A systematic review of institu- Register of Systematic Reviews (CRD42015029197). A detailed de- tional abuse indicated that physical abuse often occurs as a form of scription of the method has been published elsewhere. A brief staff retaliation against physically aggressive residents. Similarly, description of the methodology is presented below. staff reported that they were more likely to withhold choices from A comprehensive four-step search strategy was used to identify aggressive residents. In another US national study, 1.5% of staff relevant studies. The first step consisted of searching the following self-reported that they have committed theft. There is significant 14 academic databases from inception to 26 June 2015: PubMed, awareness of the issue of elder abuse in institutional settings among PsycINFO, CINAHL, EMBASE, MEDLINE, Sociological Abstracts, the population in European Union (EU) countries. According to a ERIC, AgeLine, Social Work Abstracts, International Bibliography of 2007 Eurobarometer special report on health and long-term care in the Social Sciences, Social Services Abstracts, ProQuest Criminal the EU, 47% of European citizens think that poor treatment, neglect Justice, ASSIA, Dissertations & Theses Full Text and Dissertations and abuse of older adults are common in their country. & Theses Global. A search strategy was developed for each database There is a gap in the current literature on the prevalence of elder using a combination of free text and controlled vocabulary (i.e. abuse in nursing and residential facilities for older people. The need MeSH terms). Additional search terms were included in consult- for greater attention to this topic stems from a number of factors. ation with an information specialist (librarian) who has extensive First, according to the data from World Population Prospects,in experience in systematic reviews. Some of the search terms used 2015, the global population of older adults aged 60 years or over is included: older adults, frail elderly, aged, elderly, seniors, elder about 901 million or 12.3% of the world’s population, and by 2050, abuse, elder neglect, elder mistreatment, elder maltreatment, the global population of older adults will more than double to nearly 12 domestic violence, intimate partner violence, abuse, violence, aggres- 2.1 billion or 21.3%. Second, the number of ‘oldest-old’ adults, sion, crimes, harmful behaviour, anger, rape, hostility, conflict, aged 80 years or over, is growing faster than the population of older verbal abuse, physical abuse, sexual abuse, emotional abuse, preva- adults. For example, by 2050, the number of the ‘oldest-old’ lence, incidence, morbidity and epidemiology; nursing homes, population will have more than tripled to 434 million from 125 assisted living, residential care institutions, residential facilities, million in 2015. Third, women, on average, have a longer life health facilities and skilled nursing facilities. The full search expectancy than men, and as a result they account for 61.6% of 1,17 strategy and search terms have been previously published. those over 80 years . Fourth, it is likely that females and the Second, reference lists of publications retrieved in the first step were ‘oldest-old’ seniors in the future will remain the largest age group screened for relevant studies. Third, we searched additional web-based in long-term care facilities. platforms including specialized journals, Google for grey literature, Currently, older adults also make up the largest proportion of and the WHO’s Global Health Library for scientific literature adult populations living in institutions for adults with mental published in low and middle income countries. Finally, 26 experts disabilities in the European region. Residents of such facilities in the field were consulted by e-mail, representing each of the six are more likely to have multiple forms of impairment including WHO regions (i.e. Africa, Americas, South-East Asia, European, mental, physical or behavioural abnormalities as well as disabling Eastern Mediterranean and Western Pacific) to identify any studies conditions. Thus, due to their frailty, residents in institutional that the first three steps may have missed up to 18 December 2015. settings tend to be more dependent on others for care and may be Articles were independently screened in two stages by two reviewers: at greater risk for abuse and neglect than older adults in community first, titles and abstracts were screened for relevance. This was followed settings. Finally, the prevalence of abuse may be much higher than by the retrieval and screening of full text articles by two reviewers reported since under-reporting is estimated to be as high as 80%. using the eligibility criteria described below. If several publications Such under-reporting could be due to victims’ inability to commu- reported on a single study, the publication that provided the most nicate their abuse or due to their fear of repercussion and retaliation. data were selected for further synthesis. Inter-rater reliability was Urgent action is needed to prevent elder abuse from occurring, analyzed using the Statistical Package for Social Sciences (SPSS especially in the institutional settings. The WHO global strategy and Statistics 21). This analysis showed high levels of agreement between action plan on ageing and health (2016–20) provides a roadmap to the reviewers (: 0.86–0.96). Disagreements were resolved through prevent elder abuse and achieve healthy ageing. The strategy calls for discussion, or with the help of a third reviewer. key actions in the areas of health systems, age-friendly environments, Inclusion criteria were institutional-based samples that provided better long-term care and improvements in measurement, monitor- estimates of abuse prevalence at a national or sub-national level (e.g. ing and research. Underlying this strategy is a set of core principles states/provinces, counties, districts and large cities); and inclusion of to ensure older adults age safely in a place that affirms their basic participants that were 60 years of age and older, in line with a human rights and fundamental freedoms. Such affirmation is frequently used age limit used for data presentation and crucial to elder abuse prevention. Similarly, one of the supporting research. We excluded studies that were reviews, conference interventions in the WHO strategy and action plan for healthy proceedings or used qualitative methods only, and studies that ageing in Europe (2012–20) targets elder abuse prevention, which focused exclusively on use of restraints, self-neglect or homicide. calls for actions to improve the quality of services within institu- tional settings. Despite increasing attention, research on institu- Data extraction and quality assessment tional abuse is still lacking. To better capture and summarize existing research on institutional abuse, this systematic review and meta- Data were extracted by two reviewers: the first extracted data from analysis aims to synthesize prevalence estimates of abuse in the publications and the second cross-checked for accuracy. Three Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 60 European Journal of Public Health main categories of data were extracted: characteristics of the samples, was performed to assess the degree of publication bias, its effect on methodological characteristics of each study and prevalence the study findings, and to remove extreme outliers to correct for 20,22 estimates of elder abuse and its sub-types. The study quality was publication bias. assessed as part of the data extraction strategy by two reviewers using the Modified Newcastle-Ottawa Scale designed to assess the quality of non-randomized epidemiological research. To assess Results the risk of bias, reviewers rated each of the 7 items along a 4-point Of the 38 544 studies that were initially identified through the com- Likert scale from high risk of bias (i.e. 0) to low risk of bias (i.e. 3, prehensive search strategy for all elder abuse prevalence studies see Panel 1). An overall score was calculated by adding all the items, occurring in the community and the institutional settings, 55 full- thus, higher scores indicated lower risk of bias and stronger meth- text articles related to abuse in the institutions were independently odological quality. reviewed. These relevant articles fall into two categories of institutional abuse: resident-to-resident abuse and staff-to-resident abuse. From Data analysis these, 18 studies were selected for data extraction and 12 additional studies were identified through expert consultations. After further Meta-analysis was performed to synthesize the prevalence estimates. screening, 21 studies were excluded and 9 studies were selected for The decision to do a meta-analysis was made a posteriori after meta-analysis, which provided data for staff-to-resident abuse. Among ensuring sufficient studies with similar characteristics were 23–26 these, four studies examined abuse prevalence self-reported by available for meta-analysis. Prevalence rates were calculated from raw proportions or percentages reported in the selected studies. older adults including one study in which abuse was reported by proxies, close relatives to the older adults and six studies in which The pooled estimates and the 95% confidence intervals (CIs) were 23,27–31 calculated based on a random-effects model. Non-overlapping CIs abuse prevalence was self-reported by staff. Figure 1 shows the were considered as an indication of statistical significant differ- flowchart of study selection. ences. All analyses were conducted using Comprehensive Meta- The four prevalence studies, based on self-report by older adults Analysis software (CMA 3.9). Heterogeneity tests with Higgins’ and their proxies, were from the Czech Republic, Israel, Slovenia and I statistic were performed to determine the extent of variation the USA. In the studies, between 64.8 and 82.8% of the samples were 20 23,25,26 between the studies. Duval and Tweedie’s Trim and Fill method women. Two studies provided age group breakdowns with Documents retrieved Duplicate documents excluded 36239 Found through secondary search Excluded: 2365 � 1600 Elder abuse in community settings Identified for title & abstract review � 676 Not elder abuse � 61 Qualitative studies � 28 Other (e.g. lit. review, testimony etc.) Identified for full texts review Excluded: 37 � 10 No prevalence data � 10 Duplicate data Identified as relevant for data extraction sets 18 � 6 Non-institutional � 5 Restraint � 4 Literature review Identified via � 2 Under 60-years expert consultation old Included after full text review Excluded: 21 � 8 No prevalence data � 3 Non-institutional � 2 Duplicate Prevalence studies reported past year datasets abuse by staff � 2 Literature review � 2 Resident to resident abuse � 3 Observational � 1 Under 60-years old Figure 1 Summary of study selection for inclusion in analysis Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 The prevalence of elder abuse in institutional settings 61 23,25 those aged 75 years and older making up 75% of the samples. Table 1 Institutional abuse reported by older adults and staff The older adults who participated in the studies were adults with Elder abuse types Pooled estimates Lower Upper normal cognitive functioning who had the ability to communicate (%) limit (%) limit (%) and orient themselves in time and space. However, the majority of these respondents was frail and required assistance in activities of Reported by older adults over past year daily living (ADLs). The quality of the studies was assessed using the Psychological (3 studies) 33.4 6.3 78.9 19 a Physical (4 studies) 14.1 1.9 58.3 Modified Newcastle-Ottawa Scale. The maximum score for good Sexual (3 studies) 1.9 0.03 59.2 quality study on this scale (i.e. low risk of bias) was 21. On average, Neglect (3 studies) 11.6 0.4 81.8 the studies scored 11 out of 21 on the scale. Financial (3 studies) 13.8 0.7 78.3 There were six studies that were based on self-reports by staff. In Reported by staff over past year these studies, staff were asked whether they had perpetrated or Overall (4 studies) 64.2 53.3 73.9 directed abusive acts to older residents. These studies were geo- Psychological (5 studies) 32.5 16.1 54.6 Physical (5 studies) 9.3 4.4 18.4 graphically diverse from the Czech Republic, Germany, Ireland, Sexual (3 studies) 0.7 0.04 11.7 Israel and the USA. Of the six studies, between 80 and 97% of Neglect (4 studies) 12.0 2.6 41.4 the staff respondents were women. All of the respondents were over 35 years old, with five studies reporting average staff ages a: Adjusted for publication bias. 27–31 of early- to mid-40 years old. There was a wide range in the average number of years of professional experience working with 23 27 studies (N = 2711). Finally, for sexual abuse (Q[2] = 38.72.82; older adults: from less than 4 years to between 10.4 years and P < 0.0001; I = 94.8%), there were three studies (N = 2054) with a 13.8 years. Moreover, between 38 and 63% of the staff were pooled estimate of 0.7% (CI 2.6–41.4%). Figure 3 shows the forest registered nurses, licensed practical nurses or had received qualifi- 28,29,31 plots of the pooled estimates of elder abuse reported by the staff. cations in the care of older adults. The characteristics of the older adults residing in the institutions were not provided except for two studies which included adults with normal cognitive func- Discussion tioning who were frail and needed assistance with two or more 23 27 This is the first rigorous quantitative synthesis of prevalence ADLs or had high levels of dependency, including dementia. estimates for elder abuse in the institutions. Findings from this The average score on the quality assessment instrument was 14 study, based on self report by older residents, show that the past out of the maximum score of 21 (see Supplementary data Table 2). year prevalence of elder abuse in the institutional settings is high. In The pooled prevalence estimates for psychological, physical, addition, data based on staff self report, indicate that 64.2% of staff sexual, and financial abuse and neglect were independently admitted to elder abuse. However, caution is needed when calculated from studies that collected data from older adults and interpreting the estimates from staff self-report. The rates of elder their proxies (Table 1). Visual inspection of the funnel plots abuse and neglect perpetrated by staff only provide a partial picture indicated that there was evidence of publication bias for physical abuse. Tests of heterogeneity for each of the abuse subtypes were on the extent of the problem and do not indicate the overall prevalence of abuse in the institution. Yet, findings from this performed. Generally, the studies for each subtype were heteroge- neous suggesting that differences in the effect sizes do exist within study is consistent with the anecdotal evidence and the belief that 11,32 abuse in seniors’ residential facilities is widespread. this set of studies. The Higgins’ I showed high variances for each abuse subtypes (91.1–98.3%) indicating that variance came from To date there have been few studies on the prevalence of elder abuse in institutional care settings. Existing studies have provided a sources other than sampling error. The rate of psychological abuse was reported in three studies that wide range of estimates. For example, in studies based on self- reports by older adults or their proxies prevalence estimates have included a total of 694 individuals. The prevalence estimate for psy- 2 24 chological abuse (Q[2] = 116.56; P < 0.0001; I = 98.3%) in the past ranged from 31% in Israel for overall abuse —86.9% for neglect in the USA. Similarly, studies based on staff reports in Germany also year was 33.4% (CI 6.3–78.9%). There were four studies (N = 718) reporting on physical abuse. After adjusting for publication bias, the indicated a wide range of estimates: from 53.7% for psychological 28 29 abuse and neglect —78.8% for overall abuse. pooled estimate for physical abuse (Q[3] = 97.82; P < 0.0001; I = 96.9%) was 14.1% (CI 1.9–58.3%). Sexual abuse (Q[2] = 22.38; This systematic review, based on a comprehensive search strategy, P < 0.0001; I = 91.1%) was reported in three studies (N = 569) with was conducted to better understand the prevalence of elder abuse in institutional settings. Nine studies were synthesized using meta- a pooled estimate of 1.9% (CI 0.03–59.2%). Financial abuse (Q[2] = 80.69; P < 0.0001; I = 97.5%) was reported in three studies analysis to pool prevalence estimates for elder abuse. Separate meta-analyses were performed for estimates based on self-reported (N = 263) with a pooled estimate of 13.8% (CI 0.7–78.3%). Neglect (Q[2] = 92.88; P < 0.0001; I = 97.8%) was reported in three studies data by the older adults (i.e. the victims) or their proxies and by the staff (i.e. the abusers). Based on self-reported studies by the staff, (N = 658) with a pooled estimate of 11.6% (CI 0.4–81.8%). Figure 2 shows the forest plots of the pooled estimates of elder abuse reported 64.2% of them admitted to abuse. Since a minimum of three studies is required to conduct a meta-analysis, there were not enough by older adults. Estimates of perpetrating abuse were calculated from data using staff studies to be pooled for overall abuse as reported by older residents. The findings of this study on the self-reported prevalence estimates self-reports for overall abuse as well as abuse subtypes (See Table 1). Evidence of publication bias was present for psychological abuse and of elder abuse subtypes by older residents and staff suggest similarities in the magnitude of the problem. The prevalence estimates reported neglect. Tests of heterogeneity also revealed a high degree of variance for each abuse subtypes (I = 90–99.1%). There were four studies that by older residents were highest for psychological abuse (33.4%), provided data for overall abuse (N = 1405) with a pooled estimate followed by physical (14.1%), financial (13.8%), neglect (11.6%), (Q[3] = 45.54; P < 0.0001; I = 93.4%) of 64.2% (CI 53.3–73.9%) and sexual abuse (1.9%). These rates were higher compared to the within the past year. After adjusting for publication bias, the pooled prevalence rates in the community settings as reported by older psychological abuse (Q[4] = 422.83; P < 0.0001; I = 99.1%) rate was adults: psychological (11.6%), physical (2.6%), financial (6.8%), 32.5% (CI 16.1–54.6%) and neglect (Q[3]=151.04; P <0.0001; neglect (4.2%), and sexual (0.9%) abuse. I = 98.0%) was 12.0% (CI 2.6–41.4%). There were five studies An examination of risk factors for elder abuse suggests a number (N = 2706) for psychological abuse and four studies (N = 2106) for of possible explanations for the higher prevalence rate in institu- neglect. The pooled estimate for physical abuse (Q[4]=123.47; tional settings. Although no single risk factors can fully account P < 0.0001; I = 96.8%) was 9.3% (CI 4.4–18.4%) with a total of five for the occurrence of elder abuse and research on risk factors in Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 62 European Journal of Public Health 1 Year Prevalence of Psychological Abuse Reported By Older Residents in the Institutions 1 Year Prevalence of Physical Abuse Reported By Older Residents in the Institutions Figure 2 Forest plots of elder abuse subtypes reported by older adults this area suffers from several weaknesses (e.g. lack of unified oper- in institutional settings reported frailer health and greater ational definitions of abuse, measurement problems and inconsistent dependency on the staff for assistance in ADLs than non-victims. 6,32 research methodologies ), some risk factors have nevertheless been Of the studies based on self-reports by staff, a small sample of the consistently identified, including the characteristics of victims and older residents was diagnosed with dementia. In fact, between 3.4 staff, of the facilities and the working environment. and 18.5% of the residents who have been abused by staff had The main risk factors for victims of elder abuse are being female, dementia. Older residents in the institutions had many of the presence of a cognitive impairment and disability, and being older risk factors associated with abuse. Such risk factors may also be 33–35 than 74 years old. Research on elder abuse occurring in the compounded by the environment in which they lived in. community found that the majority of the victims were women. Nursing homes and other seniors’ residential facilities can be Likewise, 83% of the sample that were included in this meta- stressful environments. When asked about the main stressors, analysis was women. In fact women comprised up to 77.3% of staff attributed their experience of stress to staff shortages and the victims who reported psychological, physical and financial time pressure. Indeed research has found that staff who self- abuse. The greater share of women in institutional care is reported committing abuse described themselves as emotionally 27,29 consistent with the statistical profile of long-term care facilities in exhausted. In addition, significant correlation was found North America and where findings showed that nearly four out of between abuse and high ratio of residents to registered nurses. the five residents in care homes are women. This predominance of It was further found that an increased presence of qualified women stems, in part, from the large differences in gender ratios, nurses was associated with a reduction in resident abuse risk. especially for the highest age groups. There was wide variation in staff professional experience and There is a strong association between increasing dependency and training in this meta-analysis. Specifically, in one study, only elder abuse occurring in both community and institutional 48% of the staff were qualified nurses in the field of elder care 35,37 29 settings. The risk of dependency also increases with age. The or medical care and, in another study, only 10% of the staff majority of the sample included in the meta-analysis was 75 years were college graduates. and older. Moreover, increased risk for abuse has been associated This systematic review has several notable strengths. It is the first with declining health in Ireland and with those needing help with of its kind to use meta-analysis to synthesize global prevalence ADLs in Germany. Such findings are consistent with the sample estimates and abuse subtypes in institutional settings based on a characteristics included in the meta-analysis where victims of abuse comprehensive search strategy. This strategy included studies Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 The prevalence of elder abuse in institutional settings 63 1 Year Prevalence of Sexual Abuse Reported By Older Residents in the Institutions 1 Year Prevalence of Neglect Reported By Older Residents in the Institutions 1 Year Prevalence of Financial Abuse Reported By Older Residents in the Institutions Figure 2 continued published in various languages as well as in six different countries. In included in the synthesis was poor as reflected in the low average addition, 26 experts were consulted to further identify any relevant score on the modified Newcastle-Ottawa scale. Due to the sparseness studies that may have been missed in the searches. This review also of available literature a more flexible approach had to be adopted with provided rigorous analyses to compare prevalence rates based on regard to prevalence time periods. One study had a prevalence period of reports by staff and by older adults. the past 6 months while the others had prevalence periods of Nonetheless, the findings must be considered in light of several limi- 12 months. Ideally all studies should cover the same time period. tations. Prevalence studies were sparse or missing in many regions of the Likewise, although most studies included in the meta-analyses were world with a majority of the studies from high-income countries. based on self-reports either by older residents or staff, data from one Furthermore, among the existing studies there was wide variation in study were based on proxy reports. Prior studies have indicated that methodologies used to measure abuse. The quality of the studies proxy reports might be better at detecting abuse. Moreover, while Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 64 European Journal of Public Health 1 Year Prevalence of Self-Reported Perpetration of Overall Elder Abuse By Staff towards Older Residents in the Institution 1 Year Prevalence of Self-Reported Perpetration of Psychological Abuse By Staff towards Older Residents in the Institution Figure 3 Forest plots of elder abuse subtypes reported by staff efforts have been made to ensure homogeneity of the study samples and This study makes the following contributions to the field: (i) it to exclude studies with residents with dementia, a small proportion of provides estimates of abuse as reported by the victims and abusers the samples included residents with dementia. based on a meta-analysis of all studies showing that this is a large Given the scarcity of literature, future research should focus on public health problem and (ii) it provides insights into the meas- examining elder abuse in institutional settings. In particular, it urement of elder abuse. Given the similarity in the magnitude of should clearly define the populations; the types of abuse, such as abuse as self-reported by older residents and staff, future data staff-to-resident abuse, resident-to-resident abuse or visitor-to- collection can refine reliability and recall issue of abuse by using resident abuse; characteristics of institutions such as staff to patient both older residents and staff within the same institutions. In ratios, ratio of trained staff, training for staff, and care guidance and doing so, it can allow comparability in the prevalence of abuse. adopt a rigorous research methodology particularly in relation to the Elder abuse has serious health, social and economic consequences sampling procedure, use of standardized measurement tools, and for the victims, their families and the larger societies. It has been method of data collection such as face-to-face interview for older proposed that prevention is more cost-effective than dealing with 16,33 adults and self-administrated questionnaires for the staff. An the consequences of abuse. The findings of this study have emphasis on more uniform and systematic quality management important implications for the quality of care for older adults strategies for care might result in regular and more systematic admin- living in the institutions to ensure that they live without abuse. istrative data that can be used for future research. The present study Both the WHO global strategy and action plan on ageing and found significant heterogeneity for each abuse subtype suggesting that health (2016–20) and the WHO strategy and action plan for the variance came from sources other than sampling error. Future healthy ageing in Europe (2012–20) affirm the rights of older 15,16 research is needed to examine these sources of variance by investigating persons to live with dignity. These strategies call for strengthen- the differences in research methodology that measure and assess insti- ing of health and long-term care systems to ensure quality person- tutional elder abuse. Moreover, older people with dementia deserve centred and integrated care that allows older adults to enjoy their 15,16 special attention in future research. basic human rights and fundamental freedoms. Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 The prevalence of elder abuse in institutional settings 65 1 Year Prevalence of Self-Reported Perpetration of Physical Abuse By Staff towards Older Residents in the Institution 1 Year Prevalence of Self-Reported Perpetration of Sexual Abuse By Staff towards Older Residents in the Institution 1 Year Prevalence of Self-Reported Neglect By Staff towards Older Residents in the Institution Figure 3 continued Crucial to improving the quality of care, there is a need to build Given that the implementation of quality of care guidelines in long- capacity of multidisciplinary professionals through training and term care settings is still emerging in many countries, the strategy calls exchange of good practices across sectors for the prevention of for incorporation of the latest evidence of good practice into national elder abuse. The quality of services requires improvement, in policies and programming to prevent elder abuse. Moreover, these particular through better adaptation to the special needs of older strategies should address negative attitudinal change to avert people with functional limitations and by following guidance to prejudices towards ageing and to reinforce older people’s fundamental prevent elder abuse. right to live without abuse and violence. There is a need to improve Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 66 European Journal of Public Health the evidence based on sound models of care and to strengthen  The high prevalence of elder abuse in institutions adds to the research capacity on effective preventive interventions. increased demand for the health and social sector to An OECD report showed that while most countries have several improve the quality of care for older residents and better mechanisms to address abuse such as legislation to encourage public care management training for staff. disclosure of specific cases; provision of complaint mechanisms and establishment of ombudsman, few countries have been systematic- ally measuring whether long-term care is safe, effective and meets the 40 References needs of care recipients. The findings of this study emphasize the urgency of the demand for better, higher-quality care of older adults. 1 Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community This is particularly relevant given the demographic challenge of settings: a systematic review and meta-analysis. Lancet Glob Heal 2017;1:365–56. ageing societies in middle- and high-income. 2 World Health Organization. Elder Abuse Fact Sheet 357. Geneva: World Health Despite higher rates of abuse and neglect in the institutional settings Organization, 2017. than in the community settings, elder abuse in the institutions has not 3 Gorbien MJ, Eisenstein AR. Elder abuse and neglect: an overview. Clin Geriatr Med achieved the same public health priority as other forms of abuse. 2005;21:279–92. Greater attention and resources are needed to ensure that nursing 4 McDonald L, Beaulieu M, Harbison J, et al. 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Investment in developing interventions Gerontologist 1993;33:128–31. for older adults and the staff in institutional facilities must be a public 8 Lindbloom EJ, Brandt J, Hough LD, Meadows SE. Elder mistreatment in the nursing health priority to help reduce the effect of elder abuse. home: a systematic review. J Am Med Dir Assoc 2007;8:610–6. 9 Meddaugh DI. Covert elder abuse in nursing home. J Elder Abus Negl 1993;5:21–37. Supplementary data 10 Harris DK, Benson ML. Theft in nursing homes: an overlooked form of elder abuse. Supplementary data are available at EURPUB online. J Elder Abuse Negl 2000;11:73–90. 11 European Commission. Health and Long-term Care in the European Union, 2007. Acknowledgements 12 United Nations. 2017 Revision of World Population Prospects [Internet], 2017. Available at: https://esa.un.org/unpd/wpp/(11 November 2017, date last accessed). We thank the USC Leonard Davis School of Gerontology, the members 13 World Health Organization Regional Office for Europe. Regional Report on of the International Network for the Prevention of Elder Abuse and its Institutions Providing Long-term Care for Adults with Psychosocial and Intellectual affiliated organizations for providing their expert advice as well as Disabilities in the European Region. Copenhagen, 2018. Darja Dobermann for her assistance in reference management. 14 World Health Organization. A Global Response to Elder Abuse and Neglect: Building Primary Health Care Capacity to Deal with the Problem Worldwide: Main Disclaimer Report. Geneva: WHO Press, 2008. 15 World Health Organization. Multisectoral Action for a Life Course Approach to Healthy The views expressed by authors do not necessarily represent the Ageing: Draft Global Strategy and Plan of Action on Ageing and Health. Geneva, 2016. decisions or the stated policy of the World Health Organization. 16 World Health Organization Regional Office for Europe. Strategy and Action Plan for Healthy Ageing in Europe, 2012–2020. Copenhagen, 2012. Funding 17 Yon Y, Mikton C, Gassoumis ZD, Wilber KH. Research protocol for systematic review and meta-analysis of elder abuse prevalence studies. Can J Aging/La Rev Can This study was funded in part by the Social Sciences and Humanities du Vieil 2017;36:256–65. Research Council of Canada (SSHRC). 18 World Health Organization. World Report on Ageing and Health. Geneva: WHO, 2015. Conflicts of interest: The authors certify that they have no affiliations 19 Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for with or involvement in any organization or entity with any financial Assessing the Quality of Nonrandomised Studies in Meta-analyses. Ottawa, 2011. interest (such as honoraria; educational grants; participation in 20 Borenstein M, Hedges L V, Higgins, JP, Rothstein, HR. Introduction to Meta- speakers’ bureaus; membership, employment, consultancies, stock Analysis. West Sussex, UK: John Wiley & Sons Ltd, 2009. ownership or other equity interest; and expert testimony or patent- 21 Borenstein M, Rothstein D, Cohen J. Comprehensive Meta-Analysis: A Computer licensing arrangements), or non-financial interest (such as personal or Program for Research Synthesis. Englewood, NJ: Biostat, 2005. professional relationships, affiliations, knowledge or beliefs) in the 22 Duval S, Tweedie R. A nonparametric ‘‘Trim and Fill’’ method of accounting for subject matter or materials discussed in this manuscript. publication bias in meta-analysis. J Am Stat Assoc 2000;95:89–98. 23 Buz ˇgova ´ R, Ivanova ´ K. Violation of ethical principles in institutional care for older people. Nurs Ethics 2011;18:64–78. Key points 24 Cohen M, Halevy-Levin S, Gagin R, et al. Elder abuse in long-term care residences and the risk indicators. Ageing Soc 2010;30:1027–40. The pooled estimate of elder abuse and neglect occurring in the past 12 months in the institutional settings indicates that 25 Habjanic ˇ A, Lahe D. Are frail older people less exposed to abuse in nursing homes as compared to community-based settings? Statistical analysis of Slovenian data. Arch 64.2% of staff admitted to abuse. Gerontol Geriatr 2012;54:e261–70. Prevalence estimates for abuse subtypes reported by older residents in the institutions were highest for psychological 26 Griffore RJ, Barboza GE, Mastin T, et al. Family members’ reports of abuse in abuse, followed by physical, financial, neglect, and sexual abuse. Michigan nursing homes. J Elder Abuse Negl 2009;21:105–14. There is a serious lack of rigorous prevalence studies on 27 Drennan J, Lafferty A, Treacy M, et al. Older People in Residential Care Settings: elder abuse in the institutions especially in low-and-middle Results of a National Survey of Staff-resident Interactions and Conflicts. Dublin, 2012. income countries. 28 Goergen T. A multi-method study on elder abuse and neglect in nursing homes. J Adult Prot 2004;6:15–25. Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 Factors associated with older people’s emergency department attendance towards the end of life 67 29 Goergen T. Stress, conflict, elder abuse and neglect in German nursing homes: a 35 Rubio R. Concepto, tipos, incidencia y factores de riesgo ... - Google Scholar. In: Iborra pilot study among professional caregivers. J Elder Abuse Negl 2001;13:1–26. Marmolejo I, editor. Violencia Contra Personas Mayores. Barcelona: Ariel SA, 2005: 113–28. 30 Natan MB, Matthews P, Lowenstein A. Study of factors that affect abuse of older 36 Gasior K, Huber M, Lamura G, et al. Facts and Figures on Healthy Ageing and Long- people in nursing homes. Nurs Manag (Harrow) 2010;17:20–4. Term Care. In: Rodrigues R, Huber M, Lamura G, editors. Vienna: European Centre for Social Welfare Policy and Research, 2012. 31 Pillemer K, Bachman-Prehn R. Helping and hurting: predictors of maltreatment of patients in nursing homes. Res Aging 1991;13:74–95. 37 Lachs MS, Berkman L, Fulmer T, Horwitz RI. A Prospective Community-Based Pilot Study of Risk Factors for the Investigation of Elder Mistreatment. J Am Geriatr 32 Hawes C. Elder abuse in residential long-term care settings: what is known and what Soc 1994;42:169–73. information is needed. In: Bonnie R, Wallace R, editors. Elder Mistreatment Abus Neglect, Exploit an Aging America. Washington: National Academies Press (US), 38 Naughton C, Drennan J, Treacy M, et al. Abuse and Neglect of Older People in 2003:446–500. Ireland: Report on the National Study of Elder Abuse and Neglect. Dublin, 2010. 33 Sethi D, Wood S, Mitis F, et al., editors. European Report on Preventing Elder 39 Pillemer K, Finkelhor D. The prevalence of elder abuse: a random sample survey. Maltreatment. Copenhagen: World Health Organization, 2011. Gerontologist 1988;28:51–7. 34 Juklestad O. Institutional care for older people—the dark side. J Adult Prot 40 OECD/European Commission. A Good Life in Old Age? Monitoring and Improving 2001;3:32–41. Quality in Long-term Care. OECD Health Policy Studies. Paris: OECD Publishing, 2013. ......................................................................................................... The European Journal of Public Health, Vol. 29, No. 1, 67–74 The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com doi:10.1093/eurpub/cky241 Advance Access published on 26 November 2018 ......................................................................................................... Systematic Review and Meta-Analyses ......................................................................................................... Factors associated with older people’s emergency department attendance towards the end of life: a systematic review 1 1,2 1 1 1,3 Anna E. Bone , Catherine J. Evans , Simon N. Etkind , Katherine E. Sleeman , Barbara Gomes , 4 5 6 1 Melissa Aldridge , Jeff Keep , Julia Verne , Irene J. Higginson 1 King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK 2 Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK 3 Faculty of Medicine, University of Coimbra, Coimbra, Portugal 4 Icahn School of Medicine at Mount Sinai, Department of Geriatrics and Palliative Medicine, New York, USA 5 King’s College Hospital NHS Foundation Trust, London, UK 6 Public Health England, Bristol, UK Correspondence: Anna Bone, King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK, Tel: +44 207 848 0128, Fax: +44 207 848 5517, e-mail: anna.bone@kcl.ac.uk Background: Emergency department (ED) attendance for older people towards the end of life is common and increasing, despite most preferring home-based care. We aimed to review the factors associated with older people’s ED attendance towards the end of life. Methods: Systematic review using Medline, Embase, PsychINFO, CINAHL and Web of Science from inception to March 2017. Included studies quantitatively examined factors associated with ED attendance for people aged 65 years within the last year of life. We assessed study quality using the QualSyst tool and determined evidence strength based on quality, quantity and consistency. We narratively synthesized the quantitative findings. Results: Of 3824 publications identified, 21 were included, combining data from 1 565 187 participants. 17/21 studies were from the USA and 19/21 used routinely collected data. We identified 47 factors and 21 were included in the final model. We found high strength evidence for associations between ED attendance and palliative/hospice care (adjusted effect estimate range: 0.1–0.94); non-white ethnicity (1.03–2.16); male gender (1.04–1.83, except 0.70 in one sub-sample) and rural areas (0.98–1.79). The final model included socio- demographic, illness and service factors, with largest effect sizes for service factors. Conclusions: In this synthesis, receiving palliative care was associated with lower ED attendance in the last year of life for older adults. This has implications for service models for older people nearing the end of life. However, there is limited evidence from European countries and none from low or middle-income countries, which warrants further research. ......................................................................................................... However, half of people aged 65 years and over in the USA attend the Introduction emergency department (ED) in the month before death. Trends in ost older people who are approaching the end of life prefer to be the UK show that ED attendances in the last year of life are cared for and die in their usual place of care, remaining in increasing. Unplanned transitions to hospital may enable timely familiar surroundings with family nearby and autonomy preserved. access to health care services, but are often distressing and http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Public Health Oxford University Press

The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis

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10.1093/eurpub/cky093
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Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 58 European Journal of Public Health 25 Wahrendorf M, Blane D. Does labour market disadvantage help to explain why 34 LaCroix AZ, Guralnik JM, Berkman LF, et al. Maintaining mobility in late life. II. childhood circumstances are related to quality of life at older ages? Results from Smoking, alcohol consumption, physical activity, and body mass index. Am J SHARE. Aging Ment Health 2015;19:584–94. Epidemiol 1993; 37:858–69. 26 Wahrendorf M, Blane D, Bartley M, et al. Working conditions in mid-life and 35 Murtagh KN, Hubert HB. Gender differences in physical disability among an elderly mental health in older ages. Adv Life Course Res 2013;18:16–25. cohort. Am J Public Health 2004;94:1406–11. 36 Friedmann JM, Elasy T, Jensen GL. The relationship between body mass index and 27 International Labour Office ILO. 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Soc Forces 2009;87:2093–124. 2003;58:S327–37. 31 Amemiya A, Fujiwara T, Murayama H, et al. Adverse childhood experiences and 39 Lacey RJ, Belcher J, Croft PR. Validity of two simple measures for estimating higher-level functional limitations among older Japanese people: results from the life-course socio-economic position in cross-sectional postal survey data in an JAGES study. J Gerontol A Biol Sci Med Sci 2018;73:261–6. older population: results from the North Staffordshire Osteoarthritis Project 32 Bierman A. Functional limitations and psychological distress: marital status as (NorStOP). BMC Med Res Methodol 2012;12:88. moderator. Soc Ment Health 2012;2:35–52. 40 Chan KS, Kasper JD, Brandt J, Pezzin LE. Measurement equivalence in ADL and 33 Yip JLY, Khawaja AP, Broadway D, et al. Visual acuity, self-reported vision and falls IADL difficulty across International Surveys of Aging: findings from the HRS, in the EPIC-Norfolk Eye study. Br J Ophthalmol 2014;98:377–82. SHARE, and ELSA. J Gerontol B Psychol Sci Soc Sci 2012;67B:121–32. ......................................................................................................... The European Journal of Public Health, Vol. 29, No. 1, 58–67 World Health Organization, 2018. The World Health Organization has granted the Publisher permission for the reproduction of this article. This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 IGO License (https://creativecommons.org/ licenses/by/3.0/igo/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. doi:10.1093/eurpub/cky093 Advance Access published on 5 June 2018 ......................................................................................................... The prevalence of elder abuse in institutional settings: a systematic review and meta-analysis 1 1 2 1 1 Yongjie Yon , Maria Ramiro-Gonzalez , Christopher R. Mikton , Manfred Huber , Dinesh Sethi 1 WHO Regional Office for Europe, Copenhagen DR-2100, Denmark 2 WHO Headquarters, Geneva 1202, Switzerland Correspondence: Yongjie Yon, Division of Noncommunicable Diseases and Promoting Health through the Life-course, WHO Regional Office for Europe, Marmorvej 51, Copenhagen DR-2100, Denmark, Tel: +45 (0) 45 33 69 32, Fax: +45 (0) 45 33 70 01, e-mail: yony@who.int Background: A recent study has shown that close to one in six older adults have experienced elder abuse in a community setting in the past year. It is thought that abuse in institutions is just as prevalent. Few systematic evidence of the scale of the problem exists in elder care facilities. The aim of this review is to conduct a systematic review and meta-analysis of the problem in institutional settings and to provide estimates of the prevalence of elder abuse in the past 12 months. Methods: Fourteen academic databases and other online platforms were systematically searched for studies on elder abuse. Additionally, 26 experts in the field were consulted to identify further studies. All studies were screened for inclusion criteria by two independent reviewers. Data were extracted, and meta-analysis was conducted. Self-reported data from older residents and staff were considered separately. Results: Nine studies met the inclusion criteria from an initial of 55 studies identified for review. Overall abuse estimates, based on staff reports, suggest that 64.2% of staff admitted to elder abuse in the past year. There were insufficient studies to calculate an overall prevalence estimate based on self-reported data from older residents. Prevalence estimates for abuse subtypes reported by older residents were highest for psychological abuse (33.4%), followed by physical (14.1%), financial (13.8%), neglect (11.6%), and sexual abuse (1.9%). Conclusions: The prevalence of elder abuse in institutions is high. Global action to improve surveillance and monitoring of institutional elder abuse is vital to inform policy action to prevent elder abuse. ......................................................................................................... Organization (WHO), elder abuse is defined as ‘a single, or Introduction repeated act, or lack of appropriate action, occurring within any lder abuse is an important public health issue with serious social, relationship where there is an expectation of trust which causes economic and health consequences. The global prevalence of past harm or distress to an older person’. Elder abuse can be categorized year elder abuse in the community settings is 15.7%, or approxi- according to: type of abuse—psychological, physical, sexual, and mately one in six older adults. According to the World Health financial abuse and neglect; type of abuser—family members, Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 The prevalence of elder abuse in institutional settings 59 informal and formal caregiver, or acquaintance; or setting in which institutional settings from existing literature and to identify gaps it occurs—in the community and in an institution. Within institu- for future research directions. tional settings, abuse can be broadly categorized into resident-to- resident abuse or staff-to-resident abuse. Methods Compared with research on other forms of interpersonal violence, elder abuse research, especially in institutions, is still in its infancy. Search strategy and selection criteria However, research has shown that elder abuse occurs in every This research, focused on institutional settings, was part of a larger country with nursing and residential facilities and anecdotal systematic review of studies examining the prevalence of elder abuse evidence suggests that abuse may be very prevalent. A survey of in all settings. The study conforms to the Preferred Reporting Items nursing home staff in the USA indicated that 40% of staff for Systematic reviews and Meta-Analysis – or PRISMA – guidelines admitted to committing psychological abuse in the past year and and has been registered with PROSPERO International Prospective 10% to committing physical abuse. A systematic review of institu- Register of Systematic Reviews (CRD42015029197). A detailed de- tional abuse indicated that physical abuse often occurs as a form of scription of the method has been published elsewhere. A brief staff retaliation against physically aggressive residents. Similarly, description of the methodology is presented below. staff reported that they were more likely to withhold choices from A comprehensive four-step search strategy was used to identify aggressive residents. In another US national study, 1.5% of staff relevant studies. The first step consisted of searching the following self-reported that they have committed theft. There is significant 14 academic databases from inception to 26 June 2015: PubMed, awareness of the issue of elder abuse in institutional settings among PsycINFO, CINAHL, EMBASE, MEDLINE, Sociological Abstracts, the population in European Union (EU) countries. According to a ERIC, AgeLine, Social Work Abstracts, International Bibliography of 2007 Eurobarometer special report on health and long-term care in the Social Sciences, Social Services Abstracts, ProQuest Criminal the EU, 47% of European citizens think that poor treatment, neglect Justice, ASSIA, Dissertations & Theses Full Text and Dissertations and abuse of older adults are common in their country. & Theses Global. A search strategy was developed for each database There is a gap in the current literature on the prevalence of elder using a combination of free text and controlled vocabulary (i.e. abuse in nursing and residential facilities for older people. The need MeSH terms). Additional search terms were included in consult- for greater attention to this topic stems from a number of factors. ation with an information specialist (librarian) who has extensive First, according to the data from World Population Prospects,in experience in systematic reviews. Some of the search terms used 2015, the global population of older adults aged 60 years or over is included: older adults, frail elderly, aged, elderly, seniors, elder about 901 million or 12.3% of the world’s population, and by 2050, abuse, elder neglect, elder mistreatment, elder maltreatment, the global population of older adults will more than double to nearly 12 domestic violence, intimate partner violence, abuse, violence, aggres- 2.1 billion or 21.3%. Second, the number of ‘oldest-old’ adults, sion, crimes, harmful behaviour, anger, rape, hostility, conflict, aged 80 years or over, is growing faster than the population of older verbal abuse, physical abuse, sexual abuse, emotional abuse, preva- adults. For example, by 2050, the number of the ‘oldest-old’ lence, incidence, morbidity and epidemiology; nursing homes, population will have more than tripled to 434 million from 125 assisted living, residential care institutions, residential facilities, million in 2015. Third, women, on average, have a longer life health facilities and skilled nursing facilities. The full search expectancy than men, and as a result they account for 61.6% of 1,17 strategy and search terms have been previously published. those over 80 years . Fourth, it is likely that females and the Second, reference lists of publications retrieved in the first step were ‘oldest-old’ seniors in the future will remain the largest age group screened for relevant studies. Third, we searched additional web-based in long-term care facilities. platforms including specialized journals, Google for grey literature, Currently, older adults also make up the largest proportion of and the WHO’s Global Health Library for scientific literature adult populations living in institutions for adults with mental published in low and middle income countries. Finally, 26 experts disabilities in the European region. Residents of such facilities in the field were consulted by e-mail, representing each of the six are more likely to have multiple forms of impairment including WHO regions (i.e. Africa, Americas, South-East Asia, European, mental, physical or behavioural abnormalities as well as disabling Eastern Mediterranean and Western Pacific) to identify any studies conditions. Thus, due to their frailty, residents in institutional that the first three steps may have missed up to 18 December 2015. settings tend to be more dependent on others for care and may be Articles were independently screened in two stages by two reviewers: at greater risk for abuse and neglect than older adults in community first, titles and abstracts were screened for relevance. This was followed settings. Finally, the prevalence of abuse may be much higher than by the retrieval and screening of full text articles by two reviewers reported since under-reporting is estimated to be as high as 80%. using the eligibility criteria described below. If several publications Such under-reporting could be due to victims’ inability to commu- reported on a single study, the publication that provided the most nicate their abuse or due to their fear of repercussion and retaliation. data were selected for further synthesis. Inter-rater reliability was Urgent action is needed to prevent elder abuse from occurring, analyzed using the Statistical Package for Social Sciences (SPSS especially in the institutional settings. The WHO global strategy and Statistics 21). This analysis showed high levels of agreement between action plan on ageing and health (2016–20) provides a roadmap to the reviewers (: 0.86–0.96). Disagreements were resolved through prevent elder abuse and achieve healthy ageing. The strategy calls for discussion, or with the help of a third reviewer. key actions in the areas of health systems, age-friendly environments, Inclusion criteria were institutional-based samples that provided better long-term care and improvements in measurement, monitor- estimates of abuse prevalence at a national or sub-national level (e.g. ing and research. Underlying this strategy is a set of core principles states/provinces, counties, districts and large cities); and inclusion of to ensure older adults age safely in a place that affirms their basic participants that were 60 years of age and older, in line with a human rights and fundamental freedoms. Such affirmation is frequently used age limit used for data presentation and crucial to elder abuse prevention. Similarly, one of the supporting research. We excluded studies that were reviews, conference interventions in the WHO strategy and action plan for healthy proceedings or used qualitative methods only, and studies that ageing in Europe (2012–20) targets elder abuse prevention, which focused exclusively on use of restraints, self-neglect or homicide. calls for actions to improve the quality of services within institu- tional settings. Despite increasing attention, research on institu- Data extraction and quality assessment tional abuse is still lacking. To better capture and summarize existing research on institutional abuse, this systematic review and meta- Data were extracted by two reviewers: the first extracted data from analysis aims to synthesize prevalence estimates of abuse in the publications and the second cross-checked for accuracy. Three Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 60 European Journal of Public Health main categories of data were extracted: characteristics of the samples, was performed to assess the degree of publication bias, its effect on methodological characteristics of each study and prevalence the study findings, and to remove extreme outliers to correct for 20,22 estimates of elder abuse and its sub-types. The study quality was publication bias. assessed as part of the data extraction strategy by two reviewers using the Modified Newcastle-Ottawa Scale designed to assess the quality of non-randomized epidemiological research. To assess Results the risk of bias, reviewers rated each of the 7 items along a 4-point Of the 38 544 studies that were initially identified through the com- Likert scale from high risk of bias (i.e. 0) to low risk of bias (i.e. 3, prehensive search strategy for all elder abuse prevalence studies see Panel 1). An overall score was calculated by adding all the items, occurring in the community and the institutional settings, 55 full- thus, higher scores indicated lower risk of bias and stronger meth- text articles related to abuse in the institutions were independently odological quality. reviewed. These relevant articles fall into two categories of institutional abuse: resident-to-resident abuse and staff-to-resident abuse. From Data analysis these, 18 studies were selected for data extraction and 12 additional studies were identified through expert consultations. After further Meta-analysis was performed to synthesize the prevalence estimates. screening, 21 studies were excluded and 9 studies were selected for The decision to do a meta-analysis was made a posteriori after meta-analysis, which provided data for staff-to-resident abuse. Among ensuring sufficient studies with similar characteristics were 23–26 these, four studies examined abuse prevalence self-reported by available for meta-analysis. Prevalence rates were calculated from raw proportions or percentages reported in the selected studies. older adults including one study in which abuse was reported by proxies, close relatives to the older adults and six studies in which The pooled estimates and the 95% confidence intervals (CIs) were 23,27–31 calculated based on a random-effects model. Non-overlapping CIs abuse prevalence was self-reported by staff. Figure 1 shows the were considered as an indication of statistical significant differ- flowchart of study selection. ences. All analyses were conducted using Comprehensive Meta- The four prevalence studies, based on self-report by older adults Analysis software (CMA 3.9). Heterogeneity tests with Higgins’ and their proxies, were from the Czech Republic, Israel, Slovenia and I statistic were performed to determine the extent of variation the USA. In the studies, between 64.8 and 82.8% of the samples were 20 23,25,26 between the studies. Duval and Tweedie’s Trim and Fill method women. Two studies provided age group breakdowns with Documents retrieved Duplicate documents excluded 36239 Found through secondary search Excluded: 2365 � 1600 Elder abuse in community settings Identified for title & abstract review � 676 Not elder abuse � 61 Qualitative studies � 28 Other (e.g. lit. review, testimony etc.) Identified for full texts review Excluded: 37 � 10 No prevalence data � 10 Duplicate data Identified as relevant for data extraction sets 18 � 6 Non-institutional � 5 Restraint � 4 Literature review Identified via � 2 Under 60-years expert consultation old Included after full text review Excluded: 21 � 8 No prevalence data � 3 Non-institutional � 2 Duplicate Prevalence studies reported past year datasets abuse by staff � 2 Literature review � 2 Resident to resident abuse � 3 Observational � 1 Under 60-years old Figure 1 Summary of study selection for inclusion in analysis Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 The prevalence of elder abuse in institutional settings 61 23,25 those aged 75 years and older making up 75% of the samples. Table 1 Institutional abuse reported by older adults and staff The older adults who participated in the studies were adults with Elder abuse types Pooled estimates Lower Upper normal cognitive functioning who had the ability to communicate (%) limit (%) limit (%) and orient themselves in time and space. However, the majority of these respondents was frail and required assistance in activities of Reported by older adults over past year daily living (ADLs). The quality of the studies was assessed using the Psychological (3 studies) 33.4 6.3 78.9 19 a Physical (4 studies) 14.1 1.9 58.3 Modified Newcastle-Ottawa Scale. The maximum score for good Sexual (3 studies) 1.9 0.03 59.2 quality study on this scale (i.e. low risk of bias) was 21. On average, Neglect (3 studies) 11.6 0.4 81.8 the studies scored 11 out of 21 on the scale. Financial (3 studies) 13.8 0.7 78.3 There were six studies that were based on self-reports by staff. In Reported by staff over past year these studies, staff were asked whether they had perpetrated or Overall (4 studies) 64.2 53.3 73.9 directed abusive acts to older residents. These studies were geo- Psychological (5 studies) 32.5 16.1 54.6 Physical (5 studies) 9.3 4.4 18.4 graphically diverse from the Czech Republic, Germany, Ireland, Sexual (3 studies) 0.7 0.04 11.7 Israel and the USA. Of the six studies, between 80 and 97% of Neglect (4 studies) 12.0 2.6 41.4 the staff respondents were women. All of the respondents were over 35 years old, with five studies reporting average staff ages a: Adjusted for publication bias. 27–31 of early- to mid-40 years old. There was a wide range in the average number of years of professional experience working with 23 27 studies (N = 2711). Finally, for sexual abuse (Q[2] = 38.72.82; older adults: from less than 4 years to between 10.4 years and P < 0.0001; I = 94.8%), there were three studies (N = 2054) with a 13.8 years. Moreover, between 38 and 63% of the staff were pooled estimate of 0.7% (CI 2.6–41.4%). Figure 3 shows the forest registered nurses, licensed practical nurses or had received qualifi- 28,29,31 plots of the pooled estimates of elder abuse reported by the staff. cations in the care of older adults. The characteristics of the older adults residing in the institutions were not provided except for two studies which included adults with normal cognitive func- Discussion tioning who were frail and needed assistance with two or more 23 27 This is the first rigorous quantitative synthesis of prevalence ADLs or had high levels of dependency, including dementia. estimates for elder abuse in the institutions. Findings from this The average score on the quality assessment instrument was 14 study, based on self report by older residents, show that the past out of the maximum score of 21 (see Supplementary data Table 2). year prevalence of elder abuse in the institutional settings is high. In The pooled prevalence estimates for psychological, physical, addition, data based on staff self report, indicate that 64.2% of staff sexual, and financial abuse and neglect were independently admitted to elder abuse. However, caution is needed when calculated from studies that collected data from older adults and interpreting the estimates from staff self-report. The rates of elder their proxies (Table 1). Visual inspection of the funnel plots abuse and neglect perpetrated by staff only provide a partial picture indicated that there was evidence of publication bias for physical abuse. Tests of heterogeneity for each of the abuse subtypes were on the extent of the problem and do not indicate the overall prevalence of abuse in the institution. Yet, findings from this performed. Generally, the studies for each subtype were heteroge- neous suggesting that differences in the effect sizes do exist within study is consistent with the anecdotal evidence and the belief that 11,32 abuse in seniors’ residential facilities is widespread. this set of studies. The Higgins’ I showed high variances for each abuse subtypes (91.1–98.3%) indicating that variance came from To date there have been few studies on the prevalence of elder abuse in institutional care settings. Existing studies have provided a sources other than sampling error. The rate of psychological abuse was reported in three studies that wide range of estimates. For example, in studies based on self- reports by older adults or their proxies prevalence estimates have included a total of 694 individuals. The prevalence estimate for psy- 2 24 chological abuse (Q[2] = 116.56; P < 0.0001; I = 98.3%) in the past ranged from 31% in Israel for overall abuse —86.9% for neglect in the USA. Similarly, studies based on staff reports in Germany also year was 33.4% (CI 6.3–78.9%). There were four studies (N = 718) reporting on physical abuse. After adjusting for publication bias, the indicated a wide range of estimates: from 53.7% for psychological 28 29 abuse and neglect —78.8% for overall abuse. pooled estimate for physical abuse (Q[3] = 97.82; P < 0.0001; I = 96.9%) was 14.1% (CI 1.9–58.3%). Sexual abuse (Q[2] = 22.38; This systematic review, based on a comprehensive search strategy, P < 0.0001; I = 91.1%) was reported in three studies (N = 569) with was conducted to better understand the prevalence of elder abuse in institutional settings. Nine studies were synthesized using meta- a pooled estimate of 1.9% (CI 0.03–59.2%). Financial abuse (Q[2] = 80.69; P < 0.0001; I = 97.5%) was reported in three studies analysis to pool prevalence estimates for elder abuse. Separate meta-analyses were performed for estimates based on self-reported (N = 263) with a pooled estimate of 13.8% (CI 0.7–78.3%). Neglect (Q[2] = 92.88; P < 0.0001; I = 97.8%) was reported in three studies data by the older adults (i.e. the victims) or their proxies and by the staff (i.e. the abusers). Based on self-reported studies by the staff, (N = 658) with a pooled estimate of 11.6% (CI 0.4–81.8%). Figure 2 shows the forest plots of the pooled estimates of elder abuse reported 64.2% of them admitted to abuse. Since a minimum of three studies is required to conduct a meta-analysis, there were not enough by older adults. Estimates of perpetrating abuse were calculated from data using staff studies to be pooled for overall abuse as reported by older residents. The findings of this study on the self-reported prevalence estimates self-reports for overall abuse as well as abuse subtypes (See Table 1). Evidence of publication bias was present for psychological abuse and of elder abuse subtypes by older residents and staff suggest similarities in the magnitude of the problem. The prevalence estimates reported neglect. Tests of heterogeneity also revealed a high degree of variance for each abuse subtypes (I = 90–99.1%). There were four studies that by older residents were highest for psychological abuse (33.4%), provided data for overall abuse (N = 1405) with a pooled estimate followed by physical (14.1%), financial (13.8%), neglect (11.6%), (Q[3] = 45.54; P < 0.0001; I = 93.4%) of 64.2% (CI 53.3–73.9%) and sexual abuse (1.9%). These rates were higher compared to the within the past year. After adjusting for publication bias, the pooled prevalence rates in the community settings as reported by older psychological abuse (Q[4] = 422.83; P < 0.0001; I = 99.1%) rate was adults: psychological (11.6%), physical (2.6%), financial (6.8%), 32.5% (CI 16.1–54.6%) and neglect (Q[3]=151.04; P <0.0001; neglect (4.2%), and sexual (0.9%) abuse. I = 98.0%) was 12.0% (CI 2.6–41.4%). There were five studies An examination of risk factors for elder abuse suggests a number (N = 2706) for psychological abuse and four studies (N = 2106) for of possible explanations for the higher prevalence rate in institu- neglect. The pooled estimate for physical abuse (Q[4]=123.47; tional settings. Although no single risk factors can fully account P < 0.0001; I = 96.8%) was 9.3% (CI 4.4–18.4%) with a total of five for the occurrence of elder abuse and research on risk factors in Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 62 European Journal of Public Health 1 Year Prevalence of Psychological Abuse Reported By Older Residents in the Institutions 1 Year Prevalence of Physical Abuse Reported By Older Residents in the Institutions Figure 2 Forest plots of elder abuse subtypes reported by older adults this area suffers from several weaknesses (e.g. lack of unified oper- in institutional settings reported frailer health and greater ational definitions of abuse, measurement problems and inconsistent dependency on the staff for assistance in ADLs than non-victims. 6,32 research methodologies ), some risk factors have nevertheless been Of the studies based on self-reports by staff, a small sample of the consistently identified, including the characteristics of victims and older residents was diagnosed with dementia. In fact, between 3.4 staff, of the facilities and the working environment. and 18.5% of the residents who have been abused by staff had The main risk factors for victims of elder abuse are being female, dementia. Older residents in the institutions had many of the presence of a cognitive impairment and disability, and being older risk factors associated with abuse. Such risk factors may also be 33–35 than 74 years old. Research on elder abuse occurring in the compounded by the environment in which they lived in. community found that the majority of the victims were women. Nursing homes and other seniors’ residential facilities can be Likewise, 83% of the sample that were included in this meta- stressful environments. When asked about the main stressors, analysis was women. In fact women comprised up to 77.3% of staff attributed their experience of stress to staff shortages and the victims who reported psychological, physical and financial time pressure. Indeed research has found that staff who self- abuse. The greater share of women in institutional care is reported committing abuse described themselves as emotionally 27,29 consistent with the statistical profile of long-term care facilities in exhausted. In addition, significant correlation was found North America and where findings showed that nearly four out of between abuse and high ratio of residents to registered nurses. the five residents in care homes are women. This predominance of It was further found that an increased presence of qualified women stems, in part, from the large differences in gender ratios, nurses was associated with a reduction in resident abuse risk. especially for the highest age groups. There was wide variation in staff professional experience and There is a strong association between increasing dependency and training in this meta-analysis. Specifically, in one study, only elder abuse occurring in both community and institutional 48% of the staff were qualified nurses in the field of elder care 35,37 29 settings. The risk of dependency also increases with age. The or medical care and, in another study, only 10% of the staff majority of the sample included in the meta-analysis was 75 years were college graduates. and older. Moreover, increased risk for abuse has been associated This systematic review has several notable strengths. It is the first with declining health in Ireland and with those needing help with of its kind to use meta-analysis to synthesize global prevalence ADLs in Germany. Such findings are consistent with the sample estimates and abuse subtypes in institutional settings based on a characteristics included in the meta-analysis where victims of abuse comprehensive search strategy. This strategy included studies Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 The prevalence of elder abuse in institutional settings 63 1 Year Prevalence of Sexual Abuse Reported By Older Residents in the Institutions 1 Year Prevalence of Neglect Reported By Older Residents in the Institutions 1 Year Prevalence of Financial Abuse Reported By Older Residents in the Institutions Figure 2 continued published in various languages as well as in six different countries. In included in the synthesis was poor as reflected in the low average addition, 26 experts were consulted to further identify any relevant score on the modified Newcastle-Ottawa scale. Due to the sparseness studies that may have been missed in the searches. This review also of available literature a more flexible approach had to be adopted with provided rigorous analyses to compare prevalence rates based on regard to prevalence time periods. One study had a prevalence period of reports by staff and by older adults. the past 6 months while the others had prevalence periods of Nonetheless, the findings must be considered in light of several limi- 12 months. Ideally all studies should cover the same time period. tations. Prevalence studies were sparse or missing in many regions of the Likewise, although most studies included in the meta-analyses were world with a majority of the studies from high-income countries. based on self-reports either by older residents or staff, data from one Furthermore, among the existing studies there was wide variation in study were based on proxy reports. Prior studies have indicated that methodologies used to measure abuse. The quality of the studies proxy reports might be better at detecting abuse. Moreover, while Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 64 European Journal of Public Health 1 Year Prevalence of Self-Reported Perpetration of Overall Elder Abuse By Staff towards Older Residents in the Institution 1 Year Prevalence of Self-Reported Perpetration of Psychological Abuse By Staff towards Older Residents in the Institution Figure 3 Forest plots of elder abuse subtypes reported by staff efforts have been made to ensure homogeneity of the study samples and This study makes the following contributions to the field: (i) it to exclude studies with residents with dementia, a small proportion of provides estimates of abuse as reported by the victims and abusers the samples included residents with dementia. based on a meta-analysis of all studies showing that this is a large Given the scarcity of literature, future research should focus on public health problem and (ii) it provides insights into the meas- examining elder abuse in institutional settings. In particular, it urement of elder abuse. Given the similarity in the magnitude of should clearly define the populations; the types of abuse, such as abuse as self-reported by older residents and staff, future data staff-to-resident abuse, resident-to-resident abuse or visitor-to- collection can refine reliability and recall issue of abuse by using resident abuse; characteristics of institutions such as staff to patient both older residents and staff within the same institutions. In ratios, ratio of trained staff, training for staff, and care guidance and doing so, it can allow comparability in the prevalence of abuse. adopt a rigorous research methodology particularly in relation to the Elder abuse has serious health, social and economic consequences sampling procedure, use of standardized measurement tools, and for the victims, their families and the larger societies. It has been method of data collection such as face-to-face interview for older proposed that prevention is more cost-effective than dealing with 16,33 adults and self-administrated questionnaires for the staff. An the consequences of abuse. The findings of this study have emphasis on more uniform and systematic quality management important implications for the quality of care for older adults strategies for care might result in regular and more systematic admin- living in the institutions to ensure that they live without abuse. istrative data that can be used for future research. The present study Both the WHO global strategy and action plan on ageing and found significant heterogeneity for each abuse subtype suggesting that health (2016–20) and the WHO strategy and action plan for the variance came from sources other than sampling error. Future healthy ageing in Europe (2012–20) affirm the rights of older 15,16 research is needed to examine these sources of variance by investigating persons to live with dignity. These strategies call for strengthen- the differences in research methodology that measure and assess insti- ing of health and long-term care systems to ensure quality person- tutional elder abuse. Moreover, older people with dementia deserve centred and integrated care that allows older adults to enjoy their 15,16 special attention in future research. basic human rights and fundamental freedoms. Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 The prevalence of elder abuse in institutional settings 65 1 Year Prevalence of Self-Reported Perpetration of Physical Abuse By Staff towards Older Residents in the Institution 1 Year Prevalence of Self-Reported Perpetration of Sexual Abuse By Staff towards Older Residents in the Institution 1 Year Prevalence of Self-Reported Neglect By Staff towards Older Residents in the Institution Figure 3 continued Crucial to improving the quality of care, there is a need to build Given that the implementation of quality of care guidelines in long- capacity of multidisciplinary professionals through training and term care settings is still emerging in many countries, the strategy calls exchange of good practices across sectors for the prevention of for incorporation of the latest evidence of good practice into national elder abuse. The quality of services requires improvement, in policies and programming to prevent elder abuse. Moreover, these particular through better adaptation to the special needs of older strategies should address negative attitudinal change to avert people with functional limitations and by following guidance to prejudices towards ageing and to reinforce older people’s fundamental prevent elder abuse. right to live without abuse and violence. There is a need to improve Downloaded from https://academic.oup.com/eurpub/article/29/1/58/5033581 by DeepDyve user on 20 July 2022 66 European Journal of Public Health the evidence based on sound models of care and to strengthen  The high prevalence of elder abuse in institutions adds to the research capacity on effective preventive interventions. increased demand for the health and social sector to An OECD report showed that while most countries have several improve the quality of care for older residents and better mechanisms to address abuse such as legislation to encourage public care management training for staff. disclosure of specific cases; provision of complaint mechanisms and establishment of ombudsman, few countries have been systematic- ally measuring whether long-term care is safe, effective and meets the 40 References needs of care recipients. 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For commercial re-use, please contact journals.permissions@oup.com doi:10.1093/eurpub/cky241 Advance Access published on 26 November 2018 ......................................................................................................... Systematic Review and Meta-Analyses ......................................................................................................... Factors associated with older people’s emergency department attendance towards the end of life: a systematic review 1 1,2 1 1 1,3 Anna E. Bone , Catherine J. Evans , Simon N. Etkind , Katherine E. Sleeman , Barbara Gomes , 4 5 6 1 Melissa Aldridge , Jeff Keep , Julia Verne , Irene J. Higginson 1 King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK 2 Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK 3 Faculty of Medicine, University of Coimbra, Coimbra, Portugal 4 Icahn School of Medicine at Mount Sinai, Department of Geriatrics and Palliative Medicine, New York, USA 5 King’s College Hospital NHS Foundation Trust, London, UK 6 Public Health England, Bristol, UK Correspondence: Anna Bone, King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK, Tel: +44 207 848 0128, Fax: +44 207 848 5517, e-mail: anna.bone@kcl.ac.uk Background: Emergency department (ED) attendance for older people towards the end of life is common and increasing, despite most preferring home-based care. We aimed to review the factors associated with older people’s ED attendance towards the end of life. Methods: Systematic review using Medline, Embase, PsychINFO, CINAHL and Web of Science from inception to March 2017. Included studies quantitatively examined factors associated with ED attendance for people aged 65 years within the last year of life. We assessed study quality using the QualSyst tool and determined evidence strength based on quality, quantity and consistency. We narratively synthesized the quantitative findings. Results: Of 3824 publications identified, 21 were included, combining data from 1 565 187 participants. 17/21 studies were from the USA and 19/21 used routinely collected data. We identified 47 factors and 21 were included in the final model. We found high strength evidence for associations between ED attendance and palliative/hospice care (adjusted effect estimate range: 0.1–0.94); non-white ethnicity (1.03–2.16); male gender (1.04–1.83, except 0.70 in one sub-sample) and rural areas (0.98–1.79). The final model included socio- demographic, illness and service factors, with largest effect sizes for service factors. Conclusions: In this synthesis, receiving palliative care was associated with lower ED attendance in the last year of life for older adults. This has implications for service models for older people nearing the end of life. However, there is limited evidence from European countries and none from low or middle-income countries, which warrants further research. ......................................................................................................... However, half of people aged 65 years and over in the USA attend the Introduction emergency department (ED) in the month before death. Trends in ost older people who are approaching the end of life prefer to be the UK show that ED attendances in the last year of life are cared for and die in their usual place of care, remaining in increasing. Unplanned transitions to hospital may enable timely familiar surroundings with family nearby and autonomy preserved. access to health care services, but are often distressing and

Journal

European Journal of Public HealthOxford University Press

Published: Feb 1, 2019

Keywords: elder abuse; internship and residency; older adult; medical residencies; neglect; self-report; emotional abuse; community

References