A comparison of the nature and characteristics of elder abuse and community violence: a medico-legal analysis

Introduction In Sri Lanka, violence against the elderly (VAE) has emerged as a subject of public discussion in recent years. This study compares the nature and characteristics of elder abuse, reported to selected medico-legal units, with community violence involving elderly victims. Methods Patients 65 years and older were considered as elderly. A descriptive cross-sectional study was conducted during the period 01 January 2009 to 31 December 2013 in a few identified tertiary care hospitals. A total of 17,330 medico-legal examination forms (MLEF) of five Forensic Medical Officers were perused to identify victims of VAE. Violence committed by someone trusted by victims was classified as elder abuse (EA), while violence in general situations was classified as community violence (CV). The study aimed at comparing the nature and characteristics of EA with CV. Results Of 17,330 MLEFs, 127(0.7%) cases were VAE. Among victims of VAE, 91(71.7%) were men and 68(53.5%) were 65-69 years. A total of 125(98.4%) reported physical violence, 51(40.2%) occurred in the afternoons, 83(65.4%) occurred at home and 116(91.3%) were committed by persons known to the elder. Common alleged reasons for violence were financial 18(14.2%) and property issues 14(11.0%). Of 127 victims, 51(40.2%) experienced EA and 76(59.8%) CV. When comparing EA and CV, 12(23.5%) EA and 59(77.6%) CV occurred outside the home. (χ =8.512, df=1, p=0.004). Following CV, 62(81.6%) victims complained to the police or hospital staff by themselves while the corresponding figure in EA was only 20(39.2%). (χ =27.677, df=1, p<0.001). Conclusions CV against elders, occurring outside the home, is more likely to be reported by victims. Many similarities exist between EA and CV indicating that both groups are based in a society breeding violence. Abuse of elders in Sri Lanka is an area that needs further investigation to develop evidence based interventions. Corresponding Author: M Vidanapathirana, E-mail <mudithavidana@gmail.com> Received: January 2014, Accepted revised version: July 2014, Published: August 2014 Competing Interests: The Authors have declared that no competing interests exists Introduction Violence against the elderly (VAE) is a human rights violation and is ethically unacceptable. With the gradual shift from an extended to a nuclear family system, erosion of social values,


Introduction
Violence against the elderly (VAE) is a human rights violation 1 and is ethically unacceptable.
With the gradual shift from an extended to a nuclear family system, erosion of social values, and modernisation, coupled with an ageing population, the problem of VAE has emerged as a concern in recent years in Sri Lanka.
Unfortunately, scientific evidence to quantify this problem or determine factors responsible for VAE is scarce. Further, knowledge of such aspects is vital to design and implement interventions that would prevent VAE. This study was undertaken as a preliminary attempt to bridge this gap in scientific knowledge. The objective of the study was to compare violence against elderly in general situations (community violence; CV) with violence against the elderly committed by persons known to the victim (elder abuse; EA).

Methods
A descriptive cross-sectional study was conducted during the period 1 January 2009 to 31 December 2013 in a few identified tertiary care hospitals. A total of 17,330 medico-legal examination forms (MLEFs) of five forensic medical officers were perused to identify victims of VAE. Patients 65 years and older were considered as elderly 1 . If the violence was committed by someone trusted by the victims, it was classified as 'elder abuse (EA)'while violence in general situations was classified as 'community violence against elders (CV)'. Fatal as well as traffic trauma cases were excluded.
SPSS software package 19.0 was used in analyzing data. Chi-square tests were performed in bi-variate tests and p-values<0.05 were considered as statistically significant.
The majority EA victims 47(92.1%) were Sinhalese with 3(5.9%) Tamils and 1(2.0%) Muslims. Most 48(94.1%) had two or more children and 39(76.5%) were unemployed. In EA, the common instigators were financial 6(11.8%) and property issues 6(11.8%). Except for one victim of chronic negligence all reported were physical assaults. A total of 29(58.4%) reported being subjected to more than one type of abuse. Type of abuse is shown in Table 2.  The 'use of a random instrument or weapon' was significantly higher in EA victims aged less than 70 years 11(42.3%), than in those aged 70 years or above 4(16.0%) (χ 2 =4.249, df=1, p=0.039). Similarly, 'use of a random instrument or weapon' was significantly higher in incidents occurring in the morning 7(43.6%) compared to incidents which occurred in the evenings 4(26.7%) (χ 2 =5.343, df=1, p=0.025). No significant differences was seen in the 'use of a random instrument or weapon' based on the sex, ethnicity, marital status or number of children of the victim or based on the number of perpetrators, presence of injuries, head injuries or severity of injuries. A total of 22(43.1%) victims of EA reported a previous history of abuse.  According to a UK definition, "EA 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" 4 . EA occurs at all socio-economic levels and in all racial groups. 1 In this study too, EA was found in all ethnic groups. In our study the majority of EA victims were men. According to the National Report on Violence and Health in Sri Lanka 2008 1 , elderly women are more likely to get abused than men. The findings of this study may reflect a difference in the pattern of reporting of abuse among males and females. EA among women and men declines with age 5 . The present study confirmed this pattern.
According to the National Report on Violence and Health in Sri Lanka 2008, physical abuse is more likely to take place in institutions than at home 1 . However, none of the victims of the present study were from institutions. Thus, elder care institutions should be routinely visited and scrutinised for any un-reported incidents by authorised agencies. The commonest perpetrator in the present study was the son. The spouse was the perpetrator in 10% of instances. Late-life intimate partner violence (IPV) should be researched further for improved understanding of this issue.
Elders not having financial assets and entirely dependent on children are more likely to be abused than those who have some means of support 1 . In this study too, 18(14.2%) victims of VAE and 6(11.8%) of victims of EA alleged financial issues as one of the reasons for their experience.
EA can be classified as physical, psychological, or financial/material and several types of illtreatment may occur simultaneously 6 . Similar to previous research findings 1 , physical abuse was the most common form of VAE 125(98.4%) and comprised 36(70.5%) of EA in the study. Neglect is more common among elders living alone, in poor households 1 . A previous study in Sri Lanka revealed that only 47% of elderly are regularly visited by relatives 7 . In this study, 6(11.8%) EA victims were neglected. Financial abuse was alleged by 8(15.7%) victims of EA. Health and social care professionals must enhance their ability to detect elder financial abuse. A suitable a web resource may be accessed at www.elderfinancialabuse.co.uk 8 .
Among EA victims, the commonest site of injury was the head 20(39.2%). This is similar to a study done in Brazil, where the prevalence of head injury was 25% of total injuries 6 . 'Use of a random instrument or weapon' in EA was more against 'young-olds' (p<0.05) and in the morning (p<0.05). Though, EA is more common in the afternoon, abuse using 'weapons' was seen more in the morning. These factors should be explored in more detail when designing prevention programmes.
Reported incidents of CV 76(59.8%) were more those of than EA 51(40.2%). When comparing EA with CV, CV was more common outside the homes (p=0.004) and the victims were more likely to complain to the authorities themselves (p<0.001). EA was more likely to take place at home and victims were less likely to complain to authorities by themselves. This may be due to emotional and/or financial dependence of the victim on the perpetrator.
Further comparison of EA and CV revealed many similarities in the victims. Age, sex, ethnicity, marital status, number of children and employment status were similar sociodemographic characteristics of the victims. Time of incident, number of perpetrators, 'use of a random instrument or weapon', presence of injuries, head injuries and severity of injuries were also similar in the two categories of victims.
The segment of the population aged 65 and above is projected to increase from 1.9 million in 2001 to 4.7 million in 2031 in Sri Lanka 7 . With higher life expectancies at older ages the duration of co-residence of elderly with their children will increase further 9 . The problem of EA is likely to increase in the future, highlighting the importance of developing intervention and prevention programmes. Provision of supportive services for victims of negligence has been found to be the most effective intervention 10 . Assessment of elderly patients at risk by a multidisciplinary team including a social worker with subsequent development of individualised intervention strategies can have a positive impact on this devastating problem 11 . The American Medical Association "Guidelines for diagnosis and treatment of elder abuse and neglect" recommend mandated reporting 6 and offers potential social, legal remedies 12 .

Conclusions
Victims of elder abuse are reluctant to report abuse occurring at home. Many similarities are found between elder abuse and community violence, indicating that both groups have their basis in a society breeding violence. Elder abuse in Sri Lanka is an unmapped area needing further investigation to develop evidence based interventions. Guidelines should be developed for the diagnosis, treatment and management of elder abuse and neglect.