Archives of Gerontology and Geriatrics 42 (2006) 307–318

www.elsevier.com/locate/archger

Psychological abuse and its characteristic

correlates among elderly Taiwanese
Jing-Jy Wang *
Department of Nursing, Fooyin University, 151 Chinh-Hsuen Road, Ta-Liao Hsiang,
Kaohsiung Hsien 831, Taiwan ROC
Received 22 March 2005; received in revised form 15 August 2005; accepted 17 August 2005
Available online 7 October 2005

Abstract

This study examined the prevalence of psychological abuse and identified individual character-
istics associated with different levels of psychological abuse in a group of randomly selected elderly
Taiwanese. A cross-sectional design was performed that utilized a descriptive-correlational
approach. Data for this study were gathered from several communities in southern Taiwan. The
sample comprised 195 elderly Taiwanese aged 60 years or older, capable of verbal communication,
and partially dependent on a caregiver. The Psychological Elder Abuse Scale (PEAS), the Short
Portable Mental State Questionnaire (SPMSQ), and the Barthel’s Index were used for data collection.
The findings demonstrated that the PEAS score range was 0–24 (mean 6.32  4.6). Moreover, 44
subjects (22.6%) had scores of ten or greater. The most frequently reported indicators in the PEAS
were ‘‘wishes to see family members unfulfilled’’ and ‘‘economic dependence on others’’. The
analytical results also showed that the SPMSQ and Barthel’s Index scores were strongly related to the
PEAS score ( p < 0.001), indicating psychological abuse appeared higher among elderly people with
lower cognitive and physical functioning. The findings of this study are crucial in developing a
national system for protecting the elderly, and a continuing educational plan is required for enforcing
communication between caregivers and elders.
# 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Psychological elder abuse; Cognitive functioning; Physical functioning

1. Introduction

According to the Department of Economic and Social Affairs of the United Nations, the
older population is itself aging, with the 80 years or older segment now having become the

* Tel.: +886 7 7811151x601; fax: +886 7 7836719.

E-mail address: ns127@mail.fy.edu.tw.

0167-4943/$ – see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.archger.2005.08.006
308 J.-J. Wang / Archives of Gerontology and Geriatrics 42 (2006) 307–318

fastest growing sector of the older population. Although abuse and neglect of the elderly is
not a new phenomenon, the literature only began candidly discussing this subject as a
social problem in the 1970s both in eastern and western countries (Choi and Mayer, 2000;
Jamuna, 2003). Importantly, the problem is likely to grow in the future, with predicted
rapid growth of the elderly population worldwide, who perhaps face the highest risk of
abuse and neglect. Based on a review of the previous literature, although most discussions
of abuse of the elderly have discussed physical abuse, which frequently leaves visible scars,
bruises, or broke bones, numerous discussions have also included emotional or
psychological abuse, which inflicts anguish, pain, or distress through verbal aggression,
threats, intimidation, insults, humiliation, and harassment, and can be both intentional or
unintentional (Choi and Mayer, 2000). Abuse, regardless of its form, is largely a hidden
problem since both those abused and the perpetrators frequently feel ashamed and thus hide
the incidents from investigators. However, most studies from developed countries have
found that the most common types of maltreatment of the elderly are neglect and
psychological or emotional abuse (Soeda and Araki, 1999; Goergen, 2001; Vida et al.,
2002).
In Taiwan, physical abuse of elders is socially unacceptable and, since 2002, elderly
protective services have been provided in accordance with the Elderly Welfare Protection
Law (Ministry of Interior, 2002). However, special attention should be drawn to the more
common but harder to identify ‘‘psychological abuse of elders’’, as discussed by Choi and
Mayer (2000). However, cases of psychological abuse of the elderly are being missed
because only cases of visible physical abuse are typically reported to the relevant
governmental agencies. Psychological abuse can only be identified by observing day-to-
day interactions. As Johnson (1995) stated, psychological abuse may be especially difficult
to define because it lacks concrete behavioral criteria. Several reasons exist for the paucity
of empirical research on psychological abuse of the elderly in Taiwan. First, most
governmental officials only considered the detection of obvious physical abuse. Second,
researchers feared that if their research revealed evidence of abuse of the elderly in
domestic or institutional care, their work would be perceived as accusing family or staff
caregivers of emotional mistreatment of their charges. Third, elderly Taiwanese who have
been abused may be reluctant to report such abuse because of being dependent on their
abuser (mostly their own children) for their basic survival. Furthermore, some abused
elderly people may fear removal from their homes or being institutionalized, whereas
others fear abandonment or subsequent reprisals. Because little literature exists examining
the level of psychological abuse and its related factors among elderly Taiwanese, this study
attempts to achieve two objectives: (1) to examine the prevalence of psychological abuse of
the elderly in Taiwan, (2) to identify personal characteristics associated with abuse.

1.1. Prevalence

Studies in the United States showed that roughly 3.2–10% of adults aged 65 years and
older had experienced all types of abuse (Pillemer and Finkelhor, 1988; Podnieks et al.,
1990; Jones et al., 1997). Moreover, Jones et al. (1997) reported a figure of 68% of elderly
adults having been psychologically abused. Another investigation reported that 81% of
institutional staff claimed to have witnessed psychological abuse (Pillemer and Moore,
 J.-J. Wang / Archives of Gerontology and Geriatrics 42 (2006) 307–318 309

1989). Furthermore, a 4–16% prevalence of abuse or neglect was found in Canada, with
1.4–6% being chronic verbal aggression (Podnieks et al., 1990; Vida et al., 2002).
Psychological abuse towards elderly residents appeared common among Canadian and
American nursing care staff, and up to 36–40% of staff admitted psychologically abusing
residents (Pillemer and Finkelhor, 1988; Pillemer and Moore, 1989; Beaulieu, 1992). In
European countries, Hydle (1993) reported a 1–8% prevalence of abuse by close relatives
from a investigation carried out in Denmark, Finland, and Sweden. Moreover, in the
Netherlands, Comijs et al. (1998) reported a prevalence of 5.6% prevalence in a random
sample of 1797 elderly persons, as well as a 3.2% prevalence of verbal aggression. In
Ireland, a 3–5% prevalence of elderly abuse was found (O’Neill et al., 1990; O’Loughlin
and Duggan, 1998). In Germany, Hirseh and Brendebach (1999) found a 5-year abuse
prevalence of 10% via a postal questionnaire sample of elderly living in Bonn, generally
psychological and financial abuse. Additionally, Goergen (2001) reported that 79% of
caregivers had abused or neglected a resident at least once during the previous months, and
66% of them had witnessed victimization of residents by colleagues. Furthermore, a
Swedish study found that 11% of the nursing staff were aware of situations of abuse of the
elderly, and 2% admitted having themselves been abusive towards elderly residents
(Saveman et al., 1999). Additionally, in New Zealand, Weatherall (2001) discovered that
92% of health care managers identify at least one resident who had been subjected to abuse
during the last year, generally psychological abuse. In Asian countries such as Japan, Tyan
(1994) reported a prevalence of abuse of the elderly of approximately 4%. To summarize,
abuse of the elderly in developed countries has been reported in 1–10% prevalence of
communities of elderly people, with psychological abuse being the most common type.
However, accurate figures do not exist for the developing world. In Taiwan, a governmental
administration report demonstrated that around 10% of adults aged 65 years and older had
experienced abuse, and 15% worried about being abused (Lo et al., 2001), but forms of
abuse were not specified. However, in 2001, total abuse of the elderly referrals received by
governmental agencies were below 1000 cases for the whole of Taiwan, which is clearly an
under-estimate (Ministry of Interior, 2001). Therefore, besides reports received by
individual local governments, the only reliable sources of evidence are crime records,
journalistic or news reports, social welfare records, and case studies. Data regarding this
subject was not systematically collected from Taiwan.

1.2. Characteristic correlates

Some of the key factors related to residential abuse of the elderly include the residential
setting environment, the staff characteristics, and the resident characteristics (including
cognitive impairments and communication difficulties). Most western studies found that
the indicators of frailty and dependency among the elderly were significant predictors of
mistreatment (Coyne et al., 1993; Lachs et al., 1997; Comijs et al., 1999; Saveman et al.,
1999; Soeda and Araki, 1999). Restated, older age, impairment of activities of daily living
(ADLs), and cognitive deficits are associated with increased vulnerability to mistreatment.
The two studies by Soeda and Araki (1999) demonstrated that 42.4 and 57.6% of abused
elderly individuals are demented, indicating that the demented elders are abused more than
the normal elders. Additionally, their work found that between 72 and 81% of abused
310 J.-J. Wang / Archives of Gerontology and Geriatrics 42 (2006) 307–318

elderly people are moderately to severely dependent on their caregivers. The other aspect
of this problem is that a high proportion of individuals with cognitive impairment are
abusive towards their caregivers (Kitchen et al., 2002). Personal characteristics identified in
the literature to be prevalent among victims of abuse include female gender, minority
status, living arrangement, family relationship, and socioeconomic status. Saveman et al.
(1999) reported that two thirds of victims of abuse were women, and moreover the average
age of victims of abuse was 81 years, and most such victims had more than one handicap/
disability, for example dementia, mobility disorders, or behavioral disorders. In Japan,
daughters-in-law have been identified as the main perpetrators of elderly abuse.
Meanwhile, among the abused, over 70% are women and the majority are aged over 80
years old. Vida et al. (2002) found that patients living with non-spouse family, friends, or
others were considerably more likely to have suffered abuse than were those living with
their own spouse or in a supervised setting. Matthias and Benjamin (2003) found that
family ties played a significant role in abuse of the elderly. In Canada, ecological studies
suggest that communities with high rates of referral for cases of abuse of the elderly tend to
display lower socioeconomic status (Vida et al., 2002). In Taiwan, Chung and Jang (2000)
analyzed the characteristics of 85 elderly people referred as victims of abuse from the
Taipei City Domestic Violence Protection Center, and found that female sex, age 75 years
and older, being widowed, living at home with adult children and grandchildren, poor
health, economic dependency, and impaired physical and functional ability were
significantly correlated to abuse of the elderly.

1.3. Effect of abuse on psychological health

Reported correlates of and risk factors for abuse of the elderly are complex and vary
with investigation objectives, types of abuse, samples and methods. Several studies had
confirmed that the abuse was markedly attributed to the stress associated with caregiving
and poor relationships between caregivers and the abused (Soeda and Araki, 1999; Vida
et al., 2002). Regarding the psychological effects of maltreatment, some studies found that
abused elderly individuals displayed significantly higher rates of depression than
nonabused elders (Bristowe and Collins, 1989; Pillemer and Prescott, 1989). Other
consequences of psychological abuse include helplessness, posttraumatic stress disorder,
or feelings of guilt, shame, and fear (Wolf, 1997). Therefore, preventive programs should
be initiated to assist elderly people at risk of abuse.

2. Subjects and methods

A cross-sectional design utilizing the descriptive-correlational approach, the face-to-

face administration of study instruments and direct observation were used for this study.

2.1. Setting and sampling

The data was collected by random sampling. Data for this study were obtained from
several communities located in Kaohsiung and PingDong County. The sample comprised
 J.-J. Wang / Archives of Gerontology and Geriatrics 42 (2006) 307–318 311

99 institutionalized (50.8%) and 96 domestic (49.2%) adults aged 60 years or older,

capable of verbal communication, and partially dependent on a caregiver.

2.2. Instruments

The Psychological Elder Abuse Scale (PEAS) (Wang et al., 2005) was developed by the
investigator previous to this study for assessing level of psychological abuse of elders,
because no such instruments are available for use in Taiwan. This instrument was mainly
developed in Chinese. The PEAS is a 32-item scale based on a yes/no response format, which
is user-friendly for older adults. The PEAS was relatively easy to administer, and took just
10 min. The total psychological abuse scores of the subjects were calculated as the sum of all
items answered in the affirmative, with a higher score indicating greater psychological abuse.
A cut-off point of 10 or above suggests a greater likelihood of psychological abuse. The
expert content validity index (CVI) for the PEAS was 0.92. Furthermore, the test–retest
reliability of the PEAS was established, with the percentage agreement between two
interviewers ranging from a high of 100% for seven indicators to a low of 79% for one
indicator. Most indicators had significant Kappa values, exceeding 0.60.
A Short Portable Mental State Questionnaire (SPMSQ) (Pfeiffer, 1975) with high
validity and test–retest reliability was used. This was a 10-item questionnaire designed to
measure several intellectual domains, including general information, orientation, short and
long-term memory, and problem solving. The total score of the SPMSQ ranged from 0 to
10. A total score of eight and above represented intact cognitive functioning; 6–7 denoted
mild cognitive impairment; 3–5 indicated moderate cognitive impairment; and 0–2
represented severe cognitive impairment. The Chinese version of the SPMSQ was
validated in several studies, and the Cronbach’s alpha of the SPMSQ Chinese version was
0.70 (Chi and Boey, 1993; Chou, 2002).
The Barthel’s Index (Mahoney and Barthel, 1965) was a highly validated and
widespread instrument for assessing disability in activities of daily living (ADLs). This
instrument includes 10 tasks of self-care and physical functioning ability. The total score of
the Barthel’s Index ranged from 0 to 100. A total score of 100 represented total
independence; 91–99 denoted mild dependence; 61–90 indicated moderate dependence;
21–60 represented severe dependence; and 0–20 denoted total dependence. A Chinese
version of the Barthel’s scale was established earlier by Dai et al. (1995).

2.3. Data collection and analysis

Study sites included several community institutions and domestic homes. Residents
from all study sites who met the study criteria were recruited as potential subjects. The
researcher randomly selected potential subjects from the study sites. Then, an institutional
and home visit was made for each subject. Before the visit, the purpose of the study was
explained and the consent form signed. Following subjects were recruited, structured face-
to-face interviews and direct observation were used to administer the study instruments.
Data was collected between January 2002 and June 2003. A total of 195 subjects completed
the study. The PEAS was administered to each participant together with the SPMSQ and
the Barthel’s index and the collection of demographic information. Data entry and analysis
312 J.-J. Wang / Archives of Gerontology and Geriatrics 42 (2006) 307–318

was performed using the SPSS 12.0 statistical software package. Mean, standard deviation,
frequency, percentage, and Pearson’s correlation were used for data analysis.

3. Results

3.1. Demographic characteristics

The sample comprised 88 males (45.1%) and 107 females (54.9%), with ages ranging
from 60 to 96 years (mean 77.9  7.6). Among the subjects, 44.1% were illiterate, and only
10 had completed a college education. Most of the participants were widowed (50.8%);
39.5% were married. Most of the subjects were born in Taiwan (75.4%), and the remainder
were immigrants from the Chinese mainland. The average number of chronic diseases per
subject was 2.2  1.6 (S.D.) (range 0–7). About 61% of the subjects had a reasonable income.
Of the 96 elderly subjects living at home, 46 were cared for by their children, 26 by spouses,
12 by in-laws, and the rest by paid-employment or other means, and 52% lived with their own
children or grandchildren. Table 1 lists the demographic characteristics of the subjects.

3.2. Prevalence of elder psychological abuse

The PEAS score range for the 195 subjects was 0–24 (mean 6.32  4.6). Moreover, the
distribution of the overall scores was positively skewed. Forty-four subjects (22.6%) had
scores of 10 or above. Regarding the 32 indicators, 62.6% of the subjects reported ‘‘wishes
to see relatives unfulfilled’’, 61% reported having ‘‘Economic dependence on others’’,
44.1% reported having ‘‘Poor sleep for unknown reasons’’, and 40.5% reported being
‘‘Left alone involuntarily’’. Additionally, between 25 and 31% of the subjects reported
‘‘Excessive dependence on caregiver’’, ‘‘Low self-esteem’’, ‘‘privacy not respected’’, and
‘‘Feeling emotionally confused, dispirited and anxious’’. The above eight indicators were
most frequently reported by the study subjects (Table 2).

3.3. Association between level of abuse and personal characteristics

The mean PEAS for the institutionalized subjects was 5.83  4.9, compared to
6.83  4.2 for the domestic subjects, revealing no significant difference (t = 1.53,
p = 0.12). Pearson correlation analysis revealed no significant correlation between the
PEAS and subject age, educational level, and number of children. However, number of
chronic diseases was significantly related to the PEAS (r = 0.23, p = 0.001), indicating that
individuals with chronic disease may experience more psychological abuse from their
caregivers. Chi-square test also indicated that subjects’ social economic status significantly
influenced level of psychological abuse ( p = 0.005). Additionally, the correlation between
overall SPMSQ and the PEAS score was 0.32 ( p < 0.001), indicating that experience of
psychological abuse increased with subject cognitive impairment. Furthermore, subject
dependence status, as indicated by the Barthel’s index, was also significantly related to the
PEAS (r = 0.362, p < 0.001), indicating that the level of psychological abuse increased
with the functional dependence of individuals.
 J.-J. Wang / Archives of Gerontology and Geriatrics 42 (2006) 307–318 313

Table 1
Demographic characteristics of the subjects (N = 195)
Variables Frequency Percentage
Gender
Male 88 45.1
Female 107 54.9
Age (year)
60–75 76 39.0
75–85 86 44.1
Over 85 33 16.9
Education (year)
0 86 44.1
1–5 26 13.3
6–9 55 28.2
9–12 18 9.2
Over 12 10 5.1
Marital status
Married 77 39.5
Widowed 99 50.8
Single 16 8.2
Divorced/separated 3 1.5
Primary caregiver
Institutionalized 99 50.8
Children 46 23.6
Spouse 26 13.3
In-law 12 6.2
Paid-employment and other 12 6.2
Living arrangement
Institutionalized 99 50.8
Alone 16 8.2
With spouse 24 12.3
With children/grandchildren 49 25.1
With friends/relatives 7 3.6
Number of chronic diseases
0 24 12.3
1–3 140 71.8
4 31 15.9
Income status
Adequate 44 22.6
Fair 120 61.5
Not adequate 31 15.9

4. Discussion

The wide range of abuse scores (0–24) obtained on the PEAS was expected because
individual subjective experience of abuse is idiosyncratic, and health practitioners must be
aware that individual subjects do not necessarily experience all indicators of abuse. The
314 J.-J. Wang / Archives of Gerontology and Geriatrics 42 (2006) 307–318

Table 2
Frequency and percentage of abuse for each of the items on the PEAS (N = 195)
# Indicators Frequency Percentage
1 Left alone involuntarily 79 40.5
2 Personal belongings used without permission 17 8.7
3 Angry at caregiver 32 16.4
4 Dependent on others economically 119 61.0
5 Wish to see relatives unfulfilled 122 62.6
6 Poor sleep for unknown reasons 86 44.1
7 Inability to make own decisions 63 32.3
8 No response to alert of health problems 27 13.8
9 Irrelevant answers to questions or unresponsive 21 10.8
10 Facial expression of dissatisfaction towards caregiver 25 12.8
11 Unexplained problems with verbal expression or language 19 9.7
12 Privacy not respected 50 25.6
13 Verbal description of abuse situation 11 5.6
14 Nightmares 41 21.0
15 Feeling emotionally confused, dispirited and anxious 49 25.1
16 Isolation and withdrawal from social activities 34 17.4
17 Unnecessary suspicions and ideation of being harmed 21 10.8
18 Feelings of shame, powerlessness and loss of dignity 30 15.4
19 Destroyed own belongings 5 2.6
20 Fear of specific persons or events 12 6.2
21 Unexplained irritability 10 5.1
22 Low self-esteem 49 25.1
23 Eating difficulties 20 10.3
24 Unreasonably inflexible viewpoint 35 17.9
25 Unexplained ideation of harm and murder of others 3 1.5
26 Take pleasure in blaming others 36 18.5
27 Taking improper medication for unknown reasons 29 14.9
28 Excessive dependence on caregiver 61 31.3
29 Dissatisfied with current conditions 33 16.9
30 Unreasonable demands 18 9.2
31 Timidity and fearfulness 37 19.0
32 Sudden loss of trust in an acquaintance 39 20.0

findings indicated that 22.6% of the subjects had PEAS of 10 or higher, indicating a higher
prevalence of elder psychological abuse than did Taiwanese government reports, which
reported a prevalence of abuse of the elderly of around 10% (Lo et al., 2001). In fact,
prevalence and incidence data from different self-report studies or governmental reports in
Taiwan are difficult to compare because of differences in instruments and samples.
Although, psychological abuse rate varied from nation to nation and from study to study,
using only cases report to governmental agencies may cause underestimation of victims.
Therefore, clinicians and health care workers must recognize that cases of psychological
abuse of the elderly are being largely missed. Therefore, better outreach and screening
program has to be established and exercised.
‘‘Wishes to see relatives unfulfilled’’ and ‘‘economic dependence on others’’ were the
two indicators most frequently reported by subjects in this study. Traditional Chinese
culture considers filial piety a strong social norm, and this piety included an obligation to
care for parents and visit them frequently after leaving home. Unfortunately, the values and
 J.-J. Wang / Archives of Gerontology and Geriatrics 42 (2006) 307–318 315

attitudes of the younger generation have changed as a result of recent revolutions in social
and family structure, and consequently young couples with children who move to live away
from their aging parents are increasingly less likely to visit their aging parents frequently.
From this perspective it is not surprising that unfulfilled expectations to see their adult
children is the most frequently reported indicator of psychological abuse of the elderly.
Consequently, children should make an effort to visit their elderly parents more frequently.
On the other hand, studies suggested an especially high association between abuse and
physical and economic dependence of the elderly (Vida et al., 2002; Jamuna, 2003). If adult
children face a higher financial burden to care for their elderly parents, then the possibility
of abuse is increased.
Other frequently reported indicators were primarily associated with the relationship
between caregivers and the elderly (excessive dependence on caregiver, being left alone
involuntarily) and the autonomy of the elderly individual (lack of respect for privacy,
inability to make their own decisions). This finding is similar to the findings of an earlier
study by Soeda and Araki (1999), which viewed the stress associated with caregiving and
the poor relationship between caregivers and elderly individuals as the most common
causes of abuse. Wood and Stephens (2003) stated that elderly people are frequently left
unsupervised both in residential and home case settings. In Taiwan, older people may rely
on powerful others such as health providers or family members to make decisions on their
behalf, thus decreasing their self-efficacy. However, respect for the decision making and
privacy of elderly people can avoid unintentionally hurting the psyche of patients.
Although the level of psychological abuse of the elderly did not differ significantly
between the institutional and the domestic subjects in this study, the domestic subjects
exhibited a higher mean score than the institutionalized elderly. This phenomenon can be
explained by the fact that in a domestic setting, caregiving is difficult to supervise and monitor
in Taiwan. The findings of this study also indicated that individuals with chronic diseases
experienced more psychological abuse from their caregivers, a phenomenon supported by
several studies indicating that people who are more physically dependent on caregivers or
who demand significant attention report more abuse (Saveman et al., 1999; Soeda and Araki,
1999; Jamuna, 2003). For example, Saveman et al. (1999) noted that most abused persons
exhibited multiple handicaps/disabilities. The above studies confirmed that the level of frailty
and dependency of the elderly is a significant predictor of maltreatment of the elderly.
The significant relationships shown between the PEAS and the measures of cognitive
status and functional activity in daily living supported are similar to previous findings
(Coyne et al., 1993; Lachs et al., 1997; Comijs et al., 1999; Saveman et al., 1999; Soeda and
Araki, 1999). Restated, impairments affecting activities of daily living (ADLs) and
cognitive deficits are associated with increased vulnerability of elders to mistreatment.
Therefore, management and prevention programs relating to abuse of the elderly should
target specific personal characteristics that are associated with such abuse.

5. Conclusions

This study demonstrates that psychological abuse of the elderly is common among
elderly Taiwanese in community setting, and that interventional services should develop
316 J.-J. Wang / Archives of Gerontology and Geriatrics 42 (2006) 307–318

multidisciplinary expertise and resources for dealing with such invisible abuse.
Additionally, caution against oversimplification of psychological abuse as a unitary
problem should be activated. Nevertheless, attention should also be paid to the personal
characteristics of the elderly, because the cognitive and physical function of the elderly was
closely associated with level of abuse. The contextual factors related to psychological
abuse of the elderly must be monitored to prevent abuse. The findings of this study can
provide a crucial component for designing a nationwide system for protecting the elderly,
and a continuing educational plan to enforce communication mode between caregivers and
elders will be needed. Health practitioners are also responsible for educating the public
about maltreatment of the elderly, including educating family caregivers, home health aids
and institutional nurse aids. O’Brien and Smock (2003) stated that the ‘‘prevention of abuse
and neglect represents a daunting task with a constantly growing population of dependent
older adults imposing an increasing demand on caregivers and on social and health
services’’ (p. 296). Formal support system resources must be made available from the
governmental health services. Most importantly, understanding and respecting the rights of
older people is crucial for preventing psychological abuse of the elderly.

5.1. Limitations and future research

The findings of this study may not be generalizable to larger populations because the
study data was gathered from a geographically limited area in southern Taiwan. The other
limitation involved instrument issue. The PEAS partly relied upon self-report of indicators
by caregivers, making it impossible to know whether respondents would have reacted in
exactly the same way in a real-life situation.
Despite the growing awareness of abuse of the elderly, risk factors associated with
caregivers, for example stress and burnout, depression and anxiety, environmental hazards,
and financial difficulties and crises should be studied. Intervention strategies should be
designed and the efficacy of these strategies should be estimated.

Acknowledgement

The authors would like to thank the National Science Council of the Republic of China,
Taiwan for financially supporting this research under Contract No. NSC 92-2314-B-242-
003.

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