Elder Mistreatment and Health Status of Rural Older Adults

Abstract

There is limited information on the nature of and health factors associated with elder mistreatment in rural areas. To address this gap in the literature, the current study described the nature of such mistreatment and investigated the association between different types of mistreatment and health factors among 897 randomly selected elderly persons in rural India. The results show that elder mistreatment was widely prevalent (21%). Furthermore, the higher frequency of and simultaneous occurrence of multiple types of mistreatment (83.4%) suggest that mistreatment was a continuous stressor. The presence of overall mistreatment was positively associated with depression symptoms and subjective health status. The higher levels of chronicity and multiple mistreatments further increased depression symptoms and lowered the health status of those who were mistreated. Although women, more than men, were more likely to experience mistreatment, chronic mistreatment, and multiple mistreatments, there were no significant gender differences in the mistreatment-health relationship. These findings suggest that older adults with depression symptoms and poor health should be screened for mistreatment.

Keywords

domestic violence alcohol and drugs elder abuse mental health and violence

Older adults who experience stressors are at an increased risk of adverse health conditions compared with those who do not. Mistreatment by family members is one such stressor that has negative mental and physical health consequences for older adults (Choi & Mayer, 2000; Chokkanathan & Lee, 2005; Comijs, Penninx, Knipscheer, & van Tilburg, 1999; Goldstein,1996; Lachs, Williams, O’Brien, & Pillemer, 2002; Mouton, Rodabough, Rovi, Brzyski, & Katerndahl, 2010). Although the adverse effects of mistreatment on the health of the mistreated older adult has been established, many questions remain unanswered. Most research focused on urban populations, and, thus, there exists very little information on the nature of mistreatment and its association with the health status of mistreated elderly persons in rural areas. Rural elderly persons generally report a lack of formal services and high levels of morbidity (Government of India, 2011; Nemet & Baile, 2000), which might heighten their vulnerability to adverse health consequences caused by mistreatment. There is also limited information on the effects of chronic and multiple forms of mistreatment on the health of mistreated older adults in rural areas. Most mistreated older adults report experiences of repeated mistreatment over a period of time and of multiple types of mistreatment (Chokkanathan, & Lee, 2005; Fisher & Regan, 2006). This issue needs to be addressed because recurrent and multiple stressors might have more detrimental outcomes than those that are episodic (Pearlin,1989; Pearlin, Schieman, Fazio, & Meersman, 2005). Therefore, there is a higher likelihood that repeated elder mistreatment and multiple mistreatments might have more adverse consequences on health than isolated incidents of mistreatment. With noted exceptions (Cisler, Amstadter, Begle, Hernandez, & Acierno, 2010; Fisher & Regan, 2006), findings on the psychological effects of mistreatment predominate in the literature, and there is scant information on the types of health indicators, such as a subjective rating, of an elder’s health status. Elder mistreatment may result in short-term and long-term deleterious physical health consequences (Lachs & Pillemer, 2004). The existing research has been lumped together by gender or focused on only one gender, mostly on females (Baker et al., 2009; Fisher & Regan, 2006; Schofield & Mishra, 2004). Gender perspective holds a central place in the development and understanding of appropriate responses to elder mistreatment. It is critical to elucidate the health consequences of mistreatment by gender because of gender differentials in access to resources, appraisal and coping with stressors, and stressor outcomes (Matud, 2004). The current study described the nature of elder mistreatment and examined its association with the health status of mistreated older adults in a rural community in India.

Elder Mistreatment in Rural Communities

Elder mistreatment is a taboo in Indian culture, which may be why it is concealed by sociocultural norms. Indian culture is characterized by collectivism, wherein family interests supersede individual interests. Older adults in India derive meaning and purpose from familial relationships and, thus, may not report abuse for fear of inflicting familial disgrace, disrupting familial harmony, and losing one’s identity by losing one’s family permanently (Chokkanathan, Natarajan, & Mohanty, 2014).

To date, no national-level data exist on the prevalence of elderly mistreatment in India. Among the very few studies on elder abuse in India, fewer studies have focused on the rural elderly population. Sebastian and Sekher (2011), in a sample of 300 rural elderly persons, reported a prevalence rate of 49%. Gaikwad, Sudeepa, and Madhukumar (2011) reported a prevalence rate of 41% among 127 older adults in rural Bangalore. The most common form of abuse was psychological (30.7%), followed by financial (30.2%), and physical (19%). In a study conducted in three villages, 40 out of a sample of 1,000 older adults reported physical abuse (Rao, 1995). However, this study did not exclusively focus on mistreatment. Despite the growing body of literature on elder abuse worldwide, only a few studies have focused on prevalence rates in rural areas. Studies conducted in rural areas of various countries show that between 5.5% (Australia; Cupitt, 1997) and 43.7% (Egypt; Abdel Rahman & El Gaafary, 2012) of older adults tend to report mistreatment. Similar to the results of the studies conducted in India, neglect (Spain; Josep et al., 2009) and psychological abuse (South Carolina; Amstadter et al., 2011) appear to be the most common forms of mistreatment. Physical abuse varies from 0.1% in Spain to 5.7% in Egypt, and financial abuse ranges from 2% (China; Wu et al., 2012) to 5.1% in South Carolina, in the United States. The generalizability of these findings is limited by the varying conceptual definitions, sample characteristics, and measures used in the studies.

Elder Mistreatment and Psychological Distress

Studies have generally shown that mistreatment inflicts pronounced psychological distress on the mistreated older adult (for a review, see Dong, Chen, Chang, & Simon, 2013).There is limited information on the association between mistreatment and the health status of elderly Indian persons in rural areas. Sebastian and Sekher (2011), after controlling for sociodemographic factors, reported that the mistreated group in their study was 12 times more likely to report depression symptoms than the non-mistreated group. A few studies in rural areas have consistently shown that older adults who have been mistreated reported higher levels of depression, loneliness, and poor health status than those who have not been mistreated (Amstadter et al., 2011; Dong & Simon, 2013).

Studies in other countries have also shown that mistreated older adults report higher levels of anxiety and lower levels of life satisfaction and quality of life (Cooper et al., 2006; Dong & Simon, 2013; Fisher & Regan, 2006; Schofield & Mishra, 2004; Tobiasz-Adamczyk, Brzyski, & Brzyska, 2014). Dong, Beck, and Simon (2010) reported that mistreated women were at a higher risk of depression than mistreated men. After controlling for support, depression symptoms for men became insignificant.

Elder Mistreatment and Subjective Health Rating

Subjective health status functions as a proxy for physical illness (Davies & Ware, 1981; Krause & Jay, 1994) and health behavior. Subjective health status also appears to measure some aspects of health that evade measurement, as suggested by its strong association with mortality, even after controlling for other health covariates (Desalvo, Bloser, Reynolds, He, & Muntner, 2006). In addition, administering a single item on overall health status reduces interview time and response fatigue, which is particularly important in studying a sensitive topic such as elder mistreatment. A few studies have indicated a positive association between elder mistreatment and physical health indicators, such as poor subjective health status (Amstadter et al., 2010; Laumann, Leitsch, & Waite, 2008), chronic illness (Fisher & Regan, 2006), and functional deficits (Choi & Mayer, 2000; Post et al., 2010). However, the results on gender differences are unclear. Some studies have shown that mistreated women report poorer health statuses than mistreated men (Sebastian & Sekher, 2011), whereas other studies have shown no such gender differences (Acierno et al., 2011).

Research Design

Cross-sectional survey involving face-to-face interviews was the design of this study. The study area was a sub-district in Tamil Nadu, a southern state in India. A two-stage sampling design (30 clusters × 31 respondents) involving a random selection of clusters (i.e., villages followed by a random selection of potential respondents from electoral lists of the selected cluster) was used in this study. The probability proportionate to size method yielded a self-weighting sample. The calculated sample size was 921 (estimated prevalence rate of 49.3% rounded to 50%, level of confidence of 95%, precision of 0.05%, a design effect of 2, and a drop-out rate of 0.2%). The final calculated sample size, rounded up to the closest number that matches the 30 clusters, was 930 elderly participants. The drop-out rate was 3.2%. Another 4 respondents were excluded due to missing responses. The analysis of the current study was based on 897 respondents aged 61 years and above. The majority of the respondents were in the young−old age group (61-70 years), married, unemployed, and living with their family members. A low proportion of them were from high-economic-status families. Female older adults, compared with male older adults, were more likely to be single, unemployed, and living alone. These differences were found to be statistically significant (Table 1).

Table 1.

Profile of Female and Male Respondents.

	Total n (%)	Female n (%)	Male n (%)	p
Age
61-70	581 (64.77)	315 (54.2)	266 (45.8)	.19
71 and above	316 (35.23)	157 (49.7)	159 (50.3)
Marital Status
Single	284 (31.7)	218 (76.8)	66 (23.2)	.000
Married	613 (68.3)	254 (41.4)	359 (58.7)
Employment
Employed	265 (30)	106 (40)	159 (60)	.000
Unemployed	632 (70)	366 (58)	266 (42)
Living arrangements
Living alone	155 (17.3)	109 (70)	46 (30)
Living with spouse	228 (25.4)	98 (43)	130 (57)	.000
Living with children/spouse/others	514 (57.3)	265 (51.6)	249 (48.4)
Wealth index
Low	360 (40)	198 (55)	162 (45)
Moderate	357 (40)	184 (51.5)	173 (48.5)	.47
High	180 (20)	90 (50)	90 (50)
Support (M)	18.7	18.1	19.30	.04

Ethical Issues

The Institutional Review Board of the National University of Singapore approved the research proposal. The data were collected in 2012. The research incorporated an adapted version of the World Health Organization’s (WHO) ethical and safety recommendations for research on domestic violence in developing countries (Ellsberg, Heise, Pena, Agurto, & Winkvist, 2001). The author oriented the interviewers to issues concerning ageing, mistreatment, and interview techniques using a variety of methods. The importance of conducting the research in privacy and maintaining confidentiality and anonymity were emphasized. The interviewers were trained to ask questions related to abuse in an empathic manner, to be receptive to distress signals, and to deal with such distress appropriately. The interviewers were also oriented toward different schemes and services available for the older adults. The interviews were conducted in complete privacy, at a time and place suggested by the respondent. Oral consent was obtained. Written consent was not possible due to the high rate of illiteracy among the older adults, and also the general fear that signatures may result in legal repercussions. The interviewers began the interviews by building rapport and discussing very general information, before asking questions about mistreatment. If there were unexpected interruptions, the interviewers skipped to additional general questions. At the end of the interview, the interviewers thanked the respondents, praised their resiliency, emphasized their right to lead an abuse-free life, and provided information on available services and referrals. The author also conducted the interviews and supervised data collection.

Tools of Data Collection

The translated Tamil version of the questionnaire was pre-tested on 20 older adult respondents from outside the study area. The mistreatment questionnaire was an adapted version of the Conflict Tactics Scale (Straus, 1979), which was used by the author in an earlier study (Chokkanathan & Lee, 2005). The scale comprises four items on psychological abuse, six items on physical abuse, three items on financial abuse, two items on neglect, and one “other” item to capture other forms of abuse. Cronbach’s alpha of the scale was .93. The response format was anchored on a 6-point scale indicating the frequency of occurrence: 0 (no mistreatment), 1 (once), 2 (twice), 3 (3-5 times), 4 (6-10 times), 5 (11-20 times), and 6 (>20 times). Three measures were generated from the mistreatment scale. The first denotes presence or absence of overall mistreatment: 0 (no mistreatment), and 1 (yes to any type of mistreatment). The second refers to chronicity of mistreatment in the past year prior to the interview. Chronicity refers to the frequency of acts among those who experienced at least one of the acts of mistreatment. The response points (0-6) were summated. Separate scores on subtypes of mistreatment were not possible because of the high overlap among the mistreatment constructs. Therefore, a summated score was computed for those who were mistreated and, based on percentile distribution, was categorized into three groups (0 = no mistreatment), (1 = low chronicity < 50 percentile), and (2 = high chronicity > 50 percentile). The third measure, multiple mistreatment, was derived by an affirmative response to more than one type of mistreatment: (0 = no mistreatment, 1= 1 type, 2 = 2 types, and 3 = 3-4 types).

Health Status

Psychological distress was measured by the 5-item Geriatric Depression Scale (Hoyl et al., 1999). The response was yes/no. A high score denotes high levels of distress. The internal reliability score was .78. A single item on subjective health status with a 5-point response (1 = excellent, 2 = very good, 3 = good, 4 = fair, and 5 = poor) was administered. A dichotomous score was derived: 0 = poor health, and 1 = excellent−fair health.

Control Variables

Age, gender, marital status, wealth index, employment status, living arrangements, and support were included as control variables. The social support questions included six items adopted from the Medical Outcomes Study Social Support Survey (Sherbourne & Stewart, 1991). The items tapped emotional, affectionate, and instrumental support. Possible responses were as follows: 5 = always, 4 = most of the time, 3 = some of the time, 2 = a little of the time, and 1 = not at all. High scores denote high levels of support. Cronbach’s alpha was good: α = .96.

Statistical Analyses

Using SPSS v.20, conditional probabilities were computed to describe the magnitude of multiple mistreatments. Stata “svy” command was used to account for the complex sampling method. Chi-square tests were conducted to examine differences on rates of mistreatment types between male and female elderly persons. Multiple linear regression analysis was conducted to model the association between each continuous health indicator and mistreatment. Multiple logistic regression analysis was conducted to examine the relation between dichotomous health indicator and mistreatment.

Results

In the sample of 897 respondents, 187 (21.0%) reported some form of mistreatment in the past 1 year prior to the interview. Bivariate analysis shows that more females than males were at a higher risk of overall mistreatment, psychological abuse, and neglect. More females than males were most likely to report higher levels of chronic mistreatment, more multiple mistreatments, poorer health status, and higher depression symptoms. The prevalence rates of multiple mistreatment in the general population was 17%. Among those who were mistreated, 156 (83.4%) of them had reported more than one type of mistreatment. Indeed, about one third (35%) of those who had been mistreated reported all four types of mistreatment, and slightly less than half (48%) had reported two to three types of mistreatment (Table 2). To further explore the nature of multiple mistreatment, conditional probabilities were calculated (Table 3). In Table 3, the diagonal depicts the unconditional percentages (i.e., the percentages of older adults who reported a specific type of abuse). The conditional probabilities are presented in columns and off the diagonal. Among the older adults who reported physical abuse, 72% had been financially abused, and 65% had been neglected. Psychological abuse co-occurred with other types of mistreatment. Among those who reported a specific type of mistreatment, between 89% (neglect) and 99% (physical abuse) also reported psychological abuse. The conditional likelihoods were higher than the unconditional likelihoods in their respective rows, suggesting that multiple mistreatments were more common than a single type. For instance, 12% of the older adults reported neglect, yet between 58% and 73% of older adults experienced multiple abuse, among which were instances of neglect. Therefore, there is a strong commonality that cuts across the different types of mistreatment.

Table 2.

Gender Mistreatment and Health Status.

	Total Sample n (%)	Female n (%)	Male n (%)	p
Mistreatment any type⁺
Yes	187 (20.1)	116 (62)	71 (38)	.004
No	710 (79.9)	356 (50.1)	354 (49)
Mistreatment—Types^a
Psychological
Yes	172 (19.8)	109 (63.4)	63 (36.6)	.002
No	725 (80.2)	363 (50.1)	362 (49.9)
Physical
Yes	111 (12.4)	68 (61.3)	43 (38.7)
No	786 (87.6)	404 (51.4)	382 (48.6)	.05
Financial
Yes	114 (12.7)	69 (60.5)	45 (39.5)
No	783 (87.3)	403 (51.5)	380 (48.5)	.72
Neglect
Yes	112 (12.5)	74 (66.1)	38 (33.9)
No	785 (87.5)	398 (50.7)	387 (49.3)	.002
Chronicity
Low chronicity	133 (14.83)	79 (59.4)	54 (40.6)
High chronicity	54 (6.02)	37 (68.5)	17 (31.5)	.008
No mistreatment	710 (79.15)	356 (50.1)	354 (49.9)
Chronicity mean (n = 187)	14.37	13.53	14.88
Multiple mistreatment
No mistreatment	710 (79.15)	356 (50.1)	354 (49.9)
One	31 (3.46)	20 (64.5)	11 (35.5)	.03
Two	56 (6.24)	33 (58.9)	23 (41.1)
Three-four	100 (11.15)	63 (63)	37 (37)
Health indicators
Depression symptoms (M)	1.71	1.82	1.52	.001
Number of illness (M)	2.14	2.22	2.02	.10
Subjective health status
Poor	164 (81.7)	107 (65.2)	57 (34.8)	.0001
Excellent–fair	733 (18.3)	365 (49.8)	368 (50.2)

There is an overlap among the subtypes.

Table 3.

Conditional Probabilities.

	Conditional Types
Type of Abuse	Psychological	Physical	Financial	Neglect
Psychological	.19	.99	.94	.89
Physical	.63	.12	.70	.64
Financial	.62	.72	.13	.75
Neglect	.58	.65	.73	.12

Elder Mistreatment and Health

Table 4 provides adjusted odds ratios (AORs) for experiencing any type of mistreatment and reporting different health problems. Past 1 year experience of any type of mistreatment was significantly associated with depression and subjective health status. The results were similar for male and female older adults. Table 5 depicts mistreatment chronicity and health indicators for male and female older adults. Regardless of gender, higher levels of chronicity elevated scores on depression symptoms and poor health status. For males, the odds ratios on poor health status for low chronicity versus no mistreatment and high chronicity versus no mistreatment was 4.22 (confidence interval [CI] = [1.2, 14.3], p = .02) and 4.72 (CI = [1.2, 17.5], p = .02), respectively. Results of multiple mistreatments were similar to those of chronic mistreatment (Table 6). For both genders, more than one type of mistreatment was related significantly with depression and subjective health status. For female older adults, the odds ratios on depression for single versus no mistreatment and three to four types versus no mistreatment were 1.12 (CI = [0.7, 1.7], p = .5) and 2.60 (CI = [1.9, 3.4], p = .0001), respectively.

Table 4.

Presence or Absence of Mistreatment and Health Indicators.

	Depression			Subjective Health
	b	AOR [CI]	p	b	AOR [CI]	p
Mistreatment yes
Total group	0.66	1.93 [1.57, 2.38]	.0001	0.82	2.27 [1.62, 3.18]	.0001
Female	0.59	1.80 [1.42, 2.28]	.0001	0.56	1.76 [1.07, 2.91]	.02
Male	0.75	2.13 [1.65, 2.74]	.0001	1.46	4.32 [1.31, 14.21]	.01

Note. Controlled for age, living arrangements, marital status, wealth index, employment, and support. AOR = adjusted odds ratio; CI = confidence interval.

Table 5.

Depression, Poor Health Status, and Chronic Mistreatment.

	Male Chronicity						Female Chronicity
	Low			High			Low			High
	b	AOR [CI]	p	b	AOR [CI]	p	b	AOR [CI]	p	b	AOR [CI]	p
Health indicators
Depression	0.73	2.09 [1.6, 2.6]	.0001	0.84	2.33 [1.4, 3.7]	.002	0.47	1.61 [1.2, 2.0]	.001	1.00	2.72 [1.9, 3.7]	.0001
Poor health	1.44	4.22 [1.2, 14.3]	.02	1.55	4.72 [1.2, 17.5]	.02	0.47	1.60 [0.91, 2.8]	.09	0.92	2.53 [1.4, 4.4]	.003

Note. Controlled for age, living arrangements, marital status, wealth index, employment, support. AOR = adjusted odds ratio; CI = confidence interval.

Table 6.

Depression, Poor Health Status, and Multiple Mistreatments.

	Multiple Mistreatment
	One			Two			Three-Four
	b	AOR [CI]	p	b	AOR [CI]	p	b	AOR [CI]	p
Male: Health indicators
Depression	1.07	2.92 [1.8, 4.5]	.0001	0.71	2.03 [1.4, 2.8]	.0001	0.71	2.04 [1.5, 2.6]	.0001
Poor health	1.89	6.68 [1.4, 29.8]	.01	1.24	3.46 [0.8, 13.5]	.07	1.41	4.13 [1.2, 14.1]	.02
Female: Health indicators
Depression	0.11	1.12 [0.7, 1.7]	.5	0.49	1.64 [1.1, 2.4]	.01	0.95	2.60 [1.9, 3.4]	.0001
Poor health	0.20	1.22 [0.4, 3.7]	.7	0.35	1.42 [0.6, 2.9]	.3	0.87	2.40 [1.4, 4.0]	.002

Note. Controlled for age, living arrangements, marital status, wealth index, employment, support. AOR = adjusted odds ratio; CI = confidence interval.

Discussion

The findings of this study reveal that elder mistreatment is a pervasive, severe, and continuous condition rather than an isolated event. Comparing prevalence rates with other studies is problematic due to differing methodologies and definitions of mistreatment. The prevalence rate in this study was lower than those reported in other Indian studies (Gaikwad et al., 2011; Sebastian & Sekher, 2011) and falls in the middle of the range, that is, between 5.5% (Cupitt, 1997) and 43.7% (Abdel Rahman & El Gaafary, 2012), as reported in other rural studies. However, the overall prevalence rate is merely the tip of the iceberg. The rate of physical abuse (12.3%) is around 3 to 12 times higher than that reported in other rural studies (Josep et al., 2009; Wu et al., 2012). Other studies have reported rates of financial abuse between 2% (Wu et al., 2012) and 5.1% (Amstadter et al., 2011), compared with 12.7% in the present study, that is, 2 to 6 times higher. The chronicity scores reveal that mistreatment is not a one-off event, but rather a recurrent phenomenon. Moreover, around 83% of those who were mistreated reported multiple types of mistreatment. This is in contrast to the findings of previous studies, which have predominantly reported single rather than multiple types of mistreatment. Wu et al. (2012) reported that among those who are abused, the ratio of single to multiple types was 7:3, whereas in this study the ratio is 3:7. Psychological abuse co-occurred with other types of mistreatment, including physical abuse. This finding may be explained by Berkowitz’s (1993) conflict-escalation theory, which states that verbal aggression, rather than being cathartic, tends to increase the risk of physical abuse. Research on elder abuse appears to support escalation theory by finding a strong correlation between emotional and physical abuse (Fisher & Regan, 2006). Moreover, the findings of this study also show that for older adults, mistreatment signifies more of a life condition than an episodic event. Therefore, presence of any form of mistreatment not only signifies persistent stressors but also is likely to erode personal resources that might help to moderate the occurrence of other types of mistreatment. There is a clear need for further studies to disentangle the relations among different types of mistreatment. The high frequency of multiple types of mistreatment also indicates that focusing on any one type of mistreatment may erroneously inflate the seriousness and consequences of that type of mistreatment. Gender differences show that more women were mistreated than men, and women were also more likely to experience higher levels of chronic mistreatment, as well as more multiple mistreatments, the results of which are consistent with those of other studies (Chokkanathan & Lee, 2005).

Consistent with previous findings (Dong & Simon, 2013), this study shows that the presence or absence of mistreatment was significantly associated with depression symptoms. Higher frequency and greater variety of mistreatments further increased the risk for depression symptoms. Recurrent occurrence of mistreatment and the presence of multiple types of mistreatment may erode and tax the coping abilities of those who are mistreated, resulting in poorer psychological health. Mostly, gender differences were not evident for the association between different types of mistreatment and depression, results in line with a study in South Carolina (Acierno et al., 2011). However, other research studies have shown that women are more likely than men to report higher levels of depression (Sebastian & Sekher, 2011). Dong, Beck, and Simon (2010) have reported that the odds ratio for the association of elder mistreatment with depression for men and women were 4.47 and 8.54, respectively. Based on a single study, one cannot negate gender differences. Perhaps, in future studies, different types of externalizing and internalizing health indicators should be used. The absence of gender differences also pinpoints that elder mistreatment is a serious a health problem for males as for females. In line with other studies (Newsom, Mahan, Rook, & Krause, 2008; Sebastian & Sekher, 2011), overall mistreatment and its various dimensions were positively associated with poorer health status. This is an important finding because self-rated health has been found to be associated with increased morbidity (Cott, Gignac, & Badley, 1999) and mortality (Ford, Spallek, & Dobson, 2008). Although the study established the association between mistreatment and health indicators, an interesting question remains unanswered: “What are the pathways through which mistreatment and its various types influence health?” Multidisciplinary studies should attempt to unravel the psychosocial and biological mechanisms involved in the mistreatment−health linkage.

The findings of this study have several implications for gerontology professionals. The high prevalence of mistreatment and its positive association with negative health indicators show that medical professionals and paraprofessionals should be trained in identifying signs and symptoms of the various elder mistreatment subtypes. The identification of the subtypes of elder mistreatment, such as psychological abuse, which not only occurs frequently but also co-occurs with other types of mistreatment, may depend on the willingness and skillset of the professional. Friedman, Avila, Shah, Tanouye, and Joseph (2014) found that physicians failed to report two thirds of physical abuse cases to Adult Protective Services. In India, elder mistreatment might be overlooked as a familial problem that should be solved within one’s family. In addition, widespread ageism (Jamuna & Ramamurti, 2007) and the belief that nothing can be done to stop older adult mistreatment might challenge the effective identification of elder mistreatment. The possibility of the occurrence of other types of mistreatment, given the occurrence of a single type of mistreatment, should be explored. Older adults using health and allied health services should be screened for overall elder mistreatment and, subsequently, receive a comprehensive assessment to establish the nature of mistreatment in terms of type, chronicity, and occurrence of multiple mistreatments.

There are several limitations to the present study. First, although the study assesses four types of mistreatment, it does not focus on sexual abuse. Two, the relative influences of the different types of mistreatment could not be examined due to substantial overlap. This is important because health effects may differ based on the subtype of mistreatment. Three, the cross-sectional nature of the study does not imply cause–effect relationships. For instance, those who are having depression may inflict a care-giving burden, resulting in mistreatment. Four, despite measures taken to maximize disclosure, elder mistreatment might be under-reported due to associated stigma.

Despite the aforementioned limitations, this study is one among the very few to examine elder mistreatment and its deleterious effects on health in a rural setting. The findings show that mistreatment is pervasive, severe, and complicated. Not only is the mere presence of mistreatment associated with poor health, but also the severity of mistreatment heightens the risk for poor health. Therefore, there is a need for early and sound screening of mistreatment among elderly persons with health problems.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Start-up grant, NUS [R-134-000-072-133].

Author Biography

Srinivasan Chokkanathan’s area of interest is social gerontology, particularly on risk factors associated with the mental health of older adults and elder mistreatment.

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