Elder abuse within the family environment in the Azores Islands

ABSTRACT Objectives: to dimension abuse against vulnerable adults within the family and community environment in the Azores Islands, identify risk factors for abuse and describe the profile of an abused elder. Method: descriptive cross-sectional study. Random sampling. The instruments used were: clinical histories of the users, Mini-Mental State Examination, Index of Independence in Basic Activities of Daily Living, Family APGAR Scale, Elder Abuse Suspicion Index and Social Work Assessment Form. Descriptive statistical analysis was used for qualitative and quantitative variables and multiple logistic regression was used to identify factors associated with elder mistreatment. Results: abuse suspicion was identified in 24.5% of elderly participants. Psychological abuse was the most common type of abuse and sons were the main abusers. Conclusion: being a woman and belonging to a dysfunctional family is associated with an increased risk of becoming a victim of abuse; the high level of domestic violence against the elderly in the Azores Islands is in line with the rest of Portugal.

reality that health professionals have to deal more and more frequently. This is particularly important in the case of nursing professionals, since they are the ones who perform most part of the home visits and, at times, they are the only ones who have contact to the abused elderly, playing a key role in the detection of elder abuse (11)(12) . Living (ADL) (14) ; validity ranging from 0.66 to 0.93 and reliability of 0.96. c) Family APGAR Scale (Adaptability, Carmona-Torres JM, Carvalhal-Silva RM, Vieira-Mendes MH, Recio-Andrade B, Goergen T, Rodríguez-Borrego MA. Partnership, Growth, Affection, and Resolve) (15) ; validity of 0.8 and reliability of 0.75. d) Elder Abuse Suspicion Index (EASI) (16) ; sensitivity ranging from 0.47 to 0.55 and specificity of 95%. e) Social Work Assessment Form (SWAF) (16) , which consists of 67 questions, with question 59 "Do you think this patient has been abused?" considered as an indicative variable to identify if this is a case of elder abuse. In addition, this variable is used to compare and validate EASI results.
The independent variables of this study were: data of the elderly (age, sex, marital status, children, number of children, economic income, level of education, work activity, official minimum income, type of cohabitation,

Results
In total, 212 elderly people participated in the study. The sociodemographic characteristics of the elderly people are shown in   where the prevalence is 39% (19) ; or Asia, such as a study conducted in China that found a prevalence of abuse of 36.2% (23) . The reasons explaining the differences in prevalence among countries include the different instruments used to measure abuse.
As in previous studies, psychological abuse is the most common form of mistreatment, followed by negligence (6,(19)(20)(21) . In addition, most of the elder abuse is committed by the sons, followed by the partner or spouse, corroborating the existing studies (10,17,(19)(20) . The fact that a vast majority of the abusers belong to the family nucleus makes it difficult to identify cases of abuse (24) , making these data even more alarming. Since the health professionals are the only ones who, in most cases, have access to the abused elderly person, and nurses are the ones who perform most part of home visits (11)(12) , it is their responsibility to detect and report cases of elder abuse. Therefore, primary care plays a decisive and fundamental role (2,18,25) .
However, some studies conclude that the phenomenon of abuse may go unnoticed due to the lack of training of the health professionals who care for possible victims (26) . In fact, some studies report that nursing students have a lack of training regarding other forms of abuse such as partner violence (27) . Therefore, it would be useful to introduce specific contents on domestic violence into the Nursing undergraduate program (27) . For all these reasons, it seems necessary to implement training programs on elder abuse within the family and community environment, in order to help health professionals to prevent, detect, evaluate and intervene in such an issue (2,25) . Several studies show that in the fields where professionals are better trained and motivated, the detection of elder abuse is also better (11) .
From the results of the medical records analysis, it is also observed that health professionals do not fill out the medical records. The same was observed in the results of other investigations that concluded that, in general, the actual activity is not reflected, there is no uniformity in the records and sometimes there is no connection between the specialized medical care centers (12) . However, the medical record is a fundamental tool to ensure communication between the different members of the multidisciplinary staff (11) .
Among the limitations of this study, it is observed that the exclusion of elderly people with cognitive impairment from this study is one of the main limitations of it, because according to the literature, the prevalence of elder abuse among elderly people with cognitive impairment is higher than that observed in mentally intact individuals. Another limitation is that EASI has Carmona-Torres JM, Carvalhal-Silva RM, Vieira-Mendes MH, Recio-Andrade B, Goergen T, Rodríguez-Borrego MA.
not been developed to identify cases of abuse, but to identify cases of "abuse suspicion", a limitation that has been mitigated by the application of FETS, by contrasting both results. The same results have been obtained in both questionnaires for cases of abuse, so that both are capable of confirming cases of abuse. Another limitation with respect to the cross-sectional design of the study is that it was not possible to know the direction of causality between abuse and the associated variables.

Conclusion
The prevalence of elder abuse in the Azores Islands was dimensioned and the profile of the abused elderly has been obtained. The most frequent form of abuse is the psychological one and the sons are the main abusers.
Being a woman and belonging to a dysfunctional family are factors associated with an increased probability of being victim of abuse. As requirement for nursing practice, it is worth emphasizing that primary care nursing professionals should aim to detect this problem, by receiving specific training so that the phenomenon does not go unnoticed. In addition, these professionals should work in a comprehensive and interdisciplinary way with the rest of the staff in order to implement tools, programs and protocols to ensure the prevention, detection and intervention in these situations.