Journals of Gerontology: Social Sciences

cite as: J Gerontol B Psychol Sci Soc Sci, 2021, Vol. 76, No. 10, 2098–2111
doi:10.1093/geronb/gbab025
Advance Access publication February 16, 2021

Research Article

Association Between Caregiver Depression and Elder

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Mistreatment—Examining the Moderating Effect of Care
Recipient Neuropsychiatric Symptoms and Caregiver-
Perceived Burden
Boye Fang, PhD,1, Huiying Liu, PhD,2,* and Elsie Yan, PhD3
School of Sociology & Anthropology, Sun Yat-sen University, Guangdong Province, China. 2Department of Sociology, Central
1

South University, Changsha, Hunan Province, China. 3Department of Applied Social Sciences, Hong Kong Polytechnic
University, Hong Kong, China.
*Address correspondence to: Huiying Liu, PhD, Department of Sociology, Central South University, Changsha 410083, Hunan Province, China.
E-mail: hyliu105@csu.edu.cn

Received: June 12, 2020; Editorial Decision Date: January 28, 2021

Decision Editor: Zhen Cong, PhD, FGSA

Abstract
Objectives: To examine the association between caregiver (CG) depression and increase in elder mistreatment and to in-
vestigate whether change in care recipient (CR) neuropsychiatric symptoms (NPS) and change in CG-perceived burden
influence this association.
Methods: Using 2-year longitudinal data, we analyzed a consecutive sample of 800 Chinese primary family CGs and their
CRs with mild cognitive impairment or mild-to-moderate dementia recruited from the geriatric and neurological depart-
ments of 3 Grade-A hospitals in the People’s Republic of China. Participatory dyads were assessed between September 2015
and February 2016 and followed for 2 years.
Results: CG depression at baseline was associated with a sharper increase in psychological abuse and neglect. For CRs with
increased NPS, having a depressed CG predicted a higher level of psychological abuse than for those CRs without NPS.
For CGs with decreased burden, the level of depression was associated with a slower increase in neglect than for CGs who
remained low burden.
Discussion: This study showed the differential impact of CG depression on the increase in elder mistreatment depending
on the change in CR NPS and CG-perceived burden. The present findings provide valuable insights into the design of a sys-
tematic and integrative intervention protocol for elder mistreatment that simultaneously focuses on treating CG depression
and perceived burden and CR NPS.
Keywords: Dementia care, Depression, Elder mistreatment, Neuropsychiatric symptoms, Perceived burden
  

Elder mistreatment is a broad term that refers to harmful
acts directed at an older adult. Elder mistreatment gener-
ally includes physical abuse, psychological abuse, neglect,
financial exploitation, and sexual abuse (World Health
Organization, 2002). Existing studies suggest that different
forms of mistreatment are associated with distinct care-
related factors (Fang et al., 2019) and case characteristics
(Jackson & Hafemeister, 2014), which emphasizes the im-
portance of differentiating abuse subtypes when studying
elder mistreatment.
Elder mistreatment has become an alarming global
health problem associated with increased morbidity

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Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10
and mortality among older victims (Dong, 2015). Older
persons with cognitive impairment experience irrevers-
ible deterioration in their ability to perform activities of
daily living and require intensive support from a care-
giver (CG). Providing care for persons with dementia
may create care burden (Yan, 2014) and significant
physical, psychological, and financial stress on the CG
(Dong et al., 2014). Cognitive and functional deteriora-
tion associated with dementia (Cooper et al., 2010; Fang
et al., 2019), compounded by the severe CG burden and
caregiving-related negative affect (i.e., distress, frustra-
tion, anger, aggression), may compromise the quality of
care and contribute to an increased risk of CG abusive
behaviors against older CRs (Yan, 2014). Not surpris-
ingly, mistreatment in domestic settings appears to be
more prevalent in older adults with cognitive impairment
(17.2%–78.4%) than in those with intact cognitive func-
tioning (10.0%–34.3%; Ho et al., 2017).
Elder mistreatment should be interpreted within the
cultural context where it occurs. Possibly due to the lack
of suitable alternative placements and high costs, family
care remains predominant for older Chinese adults with
dementia (Yan, 2014). The erosion of filial piety by mod-
ernization in urban China (Cheung & Kwan, 2009) means
that such traditional values might no longer guarantee re-
spect for older adults or protect them from mistreatment.
Furthermore, China is an aging society where approxi-
mately 9.5 million older adults have a dementia diagnosis,
representing over one-fifth of the total cases globally (Chen
et al., 2017). The realization that dementia is associated
with an increased risk of mistreatment compounds con-
cerns about the sociocultural change and the rapid growth
of the aging population, including older adults with de-
mentia in China.
Theories on Elder Mistreatment
The CG stress theory is the predominant situational theory
that explains elder mistreatment (Pearlin et al., 1990). This
theory focuses on responding to caregiving stressors faced
by family CGs when providing care for an older adult with
cognitive impairment (Pearlin et al., 1990). The nature and
the magnitude of care demands and strain associated with
caregiving responsibilities and other life aspects (e.g., role
captivity, constriction of social life) may affect CGs’ mo-
tivation and ability to provide effective care and to main-
tain their well-being (Roberto & Teaster, 2017). Applied to
the study of elder mistreatment, the CG stress hypothesis
postulates that increased caregiving demand arising from
deteriorating cognitive and functional capability of the care
recipient (CR) may create a potential for mistreatment.
However, other scholars criticized this theoretical perspec-
tive for victim-blaming and suggested that CG characteris-
tics, such as their psychological status and personality, may
affect the likelihood of CG abusive behaviors as well (Fang
& Yan, 2018; Suitor & Pillemer, 1988).
2099
From the perspective of symbolic interactionism
(Charon, 2010), depression may affect CGs’ cognitive ap-
praisal of the caregiving situation. Depressed CGs tend to
interpret their caregiving tasks as more stressful and per-
ceive a greater level of burden; thus, they may develop a
motivation to abuse their CRs as a maladaptive approach
to cope with their stress (Collins & Kishita, 2020). CR
neuropsychiatric symptoms (NPS), as a common dementia
syndrome associated with increased CG stress, may further
compromise the quality of the CG–CR relationship and the
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interactive process, potentially increasing the risk of dyadic
conflicts and CG abusive behaviors (Vernon et al., 2019).
Literature Review
CG Characteristics and Elder Mistreatment
Existing studies on the etiology of elder mistreatment
mainly focus on victim-related factors, while comparatively
less progress has been made in identifying how perpetrator
characteristics affect mistreatment outcomes. The insuffi-
cient attention to abusers compared with victims is mainly
due to the understanding of and modes of intervention of
elder mistreatment, which are based on social work services
models that are targetted at supporting and protecting vic-
tims instead of criminal justice paradigms that focus on the
prosecution of abusers (Mosqueda et al., 2016). However,
recent evidence showed that perpetrator factors had more
substantial predictive power than victim characteristics
(DeLiema et al., 2018), and that varying psychological and
physical conditions of the abusers may affect their abusive
impulsivity (Jackson, 2016). In the context of a close care-
giving relationship, caregiving stress and intensive CG–CR
interaction may further give rise to an increased risk of dy-
adic conflicts (Yan & Fang, 2017). CGs who fail to adopt
positive appraisal and effective coping strategies may resort
to maladaptive or aggressive behaviors, with the worst-case
scenario being elder mistreatment (Yan & Fang, 2017). The
CRs’ heavy reliance on CG support and isolation from so-
cial networks can further increase their vulnerability to CG
abusive behaviors (Fang & Yan, 2021). Thus, to better un-
derstand the context where CG abusive behaviors occur, it
is necessary to examine the interaction effect of CG and CR
characteristics and how this effect influences mistreatment
outcomes.
CG Depression, CR NPS, and Elder Mistreatment
Recent evidence and expert opinions have suggested a rela-
tionship between depression and domestic violence perpe-
tration (Fazel et al., 2015; Yu et al., 2017). Following the
emotional perspective, dementia CGs are at an increased
risk of experiencing distress and depression (Cooper et al.,
2010), which may reduce their emotional regulation ca-
pacity and behavior control, thus increasing the risk of
aggressive behaviors (Leibenluft & Stoddard, 2013).
2100
However, despite the potential association between depres-
sion and violence observed in clinical and empirical evi-
dence, current clinical guidelines are inconsistent about the
assessment and management of violence risk in depressed
individuals. The evaluation of the direction and the strength
of the depression–violence relationship can be particularly
important in the dementia care context, where CG depres-
sion might interact with other contextually specific charac-
teristics to affect the risk of violent behaviors.
In the family care setting, the relationship between de-
pression and violence can be influenced by certain situa-
tional factors, including objective caregiving stressors such
as CR NPS (Cooper et al., 2010). Compared with cognitive
deterioration, NPS and its deterioration are more closely
associated with CG burden (Torrisi et al., 2017) and may
contribute to CG mood instability and violent impulsivity
(Rocca et al., 2010), with both predicting actual abusive
behaviors (Ho et al., 2017). Additional literature indicates
that an increase in CR NPS predicts CG resentment and
that depressed CGs with resentment have a greater propen-
sity to mistreat their CRs than other depressed CGs without
resentment (Gitlin et al., 2016; Shaffer et al., 2007). More
frequent and severe NPS was also linked to increased CG
stress and depression (Ornstein & Gaugler, 2012). These
findings suggest that change in CR NPS over time may
serve as an important contextual factor that intervenes in
the relationship between CG depression and mistreatment
of the CRs.
Additionally, CG burden in the dementia care context
has been studied. Existing evidence suggests that depressed
CGs tend to perceive a higher level of care burden (Cooper
et al., 2010) and that CG-perceived burden is significantly
associated with abusive behaviors (Yan, 2014). In a ran-
domized controlled trial, mindfulness-based intervention
strategies that were effective in reducing depressive symp-
toms were also found to alleviate CG burden (Whitebird
et al., 2013). These results suggest that CG burden might
play a role in altering the association between CG depres-
sion and abusive behaviors.
Although prior studies have shown that elder mis-
treatment was independently predicted by CG depression
(Cooper et al., 2010), CG-perceived burden (Yan & Kwok,
2011), and CR NPS (Fang et al., 2019), they did not further
examine their interactions. Therefore, the current study at-
tempted to address this gap by looking at the moderating
effect of change in CR NPS and CG burden on the associa-
tion between CG depression and mistreatment.
Conceptual Model of the Current Study
Based on the CG stress theory and the symbolic interac-
tionism perspective as well as on the literature described
above, a CG–CR Dyadic Interactive Model was developed
as a conceptual guide to examine the hypothesized interac-
tion effect of CG and CR characteristics on mistreatment
outcomes (see Figure 1 for a visual presentation of the
Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10
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Figure 1. The conceptual framework showing the hypotheses about
the relations of caregiver depression, change in care recipient neu-
ropsychiatric symptoms, and change in caregiver burden and elder
mistreatment.
conceptual model). Specifically, we attempted to examine
the associations among CG psychological status (depres-
sion), objective caregiving stressor (CR NPS), CG appraisal
of the objective caregiving stressor (CG-perceived burden),
and negative caregiving outcome (elder mistreatment),
with other objective caregiving stressors (i.e., CR cogni-
tive impairment, CR impairment of instrumental activities
of daily living [IADL], CR chronic conditions) and CG–
CR premorbid relationship rewards being the covariates.
Covariates were selected based on the extensive literature
on predictors of mistreatment of older adults with dementia
(Cooper et al., 2010; Fang & Yan, 2018; Fang et al., 2019).
Hypothesis
Guided by the CG–CR Dyadic Interactive Model, we ex-
pected that CG depression would have a main effect on an
increase in elder mistreatment (Hypothesis 1). Further, we
hypothesized that change in the CR NPS would moderate
the association between CG depression and an increase in
elder mistreatment (Hypothesis 2), and that change in the
CG-perceived burden would moderate the association be-
tween CG depression and an increase in elder mistreatment
(Hypothesis 3).
Considering the different conceptual definitions of phys-
ical abuse (use of physical force that may result in bodily
injury or physical pain), psychological abuse (infliction of
anguish, pain, or distress through verbal or nonverbal acts),
neglect (refusal, or failure, to fulfill any part of a person’s
obligations or duties to an older person), and financial
exploitation (illegal or improper use of an older person’s
funds, property, or assets; WHO, 2002) and their possibly
differential associations with CG depression, these mis-
treatment subtypes were treated as separate outcome vari-
ables in subsequent analysis.
Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10
Method
The present study was conducted in Guangdong Province
of the People’s Republic of China between September 2015
and February 2016. Baseline data were collected from the
geriatric and neurological departments of three Grade-A
hospitals (also called Tier 3 hospitals), which have multiple
differentiated departments and at least 500 beds. Inclusion
criteria were older outpatients (≥55 years) with a clinical
diagnosis of mild cognitive impairment (MCI) or mild-to-
moderate dementia together with their primary family CGs
who were providing care for ≥4 hr/week and were iden-
tified as the primary care providers by themselves and by
their CRs (Cooper et al., 2010; Fang et al., 2019). MCI
and dementia (mild-to-moderate level) were diagnosed ac-
cording to the following operational criteria: (a) subjective
complaints of memory decline; (b) results of a neuropsy-
chological examination, brain image, and blood test. The
neuropsychological examination was performed to eval-
uate behaviors, visuospatial abilities, language, abstraction,
memory, planning and mental control, and intelligence
and motor skills, which were used to assess the brain’s
functioning. Brain imaging such as Magnetic Resonance
Imaging was used to examine structural changes of the
hippocampus, entorhinal cortex, and gray matter struc-
tures in the medial temporal lobe. Blood test was used to
detect treatable conditions that may contribute to changes
in memory or cognitive functioning, such as CBC (com-
plete blood count), CMP (comprehensive metabolic panel),
TSH (thyroid stimulating hormone), vitamin B12, and RPR
(rapid plasma reagin); (c) objective cognitive impairment
as determined by a global cognitive function score below
the local cutoff for normal cognitive function among age-
and education-matched participants (i.e., reversed Mini-
Mental State Examination [MMSE] score ≤ 3 or Clinical
Dementia Rating [CDR] score = 0), but above the cutoff
score for severe dementia (i.e., reversed MMSE score ≥ 21
or CDR = 3); (d) diagnosis in each patient was determined
by a consensus made by a panel of neuropsychologists,
neurologists, and psychiatrists based on results of the neu-
ropsychological examination, brain image, blood test, and
cognitive function scores. Patients with severe dementia
were excluded, as they are associated with a unique host of
characteristics (e.g., personality change, severe behavioral
problems, and loss of activities of daily living and conversa-
tion ability) that distinguish them from those with MCI and
mild-to-moderate dementia (van der Linde et al., 2016). In
view of the fact that patients with memory decline due to
dementia and other potential causes (e.g., excessive alcohol
consumption, medication side effect, thyroid dysfunction,
vitamin deficiency, severe psychiatric and/or psychosomatic
symptoms) can be significantly different in terms of exec-
utive functions, declarative memory, and daily functioning
(Buckner, 2004), they were also excluded. All the eligible
dyads were informed that the purpose of this study was
to investigate the impact of CG depression, CR NPS, and
2101
CG burden on negative caregiving outcomes (e.g., mistreat-
ment) and that the present results may serve to improve the
quality of care in family care setting. Eventually, 857 out of
1,025 dyads meeting our inclusion criteria provided inde-
pendent informed consent and were enrolled in the baseline
study (response rate = 83.6%).
From September 2017 to February 2018, 800 dyads
of baseline participants were reassessed (attrition
rate = 6.7%). No significant differences were observed
between dyads who completed the follow-up study and
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those who did not regarding gender (χ 2 = 0.125, p = .757),
age (t = 1.597, p = .287), and severity of cognitive impair-
ment (t = 1.038, p = .382) of the CRs, as well as regarding
the levels of depression (t = 0.972, p = .331), burden
(t = 1.563, p = .188), and abusive behaviors related to the
CGs (t = 1.160, p = .246 for psychological abuse, t = 0.913,
p = .361 for physical abuse, t = 1.139, p = .255 for neglect,
and t = −0.700, p = .484 for financial exploitation).
During the follow-up stage, face-to-face interviews and
self-administered questionnaire interviews were admin-
istered to the CRs and the CGs, respectively, in separate
rooms. A research team, including one physician, two resi-
dent physicians, three geriatric nurses, and six medical so-
cial workers, administered the interviews. The interviews
lasted for 35 and 15 min for the CGs and the CRs, re-
spectively. This study protocol was approved by the ethics
committee of the University of Hong Kong. The time delay
between baseline and follow-up was roughly the same
across the participants (mean = 24 months, SD = 8 days).
Measures
Outcome variables
Elder mistreatment, as measured at both baseline and fol-
low-up, was assessed using a 40-item scale covering psy-
chological abuse, physical abuse, financial abuse, and
neglect by the primary family CGs over the past 12 months.
Specifically, physical and psychological abuse were meas-
ured, respectively, using the 8-item psychological aggres-
sion subscale (internal reliability alpha = 0.838 for baseline
and 0.806 for follow-up) and the 12-item physical assault
subscale (internal reliability alpha = 0.782 for baseline
and 0.725 for follow-up) from the Chinese version of the
Revised Conflict Tactics Scale (Tiwari et al., 2007). Neglect
was assessed using six items developed based on Pillemer’s
criteria and Ayalon’s elder neglect scale (not preparing
meals, nutrition; not providing access to medical services;
not providing assistance with transportation, not assisting
with keeping personal hygiene, not assisting with house-
hold tasks; not providing installation, repair, or replace-
ment of assistive devices; Pillemer & Finkelhor, 1988). The
internal reliability alpha was 0.808 for baseline and 0.755
for follow-up. Financial exploitation was measured using
14 items adapted from the Old Adult Financial Exploitation
Measure (Conrad et al., 2010). The internal reliability alpha
2102
was 0.729 for baseline and 0.705 for follow-up. To assess
the level of each type of mistreatment, CGs rated each item
on a 5-point scale, with a higher summed score indicating a
higher level of mistreatment (0–32 for psychological abuse,
0–48 for physical abuse, 0–24 for neglect, and 0–56 for
financial exploitation.). The occurrence of each mistreat-
ment subtype was defined as a positive answer to any item
on the respective scale, as provided by the CGs.
Main independent variables
CG depression at baseline was assessed using the Chinese
version of the Center for Epidemiological Studies-
Depression (CES-D; Cheng & Chan, 2005), in which two
items are positively phrased (e.g., generally satisfied, feel
pretty good) and eight items are negatively phrased (e.g.,
trouble concentrating, feeling alone, feeling tired). The
summed CES-D scores were calculated by adding responses
across all 10 items, with reversed scores for positively
phrased items. With a possible range of 0–30, a higher
score represents more depressive symptoms (internal reli-
ability alpha = 0.857).
Moderating variables
CR NPS were assessed at both baseline and follow-up using
the Chinese version of the Neuropsychiatric Inventory that
measures agitation/aggression, aberrant motor behavior,
disinhibition, irritability, delusion, hallucination, depres-
sion, anxiety, sleep, appetite changes, apathy, and euphoria
(Wang et al., 2012). For each item, the severity (score 1–3)
and frequency (score 1–4) yields a score of 1–12. Along
with a summed score potentially ranging from 12 to 144,
a higher score indicates more severe and frequent NPS (in-
ternal reliability alpha = 0.858 for baseline and 0.796 for
follow-up).
CG burden was measured at both baseline and follow-up
using the Chinese version of the Zarit Burden Interview
(Ko et al., 2008). CGs responded on a 5-point scale, with a
higher score indicating a greater level of perceived burden
(internal reliability alpha = 0.816 for baseline and 0.776
for follow-up).
Covariates
Demographic characteristics collected from the CRs at base-
line were age, gender, and body mass index. Demographic
variables gathered from the CGs at baseline were age,
gender, education levels, and relationship to the CRs.
CR cognitive impairment was evaluated at baseline using
the Chinese version of the MMSE (Huang et al., 2009),
ranging from 0 to 30. Using reversed scoring, a higher score
indicates more severe cognitive impairment (internal relia-
bility alpha = 0.755).
CR IADL impairment was measured at baseline using
the Chinese version of the Lawton Instrumental Activities
of Daily Living (Tong & Man, 2002), ranging from 9 to 36.
A higher score indicates more severe impairment (internal
reliability = 0.795).
Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10
CR multiple chronic conditions were measured at base-
line using the Chinese version of the Charlson Comorbidity
Index (Chan et al., 2014), with a higher score (range 0–37)
indicating higher disease burden and an increased risk of
mortality (internal reliability alpha = 0.757).
Premorbid relationship rewards were measured at base-
line using the Relationship Rewards Scale (RRS; Shaffer
et al., 2007). Translation and back-translation were per-
formed to ensure compatibility with the original version.
The summed score of RRS ranges from 0 to 16, with a
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higher score indicating greater perceived rewards (internal
reliability alpha = 0.706).
CG experience of previous abuse was defined as whether
the CG had experienced any form of abuse throughout
their life, which was assessed at baseline.
Data Analysis
Sample characteristics were analyzed using descriptive sta-
tistics and tested for their binary associations with elder
mistreatment. Separate models were used for different mis-
treatment subtypes as outcome variables, due to their dif-
ferences in terms of conceptual definitions, prevalence, and
associations with covariates. Specifically, mixed-effects re-
gression models were performed to estimate the increase
in the levels of psychological abuse and neglect separately
as predicted by CG depression, change in CR NPS, and
change in CG burden, adjusting for potential confounders
that were significantly associated with increase of mistreat-
ment in previous binary analyses (although CG burden and
CR NPS at baseline were significantly related to a faster
increase in mistreatment, they were not included into
model testing due to multicollinearity). To test the hypothe-
sized moderation effects, the interaction between CG de-
pression and change in CR NPS (increased NPS, unchanged
NPS, decreased NPS, and absence of NPS at both baseline
and follow-up), as well as the interaction between CG de-
pression and change in CG burden (increased burden, re-
mained high burden, decreased burden, and remained low
burden at both baseline and follow-up), was further added
into the models estimating psychological abuse and neglect,
respectively. To better understand the moderating effect,
the predicted scores of psychological abuse and neglect by
the change in CR NPS and CG burden were calculated,
respectively. Generalized linear modeling (with Poisson
distribution and Log link) was performed to examine the
increase in the occurrence of physical abuse as predicted
by CG depression, change in CR NPS, and change in CG
burden, after adjusting for the same set of variables men-
tioned above (the marginalized parameter estimates were
reported). Multicollinearity diagnoses were conducted
prior to the performance of multilevel regression (the var-
iance inflation factor ranged from 1.28 to 3.76 across all
independent variables, suggesting no significant problem
related to multicollinearity). Financial exploitation was ex-
cluded from multilevel modeling, as it was not related to
Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10
CG depression, CR NPS, or CG burden in binary analysis.
Data were analyzed using STATA 15.0.
Results
Sample Characteristics, Prevalence, and
Correlates of Elder Mistreatment
Participants included 800 primary family CGs of older
Chinese adults with MCI or mild-to-moderate dementia.
Over half of the CGs were male (52.4%), with their mean
age of 45.79 (SD = 14.95). The majority of the CGs were
adult children (58.0%) of the CRs, followed by spouses
(22.5%) and other relatives (19.5%). Over one-third of
CGs (39.8%) received support from a secondary CG, and
most of them had received primary (49.5%) or secondary
education (50.6%). The mean CES-D score for the en-
tire sample was 7.25 (SD = 3.58) at baseline. The mean
score on CG burden was 39.15 (SD = 5.76) and 40.83
(SD = 6.26) at baseline and follow-up, respectively. During
the 2-year observation period, a greater proportion of CGs
reported increased burden (52.3%), compared to those
who remained high burden (8.8%), decreased (28.3%), or
remained low burden (10.8%).
Over half of the CRs were female (50.3%), with a
mean age of 70.22 (SD = 17.18). Neglect (50.3% at base-
line, 55.8% at follow-up) was the most common form of
mistreatment, followed by psychological abuse, financial
exploitation, and physical abuse. The prevalence of MCI,
mild dementia, and moderate dementia among the CRs was
9.8%, 31.6%, and 58.6%, respectively. The mean score for
NPS was 48.42 (SD = 12.56) and 52.86 (SD = 15.58) at
baseline and follow-up, respectively. Over the 2-year ob-
servation period, there was a much higher prevalence of
CRs who had an increased severity and frequency of NPS
(48.6%) than of those with decreased (28.5%), unchanged
(13.4%), or absence of NPS (9.5%).
Binary analyses suggested a similar cluster of poten-
tial confounders for physical and psychological abuse
and neglect, whereas financial exploitation was asso-
ciated with a different set of variables and was not re-
lated to CG depression, CR NPS, or CG burden (Table
1). Therefore, financial exploitation was excluded from
subsequent modeling.
Changes in the Level of Psychological Abuse
Predicted by CG Depression, Change in CR NPS,
and Change in CG Burden
As shown in Table 2 (Model 1a), CG depression at baseline
was positively associated with an increased level of psycho-
logical abuse (β = 0.034, SE = 0.020, 95% CI = −0.005 to
0.073; p < .05). Relative to CRs without NPS, those with
increased NPS reported a faster increase in psychological
abuse (β = 1.207, SE = 0.180, 95% CI = 0.853 to 1.561;
p < .001). We did not find significant effects of change
2103
in CG burden on the increase of psychological abuse. In
Model 2a, the interaction of CG depression × increased CR
NPS had a significant effect on the increase in psychological
abuse (β = 0.339, SE = 0.097, 95% CI = 0.149 to 0.529;
p < .001). As shown in Figure 2 (panel A), for CRs with
increased NPS, having a depressed CG predicted a sharper
increase in psychological abuse (estimated score = 11.7 and
12.1 at Time 1 and Time 2) than for CRs without NPS (es-
timated score = 8.1 and 9.1 at Time 1 and Time 2).
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Changes in the Level of Neglect Predicted by CG
Depression, Change in CR NPS, and Change in
CG Burden
As shown in Table 3 (Model 1b), CG depression at base-
line was positively associated with an increased level of ne-
glect (β = 1.149, SE = 0.068, 95% CI = 1.01 to 1.282;
p < .001). In comparison with CRs without NPS, CRs
with increased NPS and those with unchanged NPS expe-
rienced a faster increase of neglect (β = 1.193, SE = 0.631,
95% CI = −0.044 to 2.431, p < .05; β = 1.055, SE = 0.506,
95% CI = 0.061 to 2.048, p < .05). In contrast, a slower
increase of neglect was found in CRs with decreased NPS
(β = −3.103, SE = 0.544, 95% CI = −4.170 to −2.036, p <
.001). Relative to CGs who remained low burden, CGs with
decreased burden reported a significantly slower increase
of neglect (β = −2.424, SE = 0.55, 95% CI = −3.516 to
−1.332). In Model 2b, the interaction of CG depression ×
CG decreased burden had significant effect on the change
of neglect (β = −0.761, SE = 0.179, 95% CI = −1.113 to
−0.409; p < .001). As shown in Figure 2 (panel B), for CGs
with decreased burden, the level of baseline depression
was associated with a slower increase in neglect (estimated
score = 13.5 and 13.7 at Time 1 and Time 2) than for CGs
who remained low burden (estimated score = 16.0 and 16.8
at Time 1 and Time 2).
Supplementary Analysis
We examined the impact of CG depression, change in
CR NPS, and change in CG burden on the occurrence of
physical abuse (Supplementary Table 1). CG depression
was positively associated with physical abuse occurrence.
Compared with CRs without NPS, CRs with decreased
NPS reported greater occurrence of physical abuse. Relative
to CGs who remained burden, CGs who reported increased
burden were at a higher risk of physical abuse. No signif-
icant interactive effects of CG depression × CR change in
NPS or that of CG depression × CG change in burden were
found on physical abuse occurrence.
Discussion
In this sample, the most common form of mistreatment
was neglect (55.8%), followed by psychological abuse
(47.5%), financial exploitation (38.9%), and physical
2104 Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10

Table 1. Descriptive Statistics for Major Variables and Correlates of Elder Mistreatment

Total Binary relationship Binary relationship with Binary relationship Binary relationship with
(N = 800) with physical abuse psychological abuse with neglect financial exploitation

CG characteristics
Age (18–82) 45.79 (14.95) −0.222*** −0.169*** −0.086** 0.027
(baseline)
Female gender 382 (47.6%) −0.100*** 0.076* 0.093** −0.019
(baseline)
Relationship to the 3.046 2.705 2.597 1.724

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CR (baseline)
Being a spouse 180 (22.5%)
Being a child 464 (58.0%)
Being other relative 156 (19.5%)
Coresidence with 762 (95.3%) 0.069 0.058 0.029 0.013
the CR
Duration of care 81.73 (17.14) 0.186*** 0.192*** 0.138*** 0.056
(25–115) (baseline)
Presence of a 318 (39.8%) 0.028 0.052 0.062 0.043
secondary CG
(baseline)
Perceived burden 39.15 (5.76) 0.222*** 0.339*** 0.153*** −0.005
(12–78) (baseline)
Perceived burden 40.83 (6.26) 0.218*** 0.386*** 0.139*** −0.021
(13–82) (follow-up)
Change in the level of 4.297* 5.386** 6.228** 1.926
CG care burden
Increased burden 418 (52.3%)
 Remained high 70 (8.8%)
burden
Decreased burden 226 (28.3%)
 Remained low 86 (10.8%)
burden
Education levels 0.278 2.562 1.725 1.300
(baseline)
 Primary education 367 (45.9%)
and below
 Secondary 405 (50.6%)
education
 Tertiary education 28 (3.5%)
CG–CR premorbid 9.08 (2.26) 0.063 0.108*** 0.082* 0.029
relationship rewards
(0–16)
Depression (0–18) 7.25 (3.58) 0.314*** 0.368*** 0.274*** 0.072
(baseline)
Care recipient’s characteristics
Age (55–87) 70.22 (17.18) 0.101*** 0.097** 0.141*** −0.233***
Female gender 402 (50.3%) 0.085** 0.094** 0.106*** 0.118***
(baseline)
BMI (baseline) 23.25 (3.42) 0.054 0.026 −0.016 0.047
Cognitive impairment 12.43 (3.82) 0.225*** 0.286*** 0.248*** 0.220***
(baseline, MMSE
reversed score 7–21)
Diagnosis of MCI or 7.865*** 9.693*** 7.969*** 5.843**
dementia
 MCI (baseline, 3 ≤ 78 (9.8%)
reversed MMSE
score ≤ 5, or CDR
score = 0.5)
2105 Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10

Table 1. Continued

Total Binary relationship Binary relationship with Binary relationship Binary relationship with
(N = 800) with physical abuse psychological abuse with neglect financial exploitation

 Mild dementia 253 (31.6%)

(baseline, 6 ≤
reversed MMSE
score ≤ 11, or
CDR score = 1)
 Moderate dementia 469 (58.6%)

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(baseline, 12 ≤
reversed MMSE
score ≤ 20, or
CDR = 2)
NPS (12–108) 48.42 (12.56) 0.278*** 0.271*** 0.238*** 0.028
(baseline)
NPS (15–118) 52.86 (15.58) 0.286*** 0.282*** 0.218*** 0.025
(follow-up)
Change in the 5.258** 6.539** 7.126*** 2.392
severity of CR NPS
Increased NPS 321 (40.1%)
Unchanged NPS 128 (28.5%)
Decreased NPS 85 (10.6%)
 Absence of NPS at 266 (33.3%)
both baseline and
follow-up
IADL impairment 16.85 (5.57) 0.218*** 0.207*** 0.206*** 0.215***
(9–35) (baseline)
Multiple chronic 7.25 (3.15) 0.127*** 0.215*** 0.178** 0.115***
conditions (3–15)
(baseline)
Elder mistreatment
 Physical abuse 10 (1.3%)
(baseline)
 Physical abuse 32 (4.0%)
(follow-up)
 Psychological 350 (43.8%)
abuse (baseline)
 Psychological 380 (47.5%)
abuse (follow-up)
Neglect (baseline) 402 (50.3%)
Neglect (follow-up) 446 (55.8%)
 Financial 262 (32.8%)
exploitation
(baseline)
 Financial exploita- 311 (38.9%)
tion (follow-up)

Notes: BMI = body mass index; CDR = Clinical Dementia Rating; CG = caregiver; CR = care recipient; IADL = instrumental activities of daily living; MCI = mild
cognitive impairment; MMSE = Mini-Mental State Examination; NPS = neuropsychiatric symptoms. *p < .05. **p < .01. ***p < .001.

abuse (4.0%). Possibly due to people’s tolerance of mis-
treatment involving cognitively impaired older persons in
general (Fang & Yan, 2018), rates cited in this study were
higher than those in general older Chinese adults (0.2%–
36.2%), but were comparable with those yielded from
other older Chinese populations with impaired cognitive
functioning (62.3% in Yan & Kwok, 2011). Previous re-
search has suggested that CGs might abuse their CRs un-
intentionally merely due to their lack of knowledge about
elder mistreatment (Richardson et al., 2002) and about
proper dementia care (Selwood et al., 2009). In fact, pre-
vious evidence showed that CGs who accompanied their
Table 2. Mixed-Effects Linear Regression Predicting Psychological Abuse With the Caregiver Depression, Change in Neuropsychiatric Symptoms, and Change in Caregiver
Burden

Model 1a Model 2a

Fixed effects Coef. SE 95% CI Coef. SE 95% CI

Intercept 6.412*** 0.530 5.373 7.452 6.869*** 0.889 5.126 8.611

Time 0.054*** 0.009 0.036 0.072 0.053*** 0.008 0.035 0.070
CG age 0.003 0.00 −0.005 0.011 0.009* 0.004 0.000 0.017
CG female gender 0.102 0.075 −0.046 0.250 0.081 0.073 −0.061 0.224
CG duration of care 0.005** 0.001 0.002 0.008 0.003* 0.001 0.001 0.006
CR age −0.010 0.006 −0.023 0.002 −0.011 0.006 −0.024 0.000
CR female gender −0.044 0.075 −0.193 0.103 −0.052 0.073 −0.195 0.090
CR IADL impairment 0.013* 0.007 0.001 0.027 0.010 0.006 −0.002 0.024
CR cognitive impairment 0.070*** 0.008 0.053 0.087 0.060*** 0.008 0.044 0.076
CR multiple chronic conditions 0.019 0.115 −0.208 0.245 0.021 0.111 −0.197 0.239
CR experience of previous abuse 1.966*** 0.088 1.793 2.140 1.953*** 0.085 1.790 2.127
CG–CR premorbid relationship rewards −0.039 0.062 −0.185 0.108 −0.053 0.082 −0.199 0.098
CG depression 0.034* 0.020 0.005 0.073 −0.001 0.088 −0.1742 0.172
Change in CR NPS
Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10

Increased CR NPS 1.207*** 0.180 0.853 1.561 −2.192* 0.866 −3.891 −0.496
Decreased CR NPS 0.190 0.163 −0.131 0.511 0.443 0.813 −1.150 2.037
Unchanged CR NPS −0.063 0.152 −0.361 0.235 0.139 0.774 −1.377 1.656
Absence of CR NPS (ref.)
Change in CG care burden
Increased CG burden 0.206 0.147 −0.082 0.496 0.429 0.552 −0.652 1.511
Decreased CG burden −0.038 0.059 −0.154 0.077 0.158 0.237 −0.306 0.623
Remained high CG burden 0.0120 0.043 −0.073 0.097 0.082 0.269 −0.445 0.610
Remained low CG burden (ref.)
CG depression × Change in CR NPS
CG depression × Increased CR NPS 0.339*** 0.097 0.149 0.529
CG depression × Decreased CR NPS −0.025 0.093 −0.208 0.157
CG depression × Unchanged CR NPS −0.017 0.089 −0.193 0.158
CG depression × Absence of CR NPS (ref.)
CG depression × Change in CG care burden
CG depression × Increased CG burden −0.022 0.054 −0.128 0.084
CG depression × Decreased CG burden −0.016 0.021 −0.0587 0.027
CG depression × Remained high CG burden −0.007 0.025 −0.0568 0.043
CG depression × Remained low CG burden (ref.)
Random effects (intercept only)
Variance (between-individual) 1.066 0.054 0.987 0.050
Variance (residual) 0.031 0.001 0.031 0.002
Log-likelihood −1,194.658 −1,160.818
Wald chi-square 1,095.39 1,245.99
2106

Notes: CG = caregiver; CR = care recipient; IADL = instrumental activities of daily living; NPS = neuropsychiatric symptoms. *p < .05. **p < .01. ***p < .001.

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Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10
Figure 2. Predicted values of psychological abuse (panel A) and neglect
(panel B) for CG depression by change in CR NPS and change in CG
burden between Time 1 and Time 2. CG = caregiver; CR = care recipient;
NPS = neuropsychiatric symptoms.
CRs to doctors’ appointments might nevertheless act abu-
sively at home (Fang et al., 2019). Therefore, we should not
assume that CGs who are willing to take their CGs to care
providers are necessarily unharmful.
This prospective study investigated the effect of CG de-
pression on various forms of elder mistreatment, and the
role of change in the severity and frequency of CR NPS,
as well as of change in the level of CG-perceived burden
in altering these associations. Using longitudinal analysis,
we found a consistent pattern of increased levels of psy-
chological abuse and neglect and occurrence of physical
abuse in depressed family CGs. Although previous research
has reported a longitudinal relationship between depres-
sion and violence in the general population (Fazel et al.,
2015), it is difficult to generalize such findings into the
dementia care context, which is exposed to care-related
factors, such as intensive caregiving demands and consider-
able caregiving stress. There is also research showing that
CGs with depression are more likely to mistreat their CRs
(Fang et al., 2019). However, the cross-sectional design
2107
precluded further inference of the temporal relationship
between CG depression and violence. Our longitudinal de-
sign and multilevel modeling allowed for the adjustment of
previous experience of abuse and care-related factors, and
for the testing of the long-term effect of CG depression on
an increase in mistreatment, potentially serving as a foun-
dation for evaluating whether treating depression in CGs
may reduce mistreatment outcomes. Although the exact
relationship between depression and domestic violence re-
mains unclear, there is evidence showing that depressed in-
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dividuals are more likely to experience mood dysregulation
and to exhibit behavioral dyscontrol and irritability, which
predisposes a higher risk of actual abusive behaviors when
having an abusive impulse (Leibenluft & Stoddard, 2013).
We also attempted to ascertain the differential impacts
of CG depression on increase of mistreatment depending
on the 2-year change in CR NPS, which specifies the time-
varying nature and heterogeneous patterns of the interaction
effect of CG psychological status and CR neuropsychiatric
condition on mistreatment outcomes. Specifically, we found
that increased NPS in CRs was associated with a sharper
increase in psychological abuse. More importantly, we
found that for CRs with increased NPS, having a depressed
CG predicted a faster increase in psychological abuse than
for CRs without NPS. However, this difference was not ob-
served for CRs with unchanged or decreased NPS. These
findings suggest the importance of preventing the deteriora-
tion of NPS in order to decrease older adults’ vulnerability
to mistreatment, especially when cared for by a CG with
depression. Possibly due to the general shortage of mental
health professionals in China (Tse et al., 2013), among the
534 (66.8%) older adults who presented with NPS in this
study, only 66 (12.3%) were receiving nonpharmacological
therapy in comparison to 295 (36.9%) receiving phar-
macological treatments. Simultaneously considering the
effectiveness and safety issues related to NPS treatment
options (Loi et al., 2018), it would be necessary to de-
velop a systematic intervention protocol that combines
pharmacological with nonpharmacological therapies (e.g.,
physical exercise, multisensory stimulation, massage ther-
apies) in order to prevent NPS deterioration (Brodaty &
Arasaratnam, 2012).
Furthermore, we examined the role of change in CG
burden and found that decreased CG burden significantly
mitigated the increase of neglect. Meanwhile, for CGs with
decreased burden, the level of depression was associated
with a slower increase in neglect than for those CGs who
reported no burden. This result was consistent with ex-
isting evidence, which suggests that decreased burden may
reduce psychological stress and anxiety affect potentially
caused by caregiving-related stressors (Liu et al., 2017),
thus reducing CGs’ impulse to engage in neglectful care-
giving (Reay & Browne, 2001). Our findings suggest the
need of making intervention efforts to move CGs from
a reactive mode of automatically responding to stressors
(i.e., avoidance of caregiving responsibilities, neglectful
Table 3. Mixed-Effects Linear Regression Predicting Neglect With the Caregiver Depression, Change in Neuropsychiatric Symptoms, and Change in Caregiver Burden
2108

Model 1b Model 2b

Fixed effects Coef. SE 95% CI Coef. SE 95% CI

Intercept 9.184*** 1.675 5.901 12.468 7.833*** 2.961 2.028 13.63

Time 0.467** 0.165 0.144 0.790 0.466** 0.166 0.140 0.791
CG age 0.010 0.014 −0.018 0.038 0.002 0.014 −0.026 0.0318
CG female gender 0.040 0.252 −0.453 0.534 −0.027 0.248 −0.514 0.460
CG duration of care 0.006 0.005 −0.003 0.016 0.006 0.005 −0.004 0.016
CR age −0.022 0.021 −0.064 0.019 −0.027 0.021 −0.069 0.013
CR female gender 0.327 0.251 −0.165 0.820 0.375 0.2472 −0.109 0.859
CR IADL impairment 0.047* 0.023 0.000 0.094 0.046* 0.0236 0.000 0.092
CR cognitive impairment 0.020 0.028 −0.035 0.075 0.021 0.0284 −0.034 0.076
CR multiple chronic conditions 0.237 0.384 −0.515 0.991 0.268 0.377 −0.470 1.008
CR experience of previous abuse −0.199 0.295 −0.778 0.3796 −0.224 0.2919 −0.796 0.347
Presence of a secondary CG 0.228 0.168 −143 0.676 0.207 0.153 −101 0.769
CG depression 1.149*** 0.068 1.01 1.282 1.381*** 0.2988 0.795 1.967
Change in CR NPS
CR increased NPS 1.193* 0.631 −0.044 2.431 1.242 3.019 −4.675 7.16
CR decreased NPS −3.103*** 0.544 −4.170 −2.036 −3.489 2.801 −8.979 2.000
CR unchanged NPS 1.055* 0.506 0.061 2.048 1.160 2.661 −4.055 6.376
CR absence of NPS (ref.)
Change in CG care burden
Increased CG burden −0.614 0.499 −1.593 0.365 −0.026 0.339 −0.691 0.639
Decreased CG burden −2.424*** 0.55 −3.516 −1.332 0.049** 0.322 −0.58 0.680
Remained high CG burden 0.251 0.297 −0.332 0.834 −0.007 0.309 −0.613 0.598
Remained low CG burden (ref.)
CG depression × Change in CR NPS
CG depression × Increased CR NPS 3.498 1.962 −.3483 7.344
CG depression × Decreased CR NPS 5.596 1.966 1.742 9.451
CG depression × Unchanged CR NPS 1.271 1.279 −1.235 3.778
CG depression × Absence of CR NPS (ref.)
CG depression × Change in CG burden
CG depression × Increased CG burden −0.447 0.197 −0.835 −0.059
CG depression × Decreased CG burden −0.761*** 0.179 −1.113 −0.409
CG depression × Remained high CG burden −0.130 −0.130 0.132 −0.390
CG depression × Remained low CG burden (ref)
Random effects (intercept only)
Variance (between-individual) 6.494 0.653 5.966 0.639
Variance (residual) 10.820 0.541 10.957 0.550
Log-likelihood −4,490.911 −4,587.198
Wald chi-square 757.30 809.24
Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10

Notes: CG = caregiver; CR = care recipient; IADL = instrumental activities of daily living; NPS = neuropsychiatric symptoms. *p < .05. **p < .01. ***p < .001.

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2109
caregiving) to a response mode (Sliwinski et al., 2009), in
which they respond with the awareness of the potential
caregiving stressors and their impact, which will better pre-
pare them to effectively cope with care-related difficulties.
Recently, psychotherapy and psychoeducation targeting at
alleviating CG-perceived burden have demonstrated their
effectiveness (Donath et al., 2019). Moreover, formal and
informal social support have also been shown to reduce
CGs’ negative emotional reactions to objective caregiving
stressors (Shiba et al., 2016).
Implications
The salient effect of depression on a faster increase in the
levels of mistreatment suggests the need for assessment
and management of violence risk in depressed population.
Although clinical practice guidelines in the United States
have discussed the association between depression and vio-
lence (Fazel et al., 2015), this link has not been recognized
in clinical practice guidelines in China. If the present find-
ings are replicated and triangulated, information on risk
factors of domestic violence could be added, and treatment
of depression could be considered as an element in inter-
vention and prevention programs for domestic violence.
Furthermore, our findings that increased CR NPS
strengthened the effect of CG depression on an increase in
psychological abuse suggest the importance of alleviating
NPS in preventing mistreatment. Although NPS can be
chronic and recurrent, it is also treatable (Loi et al., 2018).
To achieve both effectiveness and safety, proper treat-
ment plans combining appropriate pharmacological and
nonpharmacological elements should be considered. Given
the buffer effect of decrease in CG burden on the associ-
ation between CG depression and an increase in neglect,
CG burden reduction should be incorporated as an essen-
tial element in mistreatment intervention and prevention
protocols. Such protocols should consider integrating psy-
chological and psychoeducational techniques to reframe
CGs’ stress appraisal and introducing appropriate social
support resources to relieve CG burden.
Limitations
Limitations should be noted. First, convenience sampling
restricted the generalizability of the present findings.
Depending exclusively on CG self-reports and lacking
other sources of information on mistreatment (i.e., clin-
ical signs of neglect, history of hospitalization for injuries)
to validate the results means that we cannot exclude the
possibility of imprecision due to reporters’ memory decay
and rater bias. Although previous evidence has shown a
moderate-to-high level of consistency between CG and CR
reports of elder mistreatment (intraclass correlation ran-
ging from 0.631 to 0.936 across mistreatment subtypes
in Fang & Yan, 2021) and suggested that most CGs were
Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10
willing to report abusive behaviors (Cooper et al., 2010),
we cannot preclude the possibility of underreporting that
might lead to an underestimate of the elder mistreatment
problem. Furthermore, although mistreatment subtypes,
CR NPS, and CG burden were measured longitudinally,
other variables including CG depression and covariates
were measured only once, making it impossible to ex-
amine whether changes in these variables interact with
change in mistreatment, CR NPS, or CG burden. Finally,
although certain other important subjective stressors in
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the caregiving stress process, such as caregiving role over-
load and role captivity, are sensitive to intervention ef-
fects and are potentially reversible (Morano & Sanders,
2006), they were not included in model testing, as they
are not available in our present data set. Future studies
with more scientific design and more representative sam-
ples are required to verify the present findings.
Conclusion
This study showed the impact of CG depression on a
sharper increase in elder mistreatment and the moderating
effect of change in CR NPS and CG burden on this asso-
ciation. These findings, if replicated in future studies with
more representative samples and more rigorous design,
will provide essential insights to the development of a
systematic and integrative intervention protocol for elder
mistreatment that focuses simultaneously on mitigating
CG depression and burden and on reducing CR NPS.
Supplementary Material
Supplementary data are available at The Journals of
Gerontology, Series B: Psychological Sciences and Social
Sciences online.
Funding
This study was supported by the National Natural Science
Foundation of China (project code: 72004236). The spon-
sors hold no role in study design, data collection, data anal-
ysis, interpretation of study results, manuscript submission,
or article publication.
Conflict of Interest
None declared.
Author Contributions
Conception and design of the study: B. Fang. Data acquisi-
tion: B. Fang and H. Liu. Data analysis: B. Fang and H. Liu.
Interpretation of the results: B. Fang, H. Liu, and E. Yan.
Manuscript writing: B. Fang, H. Liu, and E. Yan. Approval
of manuscript: all authors.
Journals of Gerontology: SOCIAL SCIENCES, 2021, Vol. 76, No. 10 2110

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