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Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 527535.
Dementia and elder abuse 531
(22.6% in Wang, 2006), and the Peoples Republic of
China (35.2% in Dong et al., 2007). This rate, however,
is comparable to those reported in dementia patients
in western societies (52% in Cooper et al., 2009 and in
Cooney et al., 2006). Previous studies have shown
that people generally perceive abusive behavior as less
abusive when the victim has dementia (Matsuda,
2007). It is possible that such an attitude contributes
to the occurrence of abuse against older persons with
dementia.
Similar to the ndings from previous investigations
(Yan and Tang, 2004; Wang, 2006; Dong et al., 2007;
Table 4 Results of hierarchical multiple regression analyses
Verbal abuse Physical abuse
Standardized
coefcients
beta
t-value R
2
F change Standardized
coefcients
beta
t-value R
2
F change
Block 1: Demographics 0.21 10.36*** 0.06 2.41
Care recipients age 0.13 1.52 0.02 0.21
No. of co-residing days 0.35 4.24*** 0.24 2.65**
Assistance from domestic helper 0.23 2.72** 0.03 0.34
Block 2: Agitated behaviors 0.25 9.94*** 0.06 1.88
Care recipients age 0.14 1.68 0.02 0.24
No. of co-residing days 0.34 4.28*** 0.24 2.63**
Assistance from domestic helper 0.19 2.32* 0.04 0.42
Agitated behaviors 0.22 2.66** 0.05 0.57
Block 3: Caregivers Burden 0.07 1.78
Care recipients age 0.13 1.58 0.30 9.72*** 0.02 0.17
No. of co-residing days 0.34 4.34*** 0.24 2.61**
Assistance from domestic helper 0.16 1.99* 0.05 0.58
Agitated behaviors 0.13 1.45 0.01 0.06
Perceived caregivers burden 0.23 2.62** 0.12 1.16
*p <0.05. **p <0.01. ***p <0.001.
Table 5 Interaction between co-residence and use of community service on caregiver burden and abuse
Standardized
coefcients beta
t-value R
2
F change
Caregiver Burden 0.00 0.13
Block 1: Main Effect 0.03 0.32
Use of community service 0.04 0.43
No. of co-residing days
0.00 0.16
Block 2: Interaction Effect 0.01 0.08
Use of community service 0.02 0.13
No. of co-residing days 0.08 0.46
Community serviceco-residing days
Verbal Abuse
Block 1: Main Effect 0.13 9.19***
Use of community service 0.02 0.22
No. of co-residing days 0.35 0.43***
Block 2: Interaction Effect 0.13 6.09**
Use of community service 0.00 0.04
No. of co-residing days 0.35 2.33*
Community serviceco-residing days 0.03 0.18
Physical Abuse
Block 1: Main Effect 0.08 4.99**
Use of community service 0.14 3.63
No. of co-residing days 0.26 2.89**
Block 2: Interaction Effect 0.09 3.69*
Use of community service 0.06 0.48
No. of co-residing days 0.13 0.83
Community serviceco-residing days 0.17 1.05
*p <0.05. **p <0.01. ***p <0.001.
Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 527535.
532 E. Yan and T. Kwok
Cooper et al., 2009), the present study found that
verbal abuse is more prevalent than physical abuse.
While 62.3% of the respondents reported verbal abuse,
only 18% reported physical abuse. Distinct predictors
were noted for the two forms of abuse. Verbal abuse
was predicted by a larger number co-residing days, lack
of any assistance from a domestic helper, a high level of
agitated behavior, and a high level of caregiver burden,
whereas physical abuse was only predicted by a larger
number co-residing days.
The result that a larger number of co-residing days
was associated with both verbal and physical abuse
supports previous nding which showed the shared
living environment to be a major factor related to the
abuse of older persons with dementia (Hansberry et al.,
2000; Shugarman et al., 2003). Living in a shared living
environment, the caregiver and the care-recipient are
exposed to increased opportunities for interpersonal
conicts, which can give rise to incidents of elder
abuse.
The nding that a high level of agitated behavior
predicts verbal abuse is also in line with previous
studies, which showed that care recipients behavioral
disturbances were associated with both caregiver bur-
den (Coen et al., 1997; Arai et al., 2004) and abuse by
caregivers (Sasaki et al., 2007). The present results
supplement the existing literature by delineating the
relationship between agitated behavior, caregiver burden,
and abuse. Specically, our results show that agitated
behavior may have an impact on the elicitation of
abusive behaviors through its effect on caregiver
burden.
Assistance from a domestic helper was related to a
lower level of verbal abuse. A possible explanation for
this is that the assistance from a domestic helper can
mitigate the daily chores that the caregiver would need
to otherwise need to carry out on his or her own, and
thus minimizes caregiver burden and conicts between
the caregiver and the care recipient. Another plausible
explanation is that the presence of a non-family
member in the household may increase the caregivers
sense of self-awareness. Under the impression that one
is constantly observed and evaluated by someone
outside of his or her own family, the caregivers may be
less likely to engage in verbally abusive behaviors.
Limitations
This study has several limitations, and caution should
be taken in interpreting and generalizing the results.
First, the present sample was recruited from local non-
governmental organizations. Caregivers who did not
receive any service or did not have any contact with
local services were not represented in this study. It thus
remains unclear the extent to which the present sample
represents the general population of family caregivers
to older Chinese with dementia. Second, this study
relied solely on self reports of family caregivers regard-
ing incidents of abuse, which were subjected to recall
and social desirability biases. It is likely that the pre-
valence of elder abuse in this study is underreported in
terms of the real cases, but the magnitude of this failure
is unclear. Third, this was a cross sectional study and its
results represented associations between variables
only, so no conclusive statement on casual effects
can be inferred from the present ndings. Fourth, in
investigating elder abuse, the present study focused on
verbal aggression and physical assault; other forms of
elder abuse, including abandonment, neglect, social
and nancial abuse were not included. Finally, it
should be noted that the use of various factors acco-
unted for the minimal variance in the reported physical
abuse. It is possible that there are different mechanisms
underlying physical and verbal abuse. In fact, various
factors that may have important implications for elder
abuse, including cognitive impairment, premorbid
relationship, personality, substance use, and history of
psychiatric illness were not assessed in this study.
Further studies are needed to address these issues.
Implications
Although the present sample consisted of a highly
self-selected group and thus the results may not be
generalizable to the whole of Hong Kong, this study
does provide certain insights into the scale of elder
abuse problem in older people with dementia and shed
light on some of the associated risk factors. The results
of this study have important implications for public
policy on dementia care and the design and implem-
entation of elder abuse intervention programs. First of
all, intervention programs should be targeted to miti-
gating the caregiver stress experienced by family caregi-
vers. Community services should be designed to better
t the needs of family caregivers. Case management
supported by multidisciplinary efforts have been sho-
wn to be effective in not only improving symptom
severity in persons with dementia, but also relieving the
psychological distress experienced by family caregivers
(Chien and Lee, 2008), and may be useful in this area.
Second, education should be provided to family care-
givers to heighten their awareness of the rights of
older care recipients, as well as the behaviors that are
considered to constitute elder abuse. Education
Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 527535.
Dementia and elder abuse 533
programs should inform family caregivers of the
prognosis of dementia, and to advance their under-
standing of the reasons for care recipients occasionally
agitated behaviors. The use of psychoeducation groups
with caregivers have demonstrated some success in
alleviating the agitation and anxiety of demented older
persons (Haupt et al., 2000) as well as the caregivers
perceived burden in relation to these problems (Hebert
et al., 2003). Such training can potentially mitigate
elder abuse through its positive inuence on caregiver
stress and reaction to the agitated behaviors of those in
their charge.
Conclusions
Despite considerable research in elder abuse and dem-
entia, few studies have reportedly examined the abuse
of elder persons with dementia. The present study
indicates that verbal and physical abuses are quite
prevalent among older Chinese with dementia in one
population in Hong Kong. The caregiver stress model
is useful in understanding verbal aggression, but not
physical assault. Further study will be needed to both
explore the mechanisms underlying the physical abuse
of older persons with dementia and to determine
whether these ndings are representative of a general
pattern in Chinese society.
Conflicts of interest
None declared.
Acknowledgements
The authors would like to express thanks to all of the
family caregivers who kindly participated in this study.
Their gratitude is also extended to the staff in the
anonymous non-governmental organization who
helped them recruit the participants and Miss Grace
Leung who assisted them in data collection and
management. Dr Chun Fan Lee for his advice on
statistical analysis. Pacic Edit reviewed the manu-
script prior to publication. This study was supported
by the Seed Funding Research Program of the
University of Hong Kong, Hong Kong.
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Key points
Verbal and physical abuses are quite prevalent
among older Chinese with dementia in Hong
Kong.
The caregiver stress model is useful in under-
standing verbal aggression but not physical assault
in this study.
Co-residence, lack of any assistance from
domestic helper, care recipient agitated behavior
and caregiver stress are associated with verbal
abuse.
Co-residence is associated with physical abuse.
Intervention programs should be targeted to
mitigate caregiver stress experienced by family
caregivers.
Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 527535.
534 E. Yan and T. Kwok
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Dementia and elder abuse 535