di
Anna Giulia Cattaneo - DBSV - University of Insubria - Varese - Italy.

According to WHO's estimate, 25% of elder people have cognitive impairment or dementia, 4-6% of older persons have suffered some form of maltreatment at home, and this trend seems to increase in countries which experience rapid increase in aged population. Since elder population is expected to increase worldwide, special attention should be given to prevention of abuse at home and institutional environments. The problem is not limited to the individual level, but it involves the community, and the strategies eventually developed to limit the abuse must be taking into account social and cultural aspects. The mistreatment is followed by increased incidence of side effects of drugs, orthopaedic and emergency accidents, development of sore pressure, rapid and progressive decline, and enhanced frequency of mental conditions, such as depression and suicidal thinking. Poorly recognized forms of abuse and neglect include inappropriate prescription of hypnotic medicaments and non-adherence to the therapy in those living at nursing home or having professional caregivers, not reported abuse, and self-neglect . This last could be especially insidious and threatening, especially for seniors living alone. It was found associated with very high rate of admission to the Emergency Care and with enhanced mortality rate within one year. The aspects of abuse, in all its forms, and of its prevention, are very different in different regions of the world.

The industrialized countries display a number of law, organization and facilities to face the problem, and however it still remains living, as demonstrated by recent studies. The Chicago Health and Aging Project, Illinois, USA, registered a prevalence of recognized abuse in older people as high as 15‰. This data was very similar to that obtained in a previous cohort study in the New Heaven population, in which a prevalence of 12‰ of abused was found among the older people. The utilization rate at the Emergency Department was higher in those at risk of abuse (2.1 vs 0.7%) and cognitive decline was an important risk factor. The rate of self-neglect, from subjects included in the same study, was about ten times higher, and was charged with higher utilization of the Emergency Department, higher mortality within 1 year and higher need of hospice utilization. The self-neglect was 4 times more frequent in black than in whites. The type of abuse more perceived was the psychological one, in comparison with financial, physical and sexual. While the childhood remained the age of life more exposed to violence, people which was abused early in life tended to suffer repeated violence at different ages, especially in the elderly. In Milwaukee County, Wisconsin, USA, the profile of elder at risk to became a victim of abuse was to be older then 75 (64%), woman (64%) and white (62%). The aggressors were more often adult children or spouses and the condition was frequently reported by the medicine professional or relatives. A true statistic concerning the dimensions of the phenomenon in Canada seems to be completely lacking in the country, at least until 2011, because of the institutional tendency to forget or even cover the problem, in the UK the rate of abuse is underreported by both the patients and the caregivers. This is the only result retrieved in the PubMed for European Countries, searching for "neglect" or "abuse" or "mistreatment" in aging people.

The First National Prevalence Survey in Israel (2004-2005) revealed a prevalence of abuse among people aged 65 yrs and more reaching 18%. The violence was mainly verbal, followed by financial exploitation. Data were evenly distributed among Arab and Jews populations. Women were more prone to be victims, and Arab women the most vulnerable. Partner with mental and social ineptitude, or unemployed, adult children were the most frequent types of perpetrators.

In Asia, a ten-year observational study, aimed to induce the governments to better surveillance, reported the following picture. Several countries, Hong Kong and Thailand among others, adopted measures to encourage the taking care of elder by younger relatives, and to discourage neglect or abuse. In other, abuse on elder people is punishable by law, but in several cases the low is only valuable for old women, being a special comma of lows protecting the females. In Singapore psychological or emotional, financial, physical, and sexual abuse is prosecutable by law, but the PubMed does not report published studies on the extent of the phenomenon. Protected homes for older needing help existed in Philippines before 1999. In 1990-2004 the Philippine Plan of Action for Older Persons included measures against abuse, neglect and marginalization, and in 2009 interventions to involve seniors in the social life of the country were planned by the government. The China promotes measures to improve the quality of life of older people. Social measures include involvement in productive activities, insurances, social integration and independent life style. Abuse and abandonment are also seriously considered by penal law, however, the modalities for obtaining help are poorly known by the patients and by their relatives or taking-care. A recent study reported a prevalence of abuse as high as 36% in a rural town of the Hubei province. Psychological mistreatment is predominant (27%), and it is also the form of abuse more perceived by those suffering from it. The India does not have a legislation specifically aimed to the protection of the elderly, but the level of attention is growing, also in the Academic environment. The Maintenance and Welfare of Parents and Senior Citizens, issued in India in 2007, was aimed to encourage the support of the oldest by the younger family members. Only five Indians states out of 28 have initiated a full integration of the Act in the legislation, additional 11 have started but not completed the process. Other laws, however, limits mistreatment against elder people. The abuse and neglect against residents in hospices and nursing homes fall under an ancient treaty, the Indian Contract Act, but the families are often unaware of it.

In conclusion, the abuse and neglect of older people seems to be an important criminal act seriously affecting the wellness of the frail patient as well that of the society. It not only reduces the self esteem of the society which tolerate and even justify these behaviour, but also imposes to it expensive interventions and treatments to repair to the damage. As the population is aging, a coordinated, decisive and harmonious intervention at social and cultural level seems to be unavoidable and urgent.

REFERENCES
Dong et al., Gerontology, 2012, 58(3):258-268. doi: 10.1159/000334256.
Lachs et al., 1996, Arch Intern Med. 156(4):449-453.
Lowenstein et al., 2009, J Elder Abuse Negl. 21(3):253-277. doi: 10.1080/08946560902997629.
McDonald & Thomas, 2013, Int Psychogeriatr., 27:1-9
McDonald, 2011, Can J Aging. 30(3):437-465. doi: 10.1017/S0714980811000286.
Shankardass MK. 2013 Int Psychogeriatr., 4:1-6.
Thomson et al., 2011, WMJ, 110(6):271-276.
Wu et al., 2013, PLoS One. 2012;7(3):e33857. doi: 10.1371/journal.pone.0033857.