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Ciência & Saúde Coletiva

Print version ISSN 1413-8123On-line version ISSN 1678-4561

Ciênc. saúde coletiva vol.22 no.9 Rio de Janeiro Sept. 2017

http://dx.doi.org/10.1590/1413-81232017229.12312017 

REVIEW

Intimate partner violence prevalence in the elderly and associated factors: systematic review

Deise Warmling1 

Sheila Rubia Lindner1 

Elza Berger Salema Coelho1 

1Programa de Pós-Graduação em Saúde Coletiva, Departamento de Saúde Pública, Centro de Ciências da Saúde, Universidade Federal de Santa Catarina. Campus Universitário Reitor João David Ferreira Lima, Trindade. 88040-900 Florianópolis SC Brasil. deisentr@gmail.com

Abstract

This article aims to identify the prevalence of intimate partner violence (IPV) in the elderly and its associated factors. A systematic review of cross-sectional population-based studies was conducted in PubMed, Lilacs and PsycInfo databases, without restrictions with respect to the period and language of publication. Two independent reviewers conducted the selection, data extraction and the methodological quality analysis. Nineteen papers were selected for the analysis. There was a variation in the type of violence, gender of respondents and tools used. Most studies had a moderate or high methodological quality. IPV occurred in elderly men and women, with greater prevalence of psychological violence and economic abuse. The most frequent associated factors were alcohol use, depression, low income, functional impairment and previous exposure to violence.

Key words: Intimate partner violence; Elderly; Prevalence; Associated factors; Elder abuse

Introduction

Population aging is a global reality, and Brazil is on a fast track lane. This phenomenon occurred initially in developed countries and has been growing steadily in developing countries1,2. In this context, elder violence is a reality in various social levels and has relevant consequences on the health of this population2. Thus, violence is a challenge to public health, as it imposes the need for specific social policies and new directions for comprehensive elderly health care1.

Intimate partner violence (IPV) includes any behavior that causes physical, psychological or sexual harm to those who are part of the intimate relationship. They include acts of physical assault, psychological abuse, controlling behavior3 and economic abuse4. In the context of elder violence, that which has been committed by an intimate partner has been less investigated, and, when addressed, is considered less severe than when applied to young women5,6.

However, in US studies, women older than 55 years were more affected by IPV than younger women7, with intimate partners accounting for 13-50% of the abuse committed8. Similarly, in Spain, 29.4% of elderly women suffered this type of violence9.

In Brazil, the prevalence of intimate partner violence in the study of elderly women and men was 5.9% for physical violence and 20.9% for psychological violence10, while in Brazil and Colombia, a study carried out with 60-74 year-olds, IPV found prevalence of psychological violence in women of 26.0% and 20.4%, respectively. This prevalence was 11.1% for men in both countries11.

IPV has a negative impact on the physical and mental health of the elderly. Among the victims of physical and psychological violence, there is a greater proportion of reports of muscular and skeletal pain, headache, stomach problems, anxiety, sleep disorders, stress and suicidal mindset12,13. Violence also has a social impact on the lives of the elderly, contributing to low self-esteem, social isolation and feelings of insecurity, reinforcing negative aspects of old age14.

Studies15-17 dealing with elder violence tend to analyze the elderly as victims of abuse in most cases by caregivers or relatives, and intimate partner violence is still a scarce approach in the literature. This fact may be embedded in the understanding that violence does not occur among elderly partners, masquerading as neglect or family violence, since the caregiver may be the intimate partner.

The concept of IPV in this age group is still little understood in the literature as a single construct, which leads us to affirm that it is important to further investigate this issue to bridge the existing gap and highlight the phenomenon in a growing and significant population that has been understudied18.

In view of the foregoing, this study aimed to identify from a systematic review of literature the prevalence and factors associated with IPV in the elderly.

Methodology

We conducted a survey of published studies on the prevalence of intimate partner violence in the elderly and factors associated with the phenomenon.

Registration and protocol

This systematic review was performed according to the guidelines outlined in the PRISMA Check List (Preferred Reporting Items for Systematic Reviews and Meta-Analysis - Prospective Register of Systematic Reviews)19. The protocol of this systematic review was registered in the International Prospective Register of Systematic Reviews database (PROSPERO).

Eligibility Criteria

Inclusion criteria were original scientific papers that covered cross-sectional population-based studies; that analyzed the prevalence of intimate partner violence and its associated factors, with a clearly described methodology; papers with target population that included the elderly; papers published in national and international journals.

Literature reviews, letters, opinion papers, experience reports, case studies, book chapters and conference presentations were excluded. There were no restrictions regarding the publication date or language.

These criteria sought to ensure that only representative studies of the general population were inserted, since they more accurately reflect the prevalence and factors associated with IPV in the elderly population.

Search strategy

The search for papers was carried out in PubMed, Lilacs and PsycInfo databases. PubMed’s search strategy was adapted for the other databases was as follows: (“Intimate Partner Violence”[Mesh] OR “Intimate Partner Violence”[All Fields] OR “Spouse abuse”[Mesh] OR “Spouse abuse”[All Fields]) AND (“Prevalence”[Mesh] OR “Prevalence”[All Fields] OR “Cross-Sectional Studies”[Mesh] OR “Cross-Sectional Studies”[All Fields]) AND (“aged”[MeSH] OR “aged”[All Fields] OR “aged, 80 and over”[MeSH] OR “80 and over aged”[All Fields] OR elderly[All Fields]) NOT (pregnancy OR child$ OR AIDS).

Search was conducted from March to September 2016. Selected papers’ reference lists were reviewed and a manual search was done for other potentially eligible publications.

Selection of studies and data extraction and review

Studies were selected by two independent reviewers. Initially, duplicate references between databases were identified and excluded using the EndNote Web reference manager (Thomson Reuters).

According to the eligibility criteria, the selection was done through the evaluation of titles and abstracts and then full texts. Any disagreement between reviewers regarding the application of criteria would require an expert’s opinion on the specific matter and would be defined by consensus. The general characteristics of papers (year and place of collection, gender and age of respondents, sample size and violence measurement tool), prevalence and factors associated with IPV and recorded in electronic spreadsheets were extracted. Data were sorted in a documentary form, analyzed in a descriptive way and shown in tables.

Evaluation of methodological quality

The methodological quality was evaluated by two independent reviewers, using the tool proposed by Loney et al20 indicated for the critical evaluation of cross-sectional studies. Authors adopt eight items in the evaluation. For each criterion not met, the study received a zero, and scored “one” point if met. High-quality studies were those scoring 7-8 points; 4-6 points indicated moderate quality studies, and 0 to 3 points, low quality studies. No papers were excluded due to the level of methodological quality. The eight evaluation criteria are:

  • Sample: adequate if the study was performed with all population or with probabilistic sampling.

  • Sampling source: adequate if it was population census-based.

  • Sample size: adequate if statistically calculated.

  • Measurement of outcome: adequate if intimate partner violence was measured by a validated tool.

  • Impartial interviewer: adequate if results were surveyed by trained interviewers.

  • Response rate: adequate if ≥ 70.0%.

  • Prevalence with 95% CI: adequate if confidence intervals of intimate partner violence prevalence were shown.

  • Similar participants: adequate if subject under study were described and stratified per age group and similar to the study question (elderly).

Results

Eight hundred forty-two papers were identified in the searched databases and five were added from the analysis of the references of the selected studies and manual search from other sources, totaling 847 articles. Of these, 49 were excluded because they were duplicates and 707 because they did not meet the eligibility criteria after reading titles and abstracts. Thus, 91 studies were submitted to full analysis, and from this process, 19 papers4,10,21-37 were chosen for this study (Figure 1).

Figura 1 Fluxograma do resultado da busca, seleção e inclusão dos estudos. 

Of the 19 papers selected, 15 included in their samples adults and elderly4,20-33 and four only elderly10,35-37. Five studies4,24,25,29,33 stratified the prevalence by age group, thus identifying IPV among the elderly. In the others, prevalence was shown for the general sample of the study, in which the elderly were included.

Papers included were published between 2004 and 2015, more frequently in the period 2012-20154,10,28-37; surveys between 2004 and 201024-30,32-34,36 predominated. There was a higher concentration of studies in Europe4,26,29,31,34,35 and the United States21,25,27,29,31,37; Brazil only had two studies10,22. In 11 studies10,23,25,28,29,31-33,36,37, respondents were men and women concomitantly, others included only women, and there were no studies with men alone. The sample size varied from 356 to 70,156 respondents.

The most widely used tool for measuring violence was the Conflict Tactics Scale (CTS), versions 1, 2 and adaptations4,10,22,23,27,29-37. The violence recall period varied, and the last 12 months was the most widely used4,10,21,22,24,27-33,36,37, followed by “in lifetime”25,26,34. The main characteristics of the studies are summarized and shown in Chart 1.

Chart 1 Characteristics of the studies included in the systematic review of intimate partner violence prevalence and its associated factors in the elderly. 

Author, year of publication Year of Collection Location Gender Age Group Sample Size IPV measurement tool
Studies with adults and elderly
Mouton, 200421 NA United States F 50-79 91,749 Own questionnaire
Reichenheim, 200622 2002/ 2003 Brazil F 15-69 6,760 CTS 1
Cohen, 200623 1999 Canada F/M ≥ 15 16,216 CTS 2 + own questionnaire
Aekplakorn, 200724 2005 Thailand F 17-78 580 Own questionnaire
Breiding, 200825 2005 United States F/M ≥ 18 70,156 Own questionnaire
Svavarsdottir, 200926 2005/ 2006 Iceland F 22-67 2,746 WAST
Sareen, 200927 2004/ 2005 United States F ≥ 20 13,928 CTS 1- adapted
Brisibe, 201228 2006 Nigeria F/M 16-65 346 Own questionnaire
Afifi, 201229 2004/ 2005 United States F/M ≥ 20 25,778 CTS 1 - adapted
Sonego, 201330 2009/ 2010 Spain F 18-70 2,835 CTS 1 - adapted + own questionnaire
Renner, 201431 1994 to 1997 United States F/M ≥ 20 1,096 CTS 1- adapted
Hellemans, 201432 2009 Belgium F/M 18-75 1,472 CTS 1 - adapted + own questionnaire
Lee, 201433 2006 South Korea F/M ≥ 30 8,877 CTS 1- adapted
Stöckl, 20154 2003/ 2004 Germany F 16-86 10,264 CTS 2 + own questionnaire
Hellemans, 201534 2011/ 2012 Belgium F/M 18-80 1,448 CTS 1 + WHO VAW
Studies with elderly only
Stöckl, 201235 2003 Germany F 65-86 10,264 CTS 2
Yan, 201236 2004 China F/M 60-100 5,049 CTS 2
Burnes, 201537 NA United States F/M ≥ 60 4,156 CTS 1- adapted
Paiva, 201510 2014 Brazil F/M ≥ 60 729 CTS 1

F = Female M = Male. IPV – Intimate Partner Violence. NA – Not available in the study. CTS – Conflict Tactics Scale. WAST - Woman Abuse Screening Tool. WHO VAW- World Health Organization Violence Against Women.

Evaluation of the methodological quality

Based on the evaluation of the methodological quality proposed by Loney et al.20, among the studies, seven22,27,29,31,33,36,37 achieved high quality; eleven4,10,21,23-25,28,30,32,34,36 obtained moderate quality, and one26 had low quality. Studies developed with samples consisting exclusively of the elderly10,35-37 achieved high or moderate quality, with an overall mean score of 6.5 points, while those with samples composed of adults and the elderly reached an overall mean score of 5.7 points. This positive difference for the group of studies exclusively with the elderly is mainly due to the item that analyzes the similarity of participants with the research question (adequate if there was a description of the subjects under study stratified by age group and similar to the research question). No work achieved the maximum score, and prevalence with a 95% confidence interval (95% CI) the item with the lowest overall mean, both for studies exclusively with the elderly and those that investigated adults and the elderly. Table 1 shows details of the methodological quality evaluation.

Table 1 Result of the evaluation of the methodological quality of the included studies. 

Author, year of publication Sample Sampling Source Sample Size Outcome Measurement Impartial interviewer Response Rate Prevalence CI95% Similar Participants Total
Studies with adults and elderly

High methodological quality
Reichenheim, 200622 1 1 1 1 1 1 1 0 7
Sareen, 200927 1 1 1 1 1 1 0 1 7
Afifi, 201229 1 1 1 1 1 1 0 1 7
Renner, 201431 1 1 1 1 1 0 1 1 7
Lee, 201433 1 1 1 1 1 1 0 1 7
Moderate methodological quality
Mouton, 200421 1 1 1 0 1 1 0 1 6
Breiding, 200825 1 1 1 0 1 0 1 1 6
Stöckl, 201235 1 1 1 1 1 0 0 1 6
Aekplakorn, 200724 0 1 1 0 1 1 0 1 5
Hellemans, 201432 1 1 1 1 1 0 0 0 5
Hellemans, 201534 1 1 1 1 1 0 0 0 5
Cohen, 200623 0 0 1 0 1 1 0 1 4
Brisibe, 201228 1 1 1 0 0 1 0 0 4
Sonego, 201330 1 1 0 1 1 0 0 0 4
Low methodological quality
Svavarsdottir, 2009 26 1 1 0 1 0 0 0 0 3
Total 13 (86.7%) 14 (93.4%) 13 (86.7%) 10 (66.7%) 13 (86.7%) 8 (53.4%) 3 (20.0%) 9 (60.0%) Mean = 5.7

Studies with elderly only

High methodological quality
Yan, 2012 36 1 1 1 1 1 1 0 1 7
Burnes, 201537 1 1 1 1 1 1 1 1 7
Moderate methodological quality
Stöckl, 201235 1 1 1 1 1 0 0 1 6
Paiva, 201510 1 1 1 1 1 0 0 1 6
Total 4 (100%) 4 (100%) 4 (100%) 4 (100%) 4 (100%) 2 (50%) 1 (20%) 4 (100%) Mean = 6.5

0 = criterion not met. 1 = criterion met.

Prevalence of Intimate Partner Violence

In the 19 studies analyzed, 144,10,22-26,31-37 had their prevalence stratified by nature of intimate partner violence (physical, psychological, sexual, controlling behavior, economic abuse), whether isolated4,10,22,23,26,32,33,34,36,37 or combined4,24,25,31,35.

Nine studies identified IPV prevalence according to the nature of the act combined and evidenced the following proportions in the elderly: 14.1% for physical and psychological violence24 among women in the last 12 months; 10-12.9% for physical and sexual violence in women4,25,35 and 5.6% for men, in lifetime25. In papers that showed the nature of violence in isolation, worth highlighting are values of psychological violence in the 60-69 age group (25.5% in women and 21.2% in men) and 70 years+ (24.5% % in women and 20.1% in men).

In studies that investigated only the elderly10,35-37, or these separately from adults4,24,25,29,33, IPV type prevalence ranged from 1.8-5.9% for physical violence10,33,36,37, 1.2% for sexual violence36 and 1.9-36.1% for psychological violence4,10,36,37. We highlight the variation found in coefficients of psychological IPV, since studies used the same measurement tool, namely, the CTS (versions 1 or 2). The country with the highest prevalence was China (36.1%)36, followed by Germany (13%)4, Brazil (5.9%)10 and the United States (1.9%) 37. It is noteworthy that only one study33 investigated in the elderly separately the controlling behavior (21%) and economic abuse (13%) in women aged 66-86 years. In the six studies that identified general prevalence in adults and the elderly, it ranged from 5.5% in the United States28 to 55.8% in Nigeria27.

The phenomenon of intimate partner violence in elderly men was identified in a study by Afifi et al.29, which found a higher IPV prevalence in this population (4.9%) when compared to elderly women (3.3%). In contrast, Breiding et al.25 and Lee et al.33 showed that the perpetration by elderly men is more prevalent than by elderly women, as can be seen in the different percentage measures regarding the nature of IPV, respectively: physical (5.1% versus 1.6%)33; psychological (25.5% versus 21.2%)33; physical and sexual (12.6% versus 5.6%)25. While coefficients are higher in women, there are also significant proportions in men, pointing to the relevance of investigating the occurrence of violence in both genders.

There were methodological variations regarding the nature, severity and directionality (suffered or perpetrated) of the violence investigated, gender of respondents and measurement tools used. The different methods implied heterogeneous prevalence. Chart 2 shows the prevalence identified according to the methodological approach of each study.

Chart 2 Prevalence of intimate partner violence in included studies. 

Author, year of publication IPV recall period Elderly age range IPV prevalence in the sample IPV prevalence in elderly
Studies with adults and elderly
Mouton, 200421 Last 12 months 50-79 years General - 11.1% NA
Reichenheim, 200622 Last 12 months NA Psychological - 75% NA
Physical minor - 21.5%
Physical severe - 12.9%
Cohen, 2006 23 Last 5 years ≥ 55 years Physical/woman - 7.8% NA
Physical/men - 6.6%
Sexual/woman - 1.4%
Psychological/woman -17.7%
Psychological/man -18.2%
Financial/woman - 7.5%
Financial/man -1.4%
Aekplakorn, 2007 24 Last 12 months ≥ 55 years Physical and psychological - 27.2% Physical and psychological - 14,1%
Breiding, 200825 Lifetime ≥ 65 years Physical and sexual/woman - 26.4% Physical and sexual/woman - 12,9%
Physical and sexual/man - 15.9% Physical and sexual/man - 5,6%
Svavarsdottir, 2009 26 Lifetime NA Physical/married - 2.0% NA
Physical/ cohabiting - 3.3%
Psychological/married - 16.7%
Psychological/cohabiting - 18.2%
Sexual/married - 1.2%
Sexual/live together - 1.3%
Sareen, 200927 Last 12 months NA General - 5.5% NA
Brisibe, 201228 Last 12 months NA General- 55.8% NA
Afifi, 201229 Last 12 months ≥ 65 years Victimization; Perpetration Victimization; Perpetration
General/women – 5.5%; 7.0% General/women – 3,3%; 3,5%
General/men – 5.8%; 4.2% General/men – 4,9%; 6,8%
Sonego, 201330 Last 12 months NA General - 12.2% NA
Renner, 201431 Last 12 months NA Physical and emocional/woman - 50.9% NA
Physical and emotional/man - 40.0%
Hellemans, 201432 Last 12 months NA Physical - 1.3% NA
Sexual (women) - 0.3%
Psychological - 14.0%
Lee, 201433 Last 12 months ≥ 60 years Victimization; Perpetration Victimization; Perpetration
Verbal/ woman Verbal/ woman
General - 28.2%; 26.7% 60-69 years - 25,5%; 22,8%
>70 years - 24,5%; 20,9%
Verbal/ man Verbal/ man
General - 24.4%; 25.0% 60-69 years - 21,2%; 23,5%
>70 years - 20,1%; 21,4%
Physical/ woman Physical/ woman
General - 6.9%; 3.4% 60-69 years - 5,1%; 1,4%
>70 years - 3,1%; 1,0%
Physical/ man Physical/ man
General - 3.4%; 5.1% 60-69 years - 1,6%; 3,7%
>70 years - 1,0%; 2,6%
Stöckl, 20154 Last 12 months 66-86 years Physical or sexual Physical or sexual
16-49 years - 8% 66-86 years - 1%
50-65 years - 3%
Psychological Psychological
16-49 years 13% 66-86 years - 13%
50-65 years 13%
Controlling behavior Controlling behavior
16-49 years 21% 66-86 years - 21%
50-65 years 21%
Economic abuse Economic abuse
16-49 years 12% 66-86 years - 13%
50-65 years 14%
Hellemans, 201534 Lifetime NA Physical - 10.0% NA
Psychological - 56.7%
Studies with elderly only
Stöckl, 201235 Current, last year, last 5 years and in lifetime 50-86 years Physical and/or sexual in life Physical and/or sexual in lifetime
General - 18% 50-65 years: 23%
66-86 years: 10%
Physical and/or sexual in the last 5 years Physical and/or sexual in the last 5 years
General - 2% 50-65 years: 3%
66-86 years: 1%
Physical and/or sexual in the last year Physical and/or sexual in the last year
General - 1% 50-65 years: 2%
66-86 years: 0%
Physical and/or sexual in the current relationship Physical and/or sexual in the current relationship
General - 11% 50-65 years: 14%
66-86 years: 5%
Yan, 201236 Lifetime; last 12 months 60-100 years Lifetime; last year
Physical - 6.6 %; 2.5%
Sexual - 3.2%; 1.2%
Psychological - 53.6%; 36.1%
General - 7.7%; 2.9%
Burnes, 201537 Last 12 months ≥ 60 years Psychological Psychological
General - 1.9% 60-69 = 0,9%
70-84 = 0,8%
> 85 = 0,1%
Physical Physical
General - 1.8% 60-69 = 1,0%
70-84 = 0,6%
> 85 = 0,2%
Paiva, 201510 Last 12 months 60 years Physical Physical
General - 5.9% 60-80 = 6,4%
> 85 = 3,8%
Psychological Psychological
General - 20.9% 60-80 = 22,1%
> 80 = 15,0%

Factors associated with intimate partner violence

Alcohol use4,24,26,28,29,33,36 was the most frequent factor associated with IPV, followed by depression26,30-32. More specifically, there was a positive association with violence, tobacco use21,26, tranquilizers32 and other drugs29, as well as anxiety35, stress38, sleep and eating disorders29.

Regarding the sociodemographic and economic factors, worth highlighting are low income21,23,24,37 and low schooling22,25,37, being divorced/separated23,37 and being a young elderly10,37. With respect to conditions related to physical health, functional impairment10,37, poor health assessment23 and HIV infection27 were associated with IPV.

Previous exposure to violence was analyzed by two studies35,36, and both found an association between IPV and having witnessed parental violence in childhood. Stöckl et al.35 linked the occurrence of physical and sexual violence among 55-65 year-olds to having suffered physical violence in childhood or violence by an aggressor other than their partner, indicating a possible perpetuation of life-threatening violence.

Most studies4,10,21,23-27,29-37 have employed regression analysis models. All the results presented were statistically significant. IPV-associated factors are shown in Table 2.

Table 2 Factors associated with Intimate Partner Violence according to the studies analyzed. 

Factors associated with intimate partner violence Papers that evidenced the associated factor n (%)
Health-related behaviors
Alcohol use 7 (36.9%)
Tobacco use 2 (10.6%)
Use of other drugs 1 (5.3%)
Mental health conditions
Depression 4 (21.0%)
Stress 2 (10.6%)
Use of tranquilizers 1 (5.3%)
Sleep disorders 1 (5.3%)
Anxiety 1 (5.3%)
Physical health conditions
Functional impairment 2 (10.6%)
HIV infection 1 (5.3%)
Gastrointestinal and pelvic symptoms 1 (5.3%)
Sexual dysfunction 1 (5.3%)
Poor health evaluation
Economic and sociodemographic factors
Low income 4 (21.0%)
Low schooling 3 (15.8%)
Being divorced / separated 2 (10.6%)
Being a young elderly 2 (10.6%)
Women schooling higher than her husbands 1 (5.3%)
Being single 1 (5.3%)
Living with spouse 1 (5.3%)
Previous exposure to violence
Witnessing parental violence in childhood 2 (10.6%)
Suffering physical punishment in childhood 1 (5.3%)
Suffering physical or sexual violence by non-partner 1 (5.3%)

Discussion

In this review, we highlight the occurrence of intimate partner violence in elderly men and women, with psychological violence and economic abuse being the most prevalent in this age group. The most frequent associated factors were alcohol consumption, depression, low income, functional impairment and exposure to violence in childhood.

National and international studies evidenced a relevant production between 2004 and 2015, mainly in Europe and the United States. This predominance may be related to the fact that these locations have a greater number of journals indexed in the databases consulted38 and specific journals on elder violence, but also because these countries have a higher proportion of elderly people, where factors related to aging are more investigated. The Latin American publication on this topic is incipient, represented by two Brazilian studies10,22.

IPV measurement was performed primarily through Conflicts Tactics Scale - FORM R (CTS-1)39, which assesses physical and psychological violence, and Review Conflicts Tactics Scale (CTS-2)40, which measures physical, sexual, and psychological violence. While the CTS tool is not specific to the elderly population, it meets the validity and reliability criteria, which gives reliability to the studies41. Economic abuse and controlling behavior among intimate partners, which were relevant in the elderly, were measured by their own questionnaires due to the lack of validated tools. Thus, it is necessary to develop and validate tools that include such violence between intimate partners to better understand the phenomenon in this population.

The methodological quality of the studies was considered moderate and high, which reinforces the reliability and representativeness of the results of the analyzed populations. The mere selection of population-based studies contributed to the quality achieved, since most studies met the three criteria for sample evaluation.

The comparison of prevalence was difficult due to studies’ methodological diversity, related to both tools used and the types of review, which were stratified by different variables such as gender, age group, nature, intensity and directionality of violence. Espíndola and Blay41, when investigating elder abuse in a review study, identified such diversity of information. However, the prevalence shown in the studies (Chart 2) indicate the relevance and magnitude of IPV in the elderly.

The various possibilities of combining the nature of violence (physical, sexual, psychological, controlling behavior and economic abuse) in research show the cruel setting of the phenomenon and limits comparison between studies. Even with this difficulty, analyzed studies4,10,23,24,32,34,36 point to high prevalence that have stratified IPV according to their nature.

However, it is assumed that intimate partner violence in the elderly is not unique to this age group, since violence is a relational process, probably established in adulthood, perpetuating in lifetime. Rennison and Rand42 argue that prevalence of physical and sexual violence declines among the elderly, but psychological violence persists and may even increase in frequency and severity42,43.

Among the studies analyzed, the economic abuse identified by Stöckl et al.35 stands out, with a prevalence of 13% among 66-86 year-olds in Germany. It is understood that hardships inherent to aging, such as dependence on family and, consequently, intimate partners can exacerbate this elderly’s exposure to both financial exploitation situations and physical and psychological violence. This setting occurs domestically and tends to perpetuate, with the possible aggravation of both violence and health conditions of the elderly. Kwong et al.44 corroborate the finding and point out that violence has deep cumulative effects in lifetime, which scale-up in this period of greater physical and emotional vulnerability.

Papers of this review highlight the violence identified in both genders24,28,32. These results emphasize the fact that there are people in situations of violence, both men and women, who may suffer or perpetrate it in an intimate relationship, and such findings are also found in other studies45-48.

Men were identified in the review as victims of intimate partner violence in two studies28,32, and in one of them28, there was a higher prevalence (4.9%) of IPV in men than in women (3.3%). According to Afifi et al.49, IPV against men in the literature in general is still scarce and, when investigated, it is only focused on these as aggressors. Lindner et al.50 affirm that it is relevant to investigate man not only as the perpetrator of violence, but also as a victim. One constraint reported by Carmo et al.51 was that men would tend to hide the assault suffered, since exposure would break with social gender roles, which attribute them characteristics of invulnerability and virility, thus contributing to the underreporting of this type of violence. Factors that permeate these relationships must be evidenced and disseminated, so that they may translate into the implementation of public policies geared to men and women in situations of violence.

Among factors associated with elder violence, alcohol use was the most identified in the studies of this review4,23,25,27,28,32,35. According to these findings, Nagassar et al.52 affirm that alcohol and other drugs abuse is one of the main reasons for physical violence, as well as a factor associated with an increased likelihood of violent acts52,53. It can be assumed that the intake of alcoholic beverages would be a strategy adopted by the victims to deal with stress caused by the context of violence52,54. One research evidence55 indicates that heavy drinking contributes to violence, but this does not mean that alcohol is a primary, necessary and sufficient condition for violence. Thus, alcohol would not determine such behaviors, but would contribute to their manifesting more intensely or severely.

Depression was also a factor associated with IPV in this review, such as Renner et al.31, who found higher likelihood of victims suffering from depressive symptoms, both for men (2.4 times) and women (3.0 times) when compared with those who did not suffer violence. However, abuse perpetration was associated with increased depressive symptoms for women, not for men. Even if cross-sectional studies cannot establish a causal and temporal relationship between the facts, longitudinal studies show that IPV can lead to depression56, as well as precede or facilitate situations of violence57.

Functional impairment was associated with IPV in two analyzed studies10,36, stating that violence may increase vulnerability, leaving the elderly with reduced ability to defend themselves against ill-treatment. They also consider that the reduced functional capacity for instrumental activities of daily living (IADL) limits the independent social participation of the elderly, restricting contact with other people, besides relatives or caregivers who live together, hindering the search for health services and specialized services to report to when subjected to violence.

It is noteworthy that only one paper26 of this review addressed HIV-IPV association, but this study did not separate adults and the elderly, and there were gaps in the specific issues among older people, and research on the subject is relevant. Alencar and Ciosak59 point out that the investigation of anti-HIV serology for the elderly is not routine in the primary health care services. Elder sexuality is made invisible by health professionals because they do not consider that they can be sexually active, and the investigation of sexual health is not part of routine consultations. However, in Brazil, the number of elderly people (> 60 years) corresponded to 2.5% of those infected in 2002, increasing to 5.0% in 2013. Increased HIV epidemic among the elderly has also occurred worldwide59,60.

Low income20,21,23 and low schooling21,24,36 are factors associated with IPV in the elderly, since they trigger conflicts between the intimate partners23. However, one study34 found that older people aged 66-86 are more likely to be in a situation of violence when women have professional qualifications and men have high schooling. One hypothesis is that because of greater empowerment of women, them would be more independent than the partner and could challenge traditional gender roles, increasing the risk of violence61,62.

A striking part in this study is that, in the papers reviewed, previous exposure to violence, such as witnessing parental violence10,35 or suffering physical punishment in childhood35 was associated with IPV in the elderly. Paixão et al.63 corroborate this finding when analyzing the intergenerationality of spouse violence experienced by women, stating that there is a relationship between violence witnessed in the family of origin and intimate partner violence. Violence intergenerational effects trigger their lifelong permanence, and the high prevalence of IPV in adulthood certainly contributes to their perpetuation in old age45.

As this systematic review of IPV in the elderly is unprecedented, information is provided to broaden knowledge about the phenomenon, aiming to contribute to the establishment of actions and strategies to prevent violence by elderly intimate partners. It is important to carry out new epidemiological studies with representative samples of the elderly population to investigate IPV prevalence and associated factors, which addresses the directionality of violence suffered and perpetrated between men and women.

In order to give visibility to the nature of the most prevalent IPV among the elderly, we suggest developing and validating specific tools for this population group, which include economic abuse and controlling behavior among intimate partners, given their relevance in this age group. The specificities and vulnerabilities of the elderly should be taken into account, with further analysis of issues regarding mental health, sexual health and functional disability, which are still incipient in the literature on IPV in this age group.

However, some limitations can be pointed out in this review. The low number of scientific publications on the subject in the elderly population stands out. In addition, we note that information is available from studies with methodological limitations, due to the non-stratification of results between adults and the elderly. Most studies were conducted from self-reported interviews as a way to keep respondents’ privacy and confidentiality. However, this type of evaluation is subject to memory bias, over or underestimation of the fact, as well as fear or shame of exposing to the interviewer situations of violence experienced in the intimate relationship.

Noteworthy is publication bias, which may occur due to the non-publication of studies in indexed journals due to the limited number of papers per journal, language, methodology, among others. With regard to the very heterogeneous characteristics of the studies found, we only conducted a qualitative evaluation of the results and quantitative data synthesis was not possible through meta-analysis.

This review shows a method according to the current recommendations for the elaboration of systematic reviews, such as comprehensive sources search, specific search strategy, no language restrictions or publication period, selection and extraction of data in pairs and evaluation of the methodological quality of the studies included. The adoption of these measures shows relevant results, which provide an overview of national and international scientific knowledge produced on prevalence and factors associated with intimate partner violence in the elderly.

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Received: March 01, 2017; Accepted: April 18, 2017; Revised: May 22, 2017

Collaborations

D Warmling participated in the design, search, review and interpretation of the result and final writing. SR Lindner participated in the search, review and interpretation of result and final writing. EBS Coelho participated in the design, review and interpretation of results, critical review and approval of final version.

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