psychological wellbeing health and ageing elder abuse and neglect

Elder abuse and neglect is a hidden public health challenge for Malaysia. The abuse is more episodic and recurrent rather than an isolated one. This paper reports the findings of elder abuse and neglect among the elderly. Criteria for the respondents are above 60 years old, assessed with mild or severe depression, victims of abuse and neglect and willing to participate in this research. This research was done using a qualitative methodology. The Hwalek-Sengstock Elder Abuse Screening Test (H-S/ EAST), which is a 14 item self-assessment, was used in this research to identify abuse and neglect among the elderly. The Geriatric Depression Scale (GDS) which is a 30 item self-report assessment was used in this research to identify depression among the elderly. The findings of this research showed that caregivers use verbal aggression in the forms of insults and statements to humiliate the elderly. The threat of abandonment and institutionalization is another form of abuse and neglect. The elderly are subjected to changing legal documents and other financial transactions. The prevalence of mild, moderate or severe depression is seen among the abused and neglected elderly. The basic needs of the elderly are not met, for example withholding food or medication. In general the respondents reported regarding the unsatisfied support from their caregivers. They have been refused assistance or reluctant in some kind of care. Relevant social policies need to be developed to support the elderly who are abused and neglected to target prevention and response. To make this possible, coordination between policy makers and practitioners needs to be improved.


Introduction
The National Research Council defines abuse as an intentional act of causing harm, serious risk of harm, or failure to protect from harm by a trusted other. It highlights 3 components in its definition which are harm, older adult and trust relationship. Harm is divided into 5 categories which are psychological abuse, financial abuse, physical abuse, sexual abuse and neglect. A trust relationship refers to individuals in whom the older adult would reasonably have confidence including family members and close acquaintances.
Elder abuse and neglect covers two broad categories which is abuse and neglect. Abuse is a positive act, commonly an act of commission, and there is active involvement or interaction on the part of the abuser [1]. Neglect by comparison is used to describe acts of omission, specifically those with a passive involvement of the abuser [2]. The easiest and most obvious type of abuse is physical abuse, while other types of abuse are less obvious and require further investigation and examination, an example of which being financial abuse [3].
Elder abuse and neglect refers to intentional actions that cause harm or create a serious risk or harm, irrespective whether the harm is intended, to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder or failure by the caregiver to satisfy the elder's basic needs or to protect the elder from harm [4]. The definition of elder abuse and neglect adopted by the World Health Organization states it to be a "Single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an elder person" [5]. Victims of elder abuse and neglect are often known to the perpetrators. Elder abuse and neglect can be broadly categorized into physical, psychological (or emotional), financial, sexual abuse and neglect with prevalence in Asian countries generally higher than Western nations [6].
Elder abuse and neglect is now recognized nationally and internationally as a serious problem which requires urgent attention from the social welfare agencies both government and non-government agencies, health care, policy makers and general public [7]. The term elder abuse and neglect is used to describe the mistreatment of older persons in both home and institutional settings. The definition of elder abuse and neglect adopted by the World Health Organization (WHO) and the International Network for the Prevention of Elder Abuse (INPEA) is "A single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person [8,9].
Legislation is seen as an important mechanism to help reduce the abuse and neglect of the elderly. The only solution which seems available to elder abuse victims is civil actions. However, it may not necessarily heal the victim of emotional abuse to bring about a civil action against the abuser. On the other hand, the criminal prosecution is a means that justice has been done to the victim [10].
In Malaysia, although elder abuse and neglect is not an offence, it is sometimes recognized as a form of domestic violence. There is also no specific legislation or law to address the elder abuse and neglect [11]. However, there is no specific data regarding elder abuse and neglect in the nation. A recent survey conducted among 291 urban poor elderly living in the Kuala Lumpur indicated that elder abuse and neglect widely exists. About 1 in every 10 of the surveyed elders reported having some form of abuse or neglect within the last 12 months. Two thirds of those reporting abuse experienced two or more incidences of abuse, with financial and psychological abuse the most common forms reported [12]. Poor public awareness, lack of knowledge among service providers and the absence of mandatory reporting are often cited as common reasons for elder abuse and neglect to remain undetected and underreported [11,13].

Method
This paper reports the findings of elder abuse and neglect among the elderly in Penang, Malaysia. The methodology used in this research is qualitative methodology. Having assessed its na-ture, a qualitative design is best for this research as it allows the respondents to give meaning to their experiences. [14] says that a qualitative study is selected because of the nature of the research question which often starts with how or what or why and the phenomena to be studied. Qualitative methodology is employed here because the experiences of the abused and neglected elderly need to be explored and understood.
According to Merriam [15], qualitative research questions are framed to seek meaning and understanding with respect to how people make sense of their lives, what people experience and how they structure their social worlds. The qualitative research is to understand how these individuals construct meaning from their selected setting to successfully conduct their day-to-day business. At least three interview sessions were conducted for each respondent.
The number of respondents sampled is indicated by the point of saturation. The sampling is terminated when no new information is forthcoming from new sampled units, thus redundancy is the primary criterion. There was hardly any new information to be added to the categories that were already emerging, signaling the saturation point [16]. The researcher stopped her in-depth interviews after five respondents when she found that she had arrived at the saturation point. The details of the socio demographic profile of the respondents are as shown in Table 1 below.
Rubin and Babbie [17] denote that qualitative approach does not restrict the study with predetermined operational indicators and it allows to generate greater and deeper understanding of the meaning of a particular phenomenon. They further emphasize that qualitative method enables researcher to gain insight into the subjective meanings of complex phenomenon, which will then guide the researcher to conceptualize the meanings and to build theory that can be tested in future. Qualitative research also helps an understanding of how a complex social phenomenon is given meaning within a context [18,19].
The criteria for the respondents are above 60 years old, assessed with mild or severe depression, victims of abuse and neglect and willing to participate in this research. The Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST), which is a 14 item selfassessment was used in this research to identify abuse and neglect among the elderly. The Geriatric Depression Scale (GDS) by [20] was used in this research to identify depression among the elderly.

Humiliation and Discrimination
The children of all the respondents have been identified as their caregiver. During the interview, the respondents said that their caregivers have not been caring enough towards them. They felt that having cared for their children it is now for their children to care for them. However, they still needed to provide for their children and their families and have to work at this old age. They also have nobody to share their problems and fears with. Everybody leads busy lifestyles and do not have the time. There is lack of understanding among the caregivers towards the respondents. Respondents do everything by themselves and loneliness has creped which has caused them to have low self-esteem and depression.
Respondents feel that they are now a burden to the family. To avoid any disagreements or quarrels with their caregivers, respondents choose to remain withdrawn and silent most of the times. Being at their place of work helps them to put aside these sad and fearful feelings and thoughts but have to deal with it directly when they are home. One respondent makes a trip to River Ganges India once in two years to help her to cope with her fears, doubts and frustrations. Another respondent stays indoors most of the time without relating to anybody as this helps her to keep away from hurting remarks by others around her. Emotional abuse and neglect often happens among the elderly who are dependent on the abuser compared with the elderly who suffer other types of abuses [21].
The daughter of one respondent forces her to work and accuses her of sitting at home doing nothing.This respondent was terminated by her employer due to old age. The other four respondents are fearful to be terminated by their employers anytime due to their age. They want to continue working for more income, but age is the main factor against them. They are worried about their finances should they stop working. Two respondents pay towards their house rent. All the respondents want to be independent without relying on their children or others. Also, none of their children are supporting them financially nor are even bothered about their food nor health. On the other hand as they are now physically weak and have some ailments, they find it quite hard to work already.
Three respondents play the role of caregiver towards a sister, grandson and husband. Another respondent was caregiver to her husband for almost 10 years before he passed away 9 years ago. Four out of five respondents are both victims of elder abuse and neglect and at the same time are caregivers. All the respondents experience abuse and neglect from their own family members, namely daughter (two respondents), son and daughter-in-law (two respondents), and husband.
The ex-husband of one respondent used to humiliate her by saying she was stupid and does not know how to entertain him. He praises other women except respondent. Now her son scolds her when she is late in cooking and does her support her when she and his wife have a quarrel. Her grandson, seeing his father scolding respondent also raises his voice at her.The son and daughter-inlaw of another respondent cook and eat themselves and respondent eats alone. She is not treated as part of the family but rather marginalized. Although she is divorced from her husband who is also her cousin 25 years ago, her relatives blame her and often pass sarcastic remarks. Her relatives have put her aside.
Another respondent is caregiver to her husband who is suffering from dementia. He uses vulgar words on respondent and accuses her of various things. The neighbors have misunderstood respondent because of these accusations leaving respondent all alone in her suffering and no financial or social support from her daughter. Victims of elder abuse often blame themselves for the violence and neglect they are subjected to. They are often reluctant to report the abuse because they are ashamed of what the family members did to them or embarrassed that they have placed rust in that person. For many victims, suffering at the hands of an abuser, violence and neglect are simply a way of life [22]. It is unreported as older people themselves do not want to discuss.

Threat of Abandonment and Institutionalization
All the respondents face loneliness by those closest to them. They are afraid to die alone. In order not to be abandoned, one respondent changed the name of her house to her son's name. However, this did not turn out the way respondent intended it to be. Her son has threatened to chase her out of the house so that she is no longer a "pest" to him and his family. The change of name has given the son the authority to manage the house as he likes, and respondent no longer has a say to anything in the house but has to act according to orders given.
The frequent quarrels and friction between respondents and those responsible for their humiliation and discrimination are indicators which arise concern that respondents do not feel comfortable and secure in their own homes with their own family. An environment which was once familiar to them has become unfamiliar and unhappy for them. The children of four respondents do not visit them at all nor keep in touch. They lead their own busy lives. This has caused distress among the respondents who feel that ultimately they would have to live alone or be placed in an institution which is never their choice. They have tried hard enough to build good relationships with their loved ones, but it is now a turnaround, something which they had least expected. However they also know that there will be nobody to care for them when they are in need. This is a hard decision for them as they fear for what the future has in store for them. The same people who have cause respondents' humiliation and discrimination are also responsible for their abandonment and institutionalization.  Elder abuse is a latent and tragic secret for many. Sometimes victims simply do not have the capacity to report it. At other times, victims are unwilling to report the abuse due to fear of rejection or abandonment by other family members [23].The findings are consistent with a study that found sons and daughters-in-law to be the main perpetrators of abuse compared with other individuals [24]. Details of the main perpetrators of abuse are as shown in Table 2.

Prevalence of Depression
Depression is an affective illness characterized by depressive symptoms such as disturbance in mood, cognition and behavior [25]. Although depression is the most common psychiatric disorder in the elderly, it is commonly misdiagnosed and under treated. The untreated depressed elderly patients have significant clinical and social implications as these disorders decreases an individual's quality of life and increases dependence on others [26]. The manifestations of depressive disorders in the elderly are also different compared to other periods of adulthood. Doctors may have problems in eliciting history as a result of the presence of cognitive impairment in the elderly. Reluctance or denial by the patient and family members may also complicate the doctor's assessment [27].
The Geriatric Depression Scale (GDS) [20] was used to assess the level of depression among the respondents in this research. GDS is a 30 item self-report assessment used to identify depression in the elderly. [28] first developed this scale in 1982. The GDS questions are answered "yes" or "no", instead of a five-category response set. This simplicity enables the scale to be used with ill or moderately cognitively impaired individuals. Results on the level of depression of respondents are as shown in Table 3.

Unsatisfied Need and Insufficient Support from Caregiver
The children of all the respondents have been identified as their caregiver. During the interview, the respondents said that their caregivers have not been caring enough towards them. They felt that having cared for their children it is now for their children to care for them. However, they still needed to provide for their children and their families and have to work at this old age. They also have nobody to share their problems and fears with. Everybody leads busy lifestyles and do not have the time. There is lack of understanding among the caregivers towards the respondents. Respondent do everything by themselves and loneliness has creeped which has caused them to have depression.
Respondents feel that they are now a burden to the family. To avoid any disagreements or quarrels with their caregivers, respondents choose to remain silent most of the times. Being at their place of work helps them to put aside these fearful thoughts but have to deal with it directly when they are home. Another respondent goes window shopping during her off days. Another respondent makes a trip to River Ganges India once in two years to help her to cope. Another respondent stays indoors most of the time without relating to anybody as this helps her not to hear hurting remarks by others around her. Emotional abuse and neglect is rampant among the elderly who are dependent on the abuser compared with the elderly who suffer other types of abuses [21].

Discussion
In all countries, effective elder abuse and neglect prevention requires the coordination of all available services including mental health care, health care, legal services, financial services and long term care [29]. However due to scarcity of resources and lack of reported cases, efforts to create a comprehensive preventive and helping approach are still in the infancy. Nevertheless, there is a need to expand these services towards the betterment and wellbeing of the elderly.
Although there is insufficient literature of elder abuse and neglect, the findings of this research suggests the importance of the role of practitioners to promote treatment and prevention of elder abuse and neglect. Practitioners are also critical for as collaborators for intervention studies and to serve as advocates for service development for victims of elder abuse and neglect. In areas where such concerted advocacy has occurred, improvements in elder abuse and neglect intervention have often followed [7].
Results of a research conducted revealed that both doctors and nurses are seriously deficient in their knowledge of indicators of elder abuse and neglect. This is particularly true among the nurses, who in spite of their greater contact time with patients, placing them in a comparatively better position to detect abuse, might be missing crucial signs of elder abuse and neglect that provide them the opportunity to prevent further harm [30].The strong emphasis on values, particularly filial piety, placing family needs above the individual [31] and avoiding bringing shame to the family may result in victims refraining from accepting external help and keeping individuals from intervening in private family matters.
As Malaysia is heading towards aging population in 2030, incidences of elder abuse and neglect will rise in accordance with a rapidly growing older adult population. The prevalence rate of elder abuse and neglect will increase and it is likely that for example, a clinician seeing 20 older adults a day may encounter a victim of elder abuse and neglect daily [32]. Prevention programs are well justified to help reduce prevalence and buffer the effect of a global aging population.
Malaysia should work towards having a law specially to protect the elderly from any kind of abuse. Countries like Singapore and Japan have already enforced a law for the well-being and protection of the elderly.

The Law on Elder Abuse in Singapore
The Maintenance of Parents Act 1994 provides for Singapore residents aged 60 years old and above who are unable to subsist on their own, to claim maintenance from their children who are capable of supporting him but are not doing so. Parents can sue their children for lack of maintenance, in the form of monthly allowances or a lump-sum payment. The Act also constituted the Tribunal for the Maintenance of Parents to review applications brought by parents. Thus, older adults who suffer financial neglect have some form of redress.
Another law is the Adult Protective Service (APS), for vulnerable older adults. The APS is characterized by special legally mandated powers of investigation, intervention, and mandatory reporting. An APS worker would assess whether an older adult is at risk of abuse or neglect and deliver the required services. Under certain circumstances, the APS worker can even intervene without the older adult's consent. Among the people who are mandated to report elder abuse are health practitioners, police officers and social service workers Another law is Guardianship. The court could declare an older adult to be incompetent on grounds of mental incapacity. The court entrusts his care to a Guardian who is appointed by the court. There are three types of guardianship: personal (affecting his person), plenary (affecting a whole range of matters) and limited (affecting specific matters).

The Law on Elder Abuse in Japan
In recognition of the fact that the elder abuse issue has become serious and that it is extremely important to prevent elder abuse so as to ensure the dignity of elderly persons, the Act on the Prevention of Elder Abuse, Support for Caregivers of Elderly Persons and Other Related Matters [33]aims to contribute to the protection of the rights and interests of elderly persons by advancing policy measures including elder abuse prevention and support for elderly persons' caregivers, by setting forth the responsibilities of the State and other parties to prevent, etc. elder abuse, providing for measures for the protection of elderly persons suffering elder abuse, and providing for support measures, etc. for elderly persons' caregivers, such as measures for alleviating the burden borne thereby (hereinafter referred to as "Support for caregivers"), that are aimed at contributing to the prevention of elder abuse by caregivers.

Conclusion
The prevalence of elder abuse and neglect is highlighted through this in-depth study. There is a need for more studies and research in this area. Education on the rights of the elderly needs serious attention so that care centers for the elderly are not seen as a place of refuge for the abused and neglected elderly. The complexities of elder abuse and neglect require the coordination of medical, social and legal professionals as well as the broader community to do the necessary intervention and treatment as well as identify the vital signs. As the number of elderly increases, the issue of elder abuse and neglect will also increase. There must be a law implemented urgently regarding the rights and care of the elderly with specific mention on the abuses faced by the elderly namely emotional abuse and neglect which has all the while been "Swept under the carpet".