Scientific evidence of the violence against the older adult: an integrative review

Abstract

Objective:

To analyze the scientific evidence of violence against the older adult, with emphasis on the prevalence, the profile of the victim, and the risk factors.

Methods:

An integrative review of articles available in the PubMed® databases, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Nursing Database (BDENF), Scientific Electronic Library Online (SciELO) and Latin American and Caribbean Research on Health Sciences (LILACS), published between 2015 and 2019, using the descriptors: “idoso” , “older adult”, “older person”, “aged”, “old”, “exposure to violence”, “ exposição à violência ”, “aging”, envelhecimento” , “elder abuse”, “domestic violence”, “violence”, “ violência”, “maus-tratos ao idoso” and “violência doméstica” . As to refine it, the four phases of the PRISMA study selection flow diagram were used.

Results:

17 articles were identified which presented as increased risk factors for violence against the older adult, family dysfunction, lack of access to social rights and chronic conditions of disability.

Conclusion:

The study brings direct contributions to professionals and sectors interested in facing violence against the older adult, which has a high prevalence in today's society.

Keywords
Violence; Aged; Domestic violence; Exposure to violence; Frail elderly

Resumo

Objetivo:

Analisar as evidências científicas da violência praticada contra a pessoa idosa, com destaque para a prevalência, o perfil da vítima e os fatores de risco.

Métodos:

Revisão integrativa de artigos disponíveis nas bases de dados da PubMed®, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Banco de Dados em Enfermagem (BDENF), Scientific Electronic Library Online (SciELO) e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), publicados entre 2015 a 2019, a partir dos descritores: “idoso”, “ elderly ”, “ older person ” , “ aged ”, “ old ”, “ exposure to violence ”, “exposição à violência”, “ aging ”, envelhecimento”, “ elder abuse ” , “ domestic violence ” , “ violence ”, “violência”, “maus-tratos ao idoso” e “violência doméstica”. Para refinamento, foram utilizadas as quatro fases do diagrama de fluxo de seleção de artigos do PRISMA.

Resultados:

Foram identificados 17 artigos que apresentaram como fatores de risco aumentados para a violência contra a pessoa idosa idade avançada, disfuncionalidade familiar, falta de acesso a direitos sociais e condições crônicas de incapacidade.

Conclusão:

O estudo traz contribuições diretas para os profissionais e setores interessados no enfrentamento da violência contra a pessoa idosa, a qual possui alta prevalência na sociedade atual.

Descritores
Violência; Idoso; Violência doméstica; Exposição à violência; Idoso fragilizado

Resumen

Objetivo:

Analizar las evidencias científicas de la violencia practicada contra personas mayores, con énfasis en la prevalencia, el perfil de la víctima y los factores de riesgo.

Métodos:

Revisión integradora de artículos disponibles en las bases de datos de PubMed®, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Banco de Dados em Enfermagem (BDENF), Scientific Electronic Library Online (SciELO) y Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS), publicados entre 2015 y 2019, a partir de los descriptores: “anciano”, “ elderly ”, “ older person ” , “ aged ”, “ old ”, “ exposure to violence ”, “exposición a la violencia”, “ aging ”, “envejecimiento”, “ elder abuse ” , “ domestic violence ” , “ violence ”, “violencia”, “malos tratos al anciano” y “violencia doméstica”. Para refinar la búsqueda, se utilizaron las cuatro fases del diagrama de flujo de selección de artículos PRISMA.

Resultados:

Se identificaron 17 artículos que presentaron los siguientes factores de riesgo aumentados en la violencia contra personas mayores: edad avanzada, disfuncionalidad familiar, falta de acceso a derechos sociales y condiciones crónicas de incapacidad.

Conclusión:

El estudio contribuye directamente para los profesionales y sectores interesados en el enfrentamiento a la violencia contra personas mayores, que tiene una alta prevalencia en la sociedad actual.

Descriptores
Violencia; Anciano; Violencia doméstica; Exposición a violencia; Anciano frágil

Introduction

The change in the age structure towards aging alters the relationship of physical, psychological, social and economic dependence of the older adult and generates specific demands for families and social policies.^(1,2)In this context, violence against the older adult emerges as a serious and growing problem in a country that is heading to be the sixth with the largest number of older adults in the world. This problem occurs in different ways and, depending on the cultural context in which it is inserted, its identification becomes difficult, with serious consequences for individuals, families, communities, and managers.⁽³⁾

The World Health Organization (WHO)⁽⁴⁾defines violence against older adults as a single or repeated act, which is presented in a relationship of trust and causes the older adult harm, suffering, or anguish. It can be represented by financial, physical, psychological, sexual, medical, emotional/social violence, abandonment, neglect and self-neglect.^(5,6)

In 2005, it was established, in Brazil, the Action Plan to Combat Violence Against the Older adult⁽⁷⁾which, in 2020, celebrates its 15th anniversary, establishing strategies for action, prevention, and confrontation of this violence . However, nowadays, it is observed that the problem is even bigger and more worrying. Every day, situations of violence against older adult are reported, either at home, in extended care facilities, or in the external environment for the older adult to use. Annual statistics indicate a high prevalence of violence, most of which is practiced by people close to the older adult.⁽⁸⁾

Data released by the Ministry of Human Rights reveal that, in 2017, 33,133 complaints and 68,870 violations against people occurred in Brazil. In the reports of violations, 76.84% involved negligence, 56.47% involved psychological violence and 42.82%, financial and economic abuse. Most of the cases occurred in the victim's own home.⁽⁸⁾

Furthermore, it is recognized that violence is not univocal, but constitutes a complex socio-historical phenomenon, which occurs in the context of different places, times, means, and circumstances. In several situations, it is practiced on the economic, political, moral, psychological, and physical levels and in violation of basic human rights, requiring a look beyond the events reported by the victim and his family. Given the above, the question is: what is the scientific evidence on the phenomenon of violence and its associated factors in the older adult population?

The aim of this study was to analyze the scientific evidence of violence against the older adult, highlighting the prevalence, the profile of the victim, and the risk factors.

Methods

This is an integrative review, consisting of six steps: developing the research question, selection of inclusion and exclusion criteria with literature search with validated protocol, categorization of studies, critical appraisal of included studies, interpretation of results and presentation of the review.⁽⁹⁾

For the development of the research question and choice of descriptors in the search for evidence on the topic, we used the PICo strategy⁽¹⁰⁾( Chart 1 ).

Chart 1
PICo strategy used in the study

Acronym	Descriptors
P – Population: older adult	Idoso , older adult , older person, aged e old
I – Intervention/Exposure: intrafamily violence	Exposure to violence, exposição à violência , aging, envelhecimento
Co – Outcome/Results/Context: mistreatment, occurrence of violence	Elder abuse, domestic violence, violence, violência, maus-tratos ao idoso, violência doméstica

• Source: Polit DF, Beck CT. Fundamentos da pesquisa em enfermagem: avaliação de evidências para a prática de enfermagem. 9ᵃ ed. Porto Alegre: ArtMed; 2018.⁽10⁾

The research was carried out from September 2019 to January 2020, on the platforms: PubMed®, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Nursing Database (BDENF), Scientific Electronic Library Online (SciELO) e and Latin American and Caribbean Research on Health Sciences (LILACS).

Combining descriptors with Boolean operators OR and AND, the search strategy for the articles was developed. On the LILACS/BDENF databases, the strategy was: (Older adult) AND (domestic violence OR exposure to violence) AND (aging OR autonomy); on MEDLINE/PubMed®, it was: ((“elder abuse”) OR (“domestic violence”) OR (violence)) AND ((“exposure to violence”) OR aging)) AND ((older adult) OR (“older person”) OR (aged) OR (old)); on CINAHL, it was: (“elder abuse” OR “domestic violence” OR violence) AND (“exposure to violence” OR aging) AND (older adult OR “older person” OR aged OR old); and on SciELO, it was: (violência doméstica OR exposição à violência) AND (envelhecimento OR autonomia), (Idoso) AND (violência doméstica OR exposição à violência) AND (envelhecimento OR autonomia) AND la: AND year_cluster:(“2019” OR “2018” OR “2017” OR “2016” OR “2015”) AND is_citable:(“is_true”) AND type:(“research-article”) .

The study selection criteria were: articles with a quantitative approach, as they are the most widely disseminated in studies with an at-risk population (prevalence) and allow investigating associations between the phenomenon under study and risk factors; articles available in full; time cut from 2015 to 2019, due to the Action Plan to Combat Violence Against the Older adult completing 15 years in Brazil and publications in Portuguese, Spanish, and English. Integrative, conceptual, and systematic reviews were excluded, as well as monographs, dissertations, theses, and qualitative studies. To refine the articles, four phases of the diagram Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) of the article selection flow were used. The Evidence Level followed the classification proposed by Melnyk and Fineout-Overholt.⁽¹¹⁾

A database was created with the definition of the sample, After the first selection, a reading was carried out for critical appraisal and interpretation of the results, which were grouped and categorized. The results were analyzed and interpreted in a descriptive way.

Results

1,733 publications were identified, of which 1,664 were excluded after applying the filters and the inclusion and exclusion criteria, leaving 69 articles. Subsequently, the selection was made after full reading the articles considered potentially eligible, whose titles and abstracts informed evidence about violence against older adult people, totaling 17 articles.^(12–28)All articles on the CINAHL database were duplicated with other databases and, therefore, were excluded ( Figure 1 ).

Figure 1
Flowchart of the study selection process

The articles were published, predominantly, in the years 2018 (41.2%)^(14–18)and 2017 (23,5%),^(21–24)most publications in the Portuguese language. Of the 17 studies, 11 (64.7%)^{(12–17,20–22,26)}were carried out in Latin America (Brazil, Ecuador, Colombia and Mexico). The journals that contributed most were those in the medical field (47.1%), followed by nursing (23.5%) ( Chart 2 ).

Chart 2
Characteristics of the selected articles

Year	Title of the Study	Journal	Country	Authors	Database
2019	A1: Violência sobre a pessoa idosa: um estudo documental	Revista Rene Online	Brazil	Alarcon et al.(12)	BDENF
2019	A2: A ocorrência da violência em idosos e seus fatores associados	Revista Brasileira de Enfermagem	Brazil	Maia et al.(13)	LILACS
2018	A3: Funcionalidad familiar y autoestima del adulto mayor, en situación de maltrato. Un estudio participativo comunitário	Revista Lasallista de Investigatión	Ecuador	Chiriboga et al.(14)	SciELO
2018	A4: Violência familiar contra a pessoa idosa: expressões do fenômeno e perspectivas para o seu enfrentamento	Textos & Contextos	Brazil	Diel et al.(15)	SciELO
2018	A5: Violência contra a pessoa idosa	Revista de Enfermagem UFPE Online	Brazil	Lopes et al.(16)	BDENF
2018	A6: Prevalência e fatores associados à violência contra idosos cometida por pessoas desconhecidas, Brasil, 2013	Epidemiologia e Serviços de Saúde	Brazil	Alencar Júnior et al.(17)	LILACS
2018	A7: Design and implementation of an empowerment model to prevent elder abuse: a randomized controlled trial	Clinical Interventions in Aging	Iran	Estebsari et al.(18)	PubMed®
2018	A8: Feasibility of intervention in elder self-neglecters: Setting the stage for future research	Journal of Elder Abuse & Neglect	The United States of America	Lee et al(19)	PubMed®
2018	A9: Frailty and life course violence: The international mobility in aging study	Archives of Gerontology and Geriatrics	Albania, Brazil, Canada and Colombia	Gomes et al.(20)	PubMed®
2017	A10: Collective violence and the health of the elderly: a cross-sectional analysis of a population-based national survey in Mexico	Revista Panamericana de Salud Pública	Mexico	García-Peña et al.(21)	SciELO
2017	A11: Cross-sectional study on the association between frailty and violence against community-dwelling elderly people in Brazil	São Paulo Medical Journal	Brazil	Belisário et al.(22)	PubMed®
2017	A12: Associations between the differential definitions of elder mistreatment and suicidal ideation outcomes in U.S. Chinese older adults: do the definitions matter?	Journals of Gerontology. Series A, Biological Sciences and Medical Sciences	The United States of America	Dong(23)	PubMed®
2017	A13: Elder abuse within the family environment in the Azores Islands	Revista Latino-Americana de Enfermagem	Portugal	Carmona-Torres et al.(24)	LILACS
2016	A14: The prevalence of resident-to-resident elder mistreatment in nursing homes	Annals of Internal Medicine	The United States of America	Lachs et al.(25)	PubMed®
2016	A15: Prevalência de violência contra idosos e fatores associados, estudo de base populacional em Florianópolis, SC	Revista Brasileira de Geriatria e Gerontologia	Brazil	Bolsoni et al.(26)	LILACS
2015	A16: Estudo sobre pessoas idosas vítimas de violência em Portugal: sociografia da ocorrência	Cadernos de Saúde Pública	Portugal	Gil et al.(27)	LILACS
2015	A17: Physical abuse against elderly persons in institutional settings	Journal of Forensic and Legal Medicine	Portugal	Frazão et al.(28)	PubMed®

It was found that 11.8%^(18,19)of the studies presented Evidence Level 2 and described outcomes that point to the importance of social support, self-efficacy and health-promoting behaviors in reducing the risk of violence/abuse and self-neglect of the older adult; 88.2% had Evidence Level 4 and highlighted the prevalence and typology of violence, the profile of the victimized older adult and risk factors for violence ( Chart 3 ).^{(12–17,20–28)}

Chart 3
Summary of the articles selected for the study

Study	Study design/EL	Objective	Results and conclusions/outcome
A1(12)	Cross-sectional, analytical and retrospective (EL4)	To associate the sociodemographic characteristics of older adult victims of violence and aggressors with the types of violence	Association between type of violence and sex, marital status, education, age, place of occurrence and the victim's form of notification; predominance of financial violence in men and psychological/moral violence in women
A2(13)	Cross-sectional, by population survey (EL4)	To analyze the occurrence of violence against the older adult and associated factors	Forms of violence: little access to social rights, verbal, moral/psychological violence, lack of care. Women are the most frequent victims; association with depressive symptoms
A3(14)	Quantitative, correlation scope and cross-sectional (EL4)	To determine the correlation between family functioning and self-esteem of adults and the older adult in situations of abuse	A correlation was found between self-esteem, family functionality and situations of abuse
A4(15)	Descriptive, quantitative and documentary (EL4)	To analyze expressions of family violence against the older adult and the perspectives of its confrontation	Main victims: older adult women, widows, with relative economic autonomy, dependent on health care by the family
A5(16)	Quantitative, epidemiological and cross-sectional (EL4)	To evaluate the occurrence of violence suffered by the older adult	Prevalence of physical violence, by non-self-inflicted injuries, performed by children and spouses
A6(17)	Quantitative and cross-sectional (EL4)	To analyze the association between sociodemographic, behavioral and health characteristics; and prevalence of violence committed by strangers	Sociodemographic characteristics were associated with violence against the older adult committed by strangers
A7(18)	Controlled and randomized (EL2)	Design and implement an empowerment educational intervention to prevent abuse of the older adult	Social support, self-efficacy and health promoting behaviors are determinants in reducing the risk of abuse of the older adult
A8(19)	Randomized controlled trial (EL2)	To carry out clinical interventions to improve critical situations of older adult people who neglect themselves	The clinical intervention made it possible to improve the participation of the older adult in self-neglect prevention programs
A9(20)	Quantitative and cross-sectional (EL4)	To estimate the prevalence of frailty; investigate associations between domestic violence and frailty throughout life	The prevalence of frailty and risk of abuse varied among the cities studied, being lowest in Canada and highest in Brazil. Physical abuse in childhood and exposure to psychological violence by the partner were associated with depression
A10(21)	Quantitative and cross-sectional (EL4)	To describe the association between collective violence and the health of the older adult in Mexico	Collective violence has an indirect influence on the health of the population, mainly older adult
A11(22)	Cross-sectional, analytical and observational (EL4)	To check the association between violence against the older adult and frailty syndrome	Association between income and physical aggression; living with another person and dependence for IADL and physical and verbal aggression; diseases and physical and/or verbal aggression
A12(23)	Quantitative and epidemiological (EL4)	To explore the association between abuse and suicidal ideation in older adult Chinese living in Chicago	Maltreatment psychological, financial abuse and neglect were associated suicidal ideation
A13(24)	Descriptive and cross-sectional (EL4)	To dimension abuse against vulnerable older adult people in the family and community environment	Prevalence of psychological violence; children as main aggressors; being a woman and belonging to a dysfunctional family are more likely to abuse
A14(25)	Observational and prevalence (EL4)	To estimate the prevalence of physical, verbal, and sexual abuse in nursing home residents	Prevalence of 20.2%; verbal, physical and sexual violence. Associated factors: cognitive impairment and institutionalized older adult
A15(26)	Cross-sectional and population-based (EL4)	To estimate prevalence of violence against the older adult and association with demographic, socioeconomic and health factors	Prevalence of verbal violence; older adult woman, single/divorced, greater chance of abuse; living with children or grandchildren twice increases the chance of abuse
A16(27)	Quantitative, descriptive and cross-sectional (EL4)	To characterize the sociodemographic, economic structure and conditions of violence in the older adult family context	Prevalence of physical and psychological violence. The victims were women, aged 70.7 years and their aggressors were family members
A17(28)	Quantitative and retrospective (EL4)	To provide knowledge about physical abuse against institutionalized older adult and correct detection of the forensic diagnosis	Prevalence in women ≥75 years, with severe disability and communication difficulties; association between neglect and disability

• EL – Evidence Level; BDENF - Nursing Database; LILACS - Latin American and Caribbean Research on Health Sciences; SciELO - Scientific Electronic Library Online ; IADL - Instrumental Activities of Daily Living

The articles were separated and composed two categories for discussion: Prevalence, typology and profile of the older adult victim of violence and contributing and risk factors for violence against the older adult.

Discussion

The limitations of this study are related to the different definitions of the types of violence, age of the target populations, which vary between developed (65 years) and developing (60 years) countries, resulting in diverging prevalence data and the use of only controlled descriptors on search platforms.

Prevalence, typology and profile of the older adult victim of violence

The studies indicated a variation in the percentage of violence against the older adult, between 1,6%⁽¹⁷⁾a 20,2%,⁽²⁵⁾committed, most of the time, by family members (children, spouse, grandchildren and stepchildren)^{(15,16,20,24,27)}and, to a lesser extent, by strangers.^(17,25)

In a multicenter study carried out in Albania, Brazil, Canada and Colombia, the prevalence of frailty and risk for violence was higher in older adult Brazilian women and lower in Canadians.⁽²⁰⁾The evidence pointed to the fact that older adult people who live alone or with a family member were twice as likely to experience violence compared to older adult people who lived in extended care facilities or who were assisted by formal caregivers.^(17,20,26)The types of violence that affected older adult people in high, middle and low income countries were similar. Psychological violence ranked highest, followed by verbal, financial, physical and negligence.^{(12,13,22–24,26,27)}Sexual violence and self-neglect appeared in only three studies.^(17,19,27)

There was a predominance of financial violence in men and psychological violence in women.^{(12–14,19,20,23,27)}In one study,⁽⁵⁾psychological, physical and financial violence had the highest rates, with sexual violence not being highlighted, and self-neglect/self-abandonment was superior to negligence - an unusual fact, since negligence almost always appears among the first occurrences in research.^{(12,13,22–24,26,27)}

The outcomes showed that the victims were older adult women, single/widows/divorced, of older age, less educated, with moderate/severe dependence to carry out their daily life activities, with depressive symptoms, cognitive impairment and poor health perception.^{(12,15,17–19,21,22,25,26,28)}The profile of the victim has not changed over time and the place where the studies took place.⁽²⁹⁾

Contributing and risk factors for violence against older adults

The advanced age represented one of the most important risk factors, being related to the degree of dependence and the loss of autonomy of the older adult. It is when the frailty conditions and need for care are installed, due to illness, cognitive disability, changes in sleep, cognitive and motor impairment, generating an increase in the demand for care for the family, almost always unprepared for this new reality.^(12,15,26)

Family dysfunction was the second major predictor of violence in this study. Belonging to a family with mild or severe dysfunction represents an 8.35 times higher probability to be abused;^(14,23)and the long-lived, physically and economically dependent, omit more to denounce their aggressor, due to the difficulties of doing so and because they fear losing support when reporting the violence.^{(12,13,15,17,20,24,26)}

The lack of access to social rights appears as an important factor that generates violence, indicating that the existing social protection devices still seem to be insufficient to face the issue.^(13,26)In Brazil, the idea that it is exclusively the family's task to support their older adult is common, however, government agencies are also responsible for the development of social protection policies for these people.^(30–32)The effects of intervention through social support, self-efficacy and health-promoting behaviors in decreasing the risk of abuse of the older adult were shown to be significant,^(18,19)proving that stereotypes regarding self-care, built around the aged person's imaginary, need to be modified.^(31,33)

Chronic conditions, the victim's disability and symptoms of depression showed a significant correlation with psychological repercussions that generate the practice of maltreatment.^{(12,15,20,23,27)}This situation also appears in a study that highlights the presence of depressive signs associated with advanced age, low education, insomnia and chronic diseases.⁽³⁴⁾Violence proved to be a strong predictor of attempts and complete suicide, and, as a reducing factor in suicide attempts and/or suicide resulting from violence, is the improvement of reception and family support services.⁽²³⁾

Human aging is a phenomenon that requires planning and resources, and it is essential to guarantee rights with effective public policies for protection and prevention.^(15,31,32)Likewise, there is no way for the family to take care without support that allows basic care and prevents, mainly, negligence related to basic care.

Conclusion

The articles analyzed in this research show evidence that goes beyond the simple analysis of isolated factors of violence against the older adult. Four important factors stand out: advanced age, representing the greatest risk factor for violence, associated to the loss of autonomy and independence and the need for the care of others; family dysfunctionality, with a high probability of abuse against the older adult; lack of access to social rights, indicating that the existing social protection devices are still insufficient to face violence; the victim's chronic conditions of incapacity and symptoms of depression, with psychological repercussions that lead to violence and attempted suicide.

Acknowledgments

The authors acknowledge to Professional Master's Program in Public Health Nursing at the State University of Amazonas, the Foundation for the Support of Research in the State of Amazonas – FAPEAM and Academic Program in Care Sciences-PACCS at Universidade Federal Fluminense.

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Publication Dates

• Publication in this collection
  14 July 2021
• Date of issue
  2021

History

• Received
  29 Feb 2020
• Accepted
  20 Aug 2020