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RESEARCH ARTICLE
Association between Physical Fitness and
Successful Aging in Taiwanese Older Adults
Pay-Shin Lin1,2☯‡*, Chih-Chin Hsieh1☯‡, Huey-Shinn
Cheng3, Tsai-Jou Tseng1, Shin-
Chang Su1
1 Department of Physical Therapy & Graduate Institute of
Rehabilitation Science, College of Medicine,
Chang Gung University, Taoyuan, Taiwan, 2 Health Aging
Research Center, Chang Gung University &
Chang Gung Memorial Hospital, Taoyuan, Taiwan, 3 Internal &
Geriatric Medicine, Chang Gung Memorial
Hospital, LinKou Branch, Taoyuan, Taiwan
☯ These authors contributed equally to this work.
‡ PSL and CCH are co-first authors on this work.
* [email protected]
Abstract
Population aging is escalating in numerous countries
worldwide; among them is Taiwan,

which will soon become an aged society. Thus, aging
successfully is an increasing concern.
One of the factors for achieving successful aging (SA) is
maintaining high physical function.
The purpose of this study was to determine the physical fitness
factors associated with SA
in Taiwanese older adults (OAs), because these factors are
intervenable. Community-
dwelling OAs aged more than 65 years and residing in Northern
Taiwan were recruited in
this study. They received a comprehensive geriatric assessment,
which includes sociode-
mographic data, health conditions and behaviors, activities of
daily living (ADL) and instru-
mental ADL (IADL) function, cognitive and depressive status,
and quality of life. Physical
fitness tests included the grip strength (GS), 30-second sit-to-
stand (30s STS), timed up-
and-go (TUG), functional reach (FR), one-leg standing, chair
sit-and-reach, and reaction
time (drop ruler) tests as well as the 6-minute walk test
(6MWT). SA status was defined as
follows: complete independence in performing ADL and IADL,
satisfactory cognitive status

(Mini-Mental State Examination� 24), no depression (Geriatric
Depression Scale < 5), and
favorable social function (SF subscale� 80 in SF-36). Adjusted
multiple logistic regression
analyses were performed. Among the total recruited OAs (n =
378), 100 (26.5%) met the
aforementioned SA criteria. After adjustment for
sociodemographic characteristics and
health condition and behaviors, some physical fitness tests,
namely GS, 30s STS, 6MWT,
TUG, and FR tests, were significantly associated with SA
individually, but not in the multi-
variate model. Among the physical fitness variables tested,
cardiopulmonary endurance,
mobility, muscle strength, and balance were significantly
associated with SA in Taiwanese
OAs. Early detection of deterioration in the identified functions
and corresponding interven-
tion is essential to ensuring SA.
PLOS ONE | DOI:10.1371/journal.pone.0150389 March 10,
2016 1 / 12
OPEN ACCESS
Citation: Lin P-S, Hsieh C-C, Cheng H-S, Tseng T-J,
Su S-C (2016) Association between Physical Fitness
and Successful Aging in Taiwanese Older Adults.
PLoS ONE 11(3): e0150389. doi:10.1371/journal.

pone.0150389
Editor: Kewei Chen, Banner Alzheimer's Institute,
UNITED STATES
Received: August 31, 2015
Accepted: February 12, 2016
Published: March 10, 2016
Copyright: © 2016 Lin et al. This is an open access
article distributed under the terms of the Creative
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are
credited.
Data Availability Statement: All relevant data are
within the paper.
Funding: This study was supported by the Ministry of
science and technology, Executive Yuan, Taiwan
(MOST 99-2410-H-182-037 & 100-2410-H-182-016-
MY2) and Chang Gung Medical Research Fund
(CMRPD 19002 & 1B0332). The funders had no role
in study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
Competing Interests: The authors have declared
that no competing interests exist.
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Introduction
The aging crisis is spreading worldwide. Taiwan is no
exception; its aging population is forecast
to surpass 14% by 2017, and to rapidly increase to 20% by 2025
[1]. In this severe population
aging era, if older people live longer but not in a healthy
manner, caring for them will place an
extreme burden on themselves, their families, and society.
Therefore, successfully aging (SA) is
a major health care and socioeconomic priority [2]. SA enables
older people to lead an inde-
pendent, high-quality, and dignified life. Rowe and Kahn [3]
proposed the concept of SA and
three constituent components: avoiding disease and disability,
maintaining high cognitive and
physical function, and engagement with life. A more
comprehensive definition proposed by
Young and colleagues [4] includes three health domains:
physiological (e.g. diseases and func-
tional impairments), psychological (e.g. emotional vitality), and
social (e.g. spirituality and
adaptation through social support mechanisms).
In the past four decades, scientist and clinicians have sought to
develop a definition that
would improve the general understanding of SA. In 2006, Depp
and Jest [5] reviewed 29 stud-
ies, noticing several variations of the SA definition in the
reviewed articles. They concluded
that the most frequently described SA components were
physical function or disability (26 of
29), followed by cognitive function, life satisfaction or well-
being, and social or productive
engagement.

Studies of different countries have proposed varying definitions
of SA. In Spain, Formiga
and colleagues [6] defined SA as achieving a Barthel Index (BI)
scores of�90 and a Mini-Men-
tal State Examination (MMSE) score of�24, as well as never
having been institutionalized. In
Singapore, Ng and colleagues [7] adapted the most rigorous
criteria for defining SA. They
defined SA as having good or excellent self-reported health
status, being independent in per-
forming instrumental activities of daily life (IADL), scoring�26
on the MMSE and�5 on the
Geriatric Depression Scale (GDS), being engaged in at least one
social and one productive
activity, and reporting a high level of life satisfaction. In
Australia, Parslow and colleagues [8]
defined SA as reporting high-level physical and mental health
and life satisfaction. Researchers
have also varied in definitions concerning the three SA
domains. Being independent in per-
forming activities of daily life (ADL) or IADL has been
frequently used for defining the physi-
cal component of SA. Several studies on SA conducted by
MacArthur, investigating and
longitudinally following OAs with high functioning, could be
considered the earliest and most
renowned studies on SA [9–11]. From then, many SA-related
factors have been reported, such
as health behaviors (smoking, physical activity, and exercise),
comorbidity, nutrition, and
some sociodemographic variables (age, sex, marital status,
education, and living arrangement)
[5–7,12–14].
High physical function is a crucial factor for SA; measures of

functional performance and
physical fitness are important, simple, and objective
observations of physical function in older
people. In addition, deterioration of these measures usually
precedes functional dependence,
which facilitates early detection and prevention. In the
MacArthur studies, the maintaining of
high physical performance was predicted by sociodemographic
data and health status charac-
teristics, exercise behavior, and emotional support from a social
network [10,11]. Furthermore,
several physical performance tests can detect the early onset of
functional dependence in OAs
without disabilities [15,16].
Recently, Kuh and colleagues [17] summarized the findings of a
review on the indicators of
healthy aging, focusing on objective measures of physical
capability, such as grip strength,
walking speed, chair rises, and standing balance. They
concluded these standardized physical
performance tests were significantly correlated with healthy
aging. However, associations of
these tests with SA needs to be further elaborated.
Physical Fitness and Successful Aging
2016 2 / 12
SA-associated factors may vary depending on cultural context.
Few related studies have
used Taiwanese older people as the study sample. In this study,
we explored SA-associated fac-

tors and predictors, specifically physical fitness tests (PFTs), in
Taiwan’s older population.
Because physical fitness is trainable, early detection and
intervention is possible.
Methods
Participants
Community-dwelling OAs aged more than 65 years were
recruited through an internal medi-
cine clinic and a community-based elderly home in Taoyuan,
Taiwan. The subjects were
screened by a medical doctor in the clinic and by two trained
physical therapists in the elderly
home. Subjects’ inclusion criteria were able to follow
instructions and perform PFTs indepen-
dently with or without assistive devices. The exclusion criteria
were any health problems or
acute trauma that would limit participation in the PFTs. The
study was approved by the Insti-
tutional Review Board of Chang Gung Memorial Hospital, and
written informed consent was
obtained from each subject prior to the initial assessment.
Measurements
Comprehensive geriatric assessment (CGA). The subjects
received a CGA by a well-
trained research assistant. Data on sociodemographic
characteristics were collected, including
age, sex, marital status, educational level, and living
arrangement. The health condition was
assessed by recording the number of comorbidities and fall
occurrences in the past year. Health
behaviors were assessed including smoking and alcohol
consumption (no, formerly, or yes),

sleeping quality (good or insomnia), and physical activity or
exercise (type, frequency, and
duration). The level of independence was measured by ADL
[18] and IADL [19]. The subjects
were asked if any difficulty in performing six ADLs, namely
eating, transferring, toileting, bath-
ing, walking indoors, and dressing, and five IADLs, namely
shopping, transportation, making
phone calls, taking medications, and managing money.
Cognitive function was measured using
the Chinese version of the MMSE [20], which has been
sufficiently validated in Taiwan [21,22].
Depression status was measured using the Chinese version of
the GDS short form [23], which
was adequately validated in Taiwan [24]. Quality of life was
evaluated using the Chinese ver-
sion of the Medical Outcomes study 36-Item Short Form (SF-
36) [25]. The SF-36 comprises
eight subscales with scores ranging from 0 to 100 for each scale
and two weighted summary
scales, namely the physical and mental component summary
scores.
Physical fitness tests (PFTs). PFTs consisted of the nine
following assessment items. First,
body composition was evaluated by calculating the body mass
index (BMI).
Muscle strength was measured with the grip strength (GS) by
using a Jamar1 hand dyna-
mometer (Sammons Preston, Bolingbrook, IL, USA) [26]. As
recommended by the American
Society of Hand Therapists, subjects were instructed to adopt
the standard testing position
[27], which is seated with shoulder and forearm of the test arm
in a neutral position and the

elbow flexed at 90°. The maximum force was recorded twice for
the dominant hand and the
higher value was used for analysis.
Muscle endurance was measured using the 30-second sit-to-
stand (30s STS) test [28]. Sub-
jects were instructed to keep their arms folded and rise as fast
as possible from a seat, which
was 0.42 m from the floor. The score was recorded as the
number of full stands performed in
30 seconds.
Aerobic endurance was assessed using the 6-minute walk test
(6MWT) [28]. Subjects were
instructed to walk as fast and as far as possible along a 25-m
corridor in 6 minutes and were
2016 3 / 12
given encouragement throughout the test. The total distance
walked within 6 minutes was
recorded.
Flexibility was assessed using the sit-and-reach test (SRT) [28].
Subjects completed trials by
assuming a sitting position on the edge of a chair, with one leg
extended and both hands over-
lapped and reaching toward the toes. The distance (in cm) from
the extended third finger to
the tip of the toe (+ beyond or–behind the toe) in two trials was
recorded, and the better perfor-

mance was used for analysis.
Balance was assessed using the functional reach (FR) test and
one-leg standing (OLS) with
eyes closed test. The FR test was performed using a Rolyan1
Functional Reach Measuring
Device (Sammons Preston). Subjects completed trials in a
standing position adjacent to a wall
with the test arm raised forward at 90° of shoulder flexion. The
farthest distance (in cm) was
recorded while subjects reached forward without taking their
heels off the floor [29], and after
practice, the mean value of two trials was used for analysis. In
the OLS test, subjects completed
trials by standing on one leg for as long as possible with the
contralateral hip and knee both
flexed at 90° and with their eyes closed [30]. The performance
time was recorded until the sus-
pended leg touched the floor, and after practice, the longest
time of two trials was used for
analysis.
The timed up-and-go (TUG) test [31] was used to assess
dynamic balance and agility. Sub-
jects stood up from a seated position, walked 3 m, turned
around, and returned to the seated
position on a chair. After a practice trial, the shortest time of
two test trials was recorded.
Finally, the reaction time was assessed using the drop ruler
(DR) test [32]. The subjects tried
to catch a ruler that was dropped without warning. The distance
(in cm) between the bottom of
the ruler and the marking where the dropped ruler was caught
by the subject was recorded.
This procedure was repeated five times. The lowest and highest

results were discarded and the
average of the remaining three results was used for analysis.
Definition of Successful Aging
Young [4] proposed a multidimensional model for SA that
includes three domains, namely
physiological, psychological, and sociological. Therefore, we
operationally defined the criteria
of SA status as respondents reporting follows:
1. Independence for performing each ADL and IADL activity
[33,34].
2. Free of cognitive impairment and depressive symptoms if
their MMSE score�24 [35] and
GDS score<5 [24], respectively.
3. Having satisfactory social functioning if their social function
subscale score of SF-36 was
more than 80. We used 80 as a cutoff because in a normative
sample of Taiwanese adults, 81
and 73 were the mean scores reported by healthy OAs aged 65–
74 and>75 years, respec-
tively [25].
According to these criteria, the subjects were categorized into
two groups: SA and non-SA.
Statistical Analysis
Descriptive statistics of sociodemographic characteristics,
health conditions, health behavior,
and PFTs were obtained for both the SA and non-SA groups.
The t test was used for comparing
continuous variables, and the chi-square test was used for
categorical variables. To determine
the variables associated with SA, series logistic regression

analyses were performed. By using
SA status as a dependent variable and possible correlated
factors as independent variables, we
constructed series logistic regression models. Sociodemographic
characteristics, health
2016 4 / 12
conditions, and health behaviors were entered in model 1. For
the univariate logistic regression
(model 2), each PFT was added individually. Finally, all the
variables of PFTs were included in
a multivariate logistic regression (model 3).
Adjusted odds ratios (ORs) with 95% confidence intervals (CIs)
were calculated. All analy-
ses were performed using SPSS 20.0. The significance level
was set at P< 0.05.
Multiple imputation procedures were performed for missing
values [36]. The procedure
involved generating five complete datasets from a set of values
yielded using the aforemen-
tioned logistic and linear regression models, for the categorical
and continuous variables [37].
The results were similar after multiple imputations, therefore,
results of the original data with-
out imputations are reported in the present study.
Results
This study enrolled 378 OAs with a mean age of 77.6 ± 6.9

years (60–102 years), 52.6% of
whom were women. Regarding education, 55.2% of the subjects
had received� 9 years of edu-
cation. Almost 60% of the subjects were married, and 70% lived
with their families or others.
Of the subjects, 202 (53.4%) were physically independent, 228
(60.3%) were cognitively and
emotionally well-functioning, and 222 (58.7%) reported
satisfactory social function. Overall,
100 (26.5%) subjects met the multidimensional criteria for SA
(Table 1).
Table 2 shows the comparison results of the sociodemographic
characteristics, health
related factors, and physical fitness measures between SA and
non-SA groups. Compared with
the non-SA group, the subjects with SA were younger, had a
higher level of education (>junior
high school), and were more likely to live with others. They
reported frequent regular exercise
(�2 days a week) and fewer falls (�1 in the past year).
Significant differences were observed in
the height and weight of the SA group subjects, who were
generally taller and heavier than the
non-SA subjects; however, BMI did not differ significantly
between two groups. In addition, no
significant difference in the number of comorbidities was
observed between two groups.
All PFTs, except the chair SRT, revealed significant differences
between the SA and non-SA
groups (Table 2). Compared with the non-SA group, the SA
group achieved a stronger GS, per-
formed more repetitions in the 30s STS test, walked a longer
distance within 6 minutes, had a
longer FR, required less time to complete the TUG test, caught

the ruler higher in the ruler
drop test, and stood for longer in the OLS test.
In the first logistic regression (model 1), age, education, and
regular exercise were found to
be significantly associated with SA; however, after multiple
imputations, there was a minor
Table 1. Prevalence of successful aging.
N = 378 Prevalence
1. Good physical function 53.4
Independent of ADL 84.4
Independent of IADL 55.6
2. Good cognitive and emotional function 60.3
MMSE≧24 73.5
GDS<5 77.0
3. Well social function (score>80) 58.7
Successful aginga 26.5
Values are in %. ADL: activities of daily living; IADL:
instrumental activities of daily living; MMSE: Mini-
Mental State Examination; GDS: Geriatric Depression Scales.
aCombined criteria (1 and 2 and 3).
doi:10.1371/journal.pone.0150389.t001

2016 5 / 12
change that the variable of height but not education showed
significant difference (Table 3). In
model 2, the GS, 30s STS, TUG, and FR tests as well as the
6MWT were significantly associated
with SA after adjusting for sociodemographic characteristics,
health conditions, and health
behaviors (Table 4). Hosmer and Lemeshow tests revealed a
good model fit for all models with
no multicollinearity (none of the independent variables in the
analyses had a standard error
larger than 2.0), and an adequate overall accuracy rate (70.1%–
75.5%). Significant PFT vari-
ables associated with SA and their unadjusted and adjusted ORs
are presented in Table 4. For
every 1-meter increase in the 6MWT, the odds of achieving SA
were 2.057 times higher. By
contrast, for every 1-second increase in the TUG test, the odds
of achieving SA decreased by
19%.
However, after all the physical fitness variables were added to
the multivariate logistic
model, none were found to be significantly associated with SA
(data not shown).
Table 2. Comparisons of measures of sociodemographic, health
condition, health behavior and physical fitness tests between SA
and non-SA.

SA (n = 100) Non-SA (n = 278) p value
Sociodemographic data
Age (years) 75.91±7.31 78.20±6.70 0.004a
Female, n(%) 47(47.0%) 152(54.7%) 0.187
Education >9 years, n(%) 58(66.7%) 85(36.6%) 0.000a
Married, n(%) 51(60.7%) 133(58.3%) 0.705
Live with families or others, n(%) 50(59.5%) 167(73.2%)
0.019a
Height (cm) 160.95±7.98 156.73±8.51 0.000a
Weight (kg) 63.10±10.61 59.01±11.09 0.002a
BMI 24.36±3.63 24.03±3.90 0.476
Health condition
Falls >1, n(%) 3(3.0%) 38(13.7%) 0.003a
Comorbidity 1.24±1.00 1.41±1.05 0.181
Health behavior
Regular exercise, n(%) 88(88.0%) 181(65.6%) 0.000a
No smoking, n(%) 82(82.8%) 218(79.3%) 0.446
No drinking, n(%) 83(83.8%) 241(87.6%) 0.341
Normal sleep, n(%) 73(73.7%) 182(66.9%) 0.210

Physical fitness tests
Grip strength (kg) 27.45±8.08 22.72±7.64 0.000a
30s STS (no. stands) 15.53±5.36 12.68±4.86 0.000a
6MWT (meter) 4.19±0.98 3.36±1.13 0.000a
TUG (seconds) 9.86±2.83 14.45±8.47 0.000a
Functional reach (cm) 28.53±5.83 23.62±6.69 0.000a
One leg standing (seconds) 4.09±4.36 2.99±4.46 0.045a
Chair sit-and-reach (cm) 0.45±13.16 -2.16±13.07 0.111
Ruler test (cm) 35.59±9.29 39.68±9.61 0.000a
Values are in mean±SD unless otherwise stated. SA: successful
aging; non-SA: no successful aging; BMI: body mass index;
Regular exercise: having
regular exercise at least two days a week for more than 20
minutes; Normal sleep: no insomnia; Falls>1: falls occurrence
over once in the past year. 30s
STS: 30-second sit to stand test; 6MWT: Six Minute Walk test;
TUG: Timed Up and Go test.
ap<0.05

2016 6 / 12
Discussion
In our sample of 378 community-dwelling Taiwanese OAs,
26.5% were recognized as in a SA
status. In addition to age, education, and regular exercise, we
found some PFT variables,
namely GS, 30s STS, 6MWT, TUG, and FR tests, to be
significant factors associated with SA
status.
Table 3. Factors associated with SA in model 1 from original
and imputed data respectively.
Variables OR (95% CI) After multiple imputation OR (95% CI)
Sociodemographic data
Age 0.951 (0.907–0.999)a 0.956(0.918–0.996)a
Gender 1.431 (0.543–3.773) 1.883(0.823–4.305)
Education 2.375 (1.214–4.647)a 1.936(0.963–3.892)
Marital status 1.384 (0.659–2.907) 1.115(0.570–2.179)
Live arrangement 0.624 (0.290–1.340) 0.718(0.356–1.448)
Height 1.062 (0.998–1.129) 1.084(1.027–1.143)a
Weight 1.015 (0.982–1.049) 1.010(0.983–1.039)
Health condition

Falls >1 0.606 (0.124–2.953) 0.534(0.146–1.952)
Comorbidity 1.112 (0.803–1.539) 0.964(0.728–1.277)
Health behavior
Regular exercise 2.414 (1.095–5.325)a 2.599(1.272–5.310)a
No smoking 1.971 (0.748–5.194) 1.446(0.642–3.258)
No drinking 0.792 (0.305–2.055) 0.861(0.378–1.961)
Normal sleep 1.391 (0.704–2.748) 1.223(0.690–2.169)
SA: successful aging; OR: odds ratio; CI: confidence interval;
BMI: body mass index; Regular exercise:
having regular exercise for more than 20 minutes at least two
days a week; Normal sleep: no insomnia;
Falls>1: falls occurrence over once in the past year.
ap<0.05
Table 4. Physical fitness tests associated with SA in both
unadjusted and adjusted univariate logistic
regressions.
Physical fitness tests Unadjusted Adjusted
Grip strength 1.077(1.045–1.110) a 1.077(1.018–1.139) a
30s STS 1.116(1.062–1.173) a 1.102(1.021–1.190) a
6MWT 2.159(1.654–2.820) a 2.057 (1.402–3.020) a

TUG 0.795(0.728–0.869) a 0.810 (0.708–0.927) a
Functional reach 1.131(1.084–1.180) a 1.089 (1.023–1.160) a
One leg standing 1.053(0.995–1.116) 0.986 (0.919–1.058)
Chair sit-and-reach 1.015(0.996–1.035) 1.013 (0.984–1.043)
Ruler test 0.955(0.930–0.980) a 0.972 (0.938–1.007)
Values are in odds ratio (95% confidence interval); Adjusted:
adjusted for sociodemographic, health
condition, health behavior measures.
30s STS: 30-second sit to stand test; 6MWT: Six Minute Walk
test; TUG: Timed Up and Go test.
ap<0.05
2016 7 / 12
Previous studies [5–7,12–14,33] have reported wide-ranging
rates of SA prevalence, from
0.4% to 95%. Regarding other primarily ethic Chinese older
populations, the SA prevalence in
our study is similar to that reported in Singapore (28.6%) [7]
but not to that reported in Hong
Kong (0.7%–33.1%) [13] and in Shanghai (46.2%) [14]. Several

methodological factors, such as
differences in sample characteristics and operational definitions
of SA, may contribute to this
variability [5]. Self-reported and performance-based
assessments are both valid and reliable
methods for assessing ADL or IADL; however, in our study,
using self-reported ADL or IADL
measurements for defining SA may have led to overestimation
of the number of subjects with
SA. The heterogeneity and lack of consistency in the SA
definition are the main limitations of
research on SA [38]. However, we attempted to use the most
suitable multidimensional defini-
tion of SA in our study.
The first logistic regression (model 1) revealed that some
sociodemographic characteristics
were associated with SA. In accordance with previous studies
[13,14], our results showed that a
younger age and higher level of education were associated with
SA. However, the number of
comorbidities was not a significant factor. Previous studies
[4,8,39] have also proposed that
chronic illness is not a necessary barrier to SA. By contrast,
performing regular exercise for
�20 min more than twice a week is beneficial. According to one
study [40], the SA rate in the
physically active Canadian older population was more than
twice that in older populations of
other countries, even after adjusting for demographic
covariates. Maintaining a high physical
activity level by performing regular exercise results in
improved physical function and fitness,
and thus aids older people to achieve SA.
Our results showed that GS, 30s STS, 6MWT, TUG, and FR test

results were significant fac-
tors associated with an SA status. A review performed by den
Ouden and colleagues [41]
describes positive associations of high handgrip and lower
extremity strength and quick gait
speed on physical mobility. Results of a 10-year follow-up
study [42] also reported that high
handgrip strength and leg strength were both associated with a
lower risk of ADL disabilities.
Formiga and colleagues [6] conducted a survey involving 328
community-dwelling OAs.
Results showed that successful agers exhibited significantly
higher scores on the Tinetti Gait
Scale than did unsuccessful agers. Achour and colleagues [12]
used a physical questionnaire to
evaluate the amount of physical activity in 686 subjects aged
over 65 years and determined the
relationships between exercise capacity and life satisfaction and
self-rated health after 7 years.
The results showed oxygen uptake (VO2) peak and activity
index were the most significant fac-
tors associated with self-reported health condition and life
satisfaction. Our results were in
agreement with those of the aforementioned studies. In
conclusion, older people with more
favorable muscle strength/endurance, gait and balance
performance, and aerobic endurance
exhibit higher physical function, exercise capacity, and
independence in performing ADL;
thus, they are more able to achieve SA.
PFTs are easy to conduct in clinical and community settings.
Previous research showed
their predictability on adverse outcomes. Some tests, such as
GS, timed chair raises, walking

speed, and standing balance, can predict mortality [43]; tests
such as timed chair raises [44]
and TUG [45] can predict disability, and others such as gait
speed can predict demand for per-
sonal care [46]. Rikli and Jones [47] developed standards for
tests that can predict the level of
capacity required for OAs to maintain physical independence,
which is a necessary component
of SA. For example, to predict a high probability of maintaining
independence, the recom-
mended score for the 30s STS test is�14 for women aged 70–74
years. Thus, an appropriate
exercise regimen can be prescribed by health professionals
aimed toward improving lower
extremity muscle strength and endurance to achieve satisfactory
performance in the 30s STS
test, i.e. physical function improvement. Therefore, PFTs are
valuable for OAs to monitor their
functional status, and for professionals to screen and detect OAs
at high risk.
2016 8 / 12
In this study, some PFTs, such as OLS, chair SRT, and DR tests
showed no significant asso-
ciation with SA. Data of the OLS test was not normally
distributed and exhibited the floor
effect. Therefore, more functional and dynamic balance tests,
such as TUG and FR, could be
more suitable options than the OLS for measuring the balance
performance in the older

population.
Flexibility, a variable closely relevant to pain and discomfort, is
also necessary for OAs to
maintain a better functional state and remain independent. A
similar result to our study was
reported by Chow et al [48]; they investigated the association of
out-of-home activities and
physical fitness with SA, and found that muscular strength and
cardiovascular fitness were sig-
nificant factors for SA, but not flexibility. Limited joint range-
of-motion is more closely associ-
ated with functional state than is flexibility. Unsatisfactory
flexibility may not represent a joint
range-of-motion limitation; however, it influences body
functioning and dependence ability.
The mean of chair SRT tests in our study were similar to those
reported in a previous study
[49].
The DR test represents the reaction time. Our results showed
that a quick reaction time or
agility is not a crucial determinant of SA.
The final multivariate logistic model found that no PFT
variables were significantly associ-
ated with SA after adjustment. After excluding
multicollinearity, it is possible that the sample
size in our study was insufficient and may have caused model
instability.
In addition to an insufficient sample size, this study has several
other limitations. First, the
study was based on a convenience sample from Northern
Taiwan. Different regions may pos-
sess different SA-associated factors; therefore, the results

should be generalized with caution,
and further research should include random sampling of a
representative geographical areas.
Moreover, we did not include OAs who could not perform the
PFTs. Although they did not
meet the SA criteria described in our study, this does not mean
that they were unsuccessful
agers. Montross et al [39] reported that of subjects who rated
themselves as successful agers,
only 30% were free of disability. SA can be considered a
subjective concept; however, in this
study, we attempted to define it objectively. SA is a
multidimentinal concept, which can be
achieved through adaption and compensation [4]. Thus, our
results cannot be generalized to
all the older population.
Second, the social domain of the SA definition adopted in our
study may not be a standard
measure. The SF-36 score may not fully represent the extent of
a person’s engagement with life.
A measurement bias may have developed. Third, certain data
were missing in our study; how-
ever, the results were similar after multiple imputation
procedures.
Finally, we conceptually defined independence in performing
ADL or IADL as the physical
component of SA, which logically may be correlated with
improved physical fitness. However,
the measures of physical fitness representing mobility function
is in a different construct to the
ADL measure. Improved physical fitness can help to achieve
independence in performing
ADL; however, a successful ager who is completely independent
in performing ADL or IADL

may not necessarily have strong physical fitness. Moreover,
deterioration of the SA-related fit-
ness measures usually precedes functional dependence, which
makes early detection and pre-
vention possible.
Conclusions
In this study, we aimed to determine the factors associated with
SA among Taiwanese commu-
nity-dwelling OAs. In the sample of 378 subjects, 26.5% of
them were successful agers. Our
results suggested that, apart from the known factors of age,
education level, and regular exer-
cise, PFTs are also SA-associated significant factors. Favorable
cardiopulmonary endurance,
2016 9 / 12
muscle strength and endurance, and balance and mobility are
crucial SA-associated factors.
However, these factors could be cause or effect. A longitudinal
study is required to investigate
the causality of the determined factors. PFTs are easy to
perform in community or clinical set-
tings. Thus, these tests are recommended for the early detection
and monitoring of SA status in
OAs.
Acknowledgments
We thank all the participants for their time and efforts in
completing the physically demanding

tests.
Author Contributions
Conceived and designed the experiments: PSL HSC. Performed
the experiments: TJT SCS PSL
HSC. Analyzed the data: CCH. Contributed
reagents/materials/analysis tools: PSL HSC. Wrote
the paper: CCH PSL.
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RESEARCH
doi: 10.1111/j.1478-5153.2012.00511.x
Critical care nurses’ perspectives
on elder abuse

Jeanette M Daly, Amy N Schmeidel Klein and Gerald J Jogerst
ABSTRACT
Aims: To explore through interviews of critical care nurses their
perspectives on elder abuse to achieve a better understanding of
the problems
of reporting and generate ideas for improving the process.
Background: In 44 states and the District of Columbia health
care providers are required by law to report elder abuse but the
patient,
patient’s family and health care providers all have barriers to
reporting allegations of elder abuse.
Design: This study design is qualitative.
Method: Through a mailed survey, critical care nurses were
invited to participate in a taped in-depth qualitative interview.
Results: Ten nurses were interviewed. A thematic analysis was
used to describe the following core themes: types of elder
abuse, suspicions
of elder abuse, reporting of elder abuse, barriers to reporting
elder abuse, legislation and improvement in practice.
Conclusions: Critical care nurses are aware of elder abuse and
somewhat systematically evaluate for abuse at admission to
their unit. They
recognize signs and symptoms of abuse and are suspicious when
it is warranted. They are aware of why an older person does not
want to
report abuse and take this into consideration when soliciting
information. Facts, values and experience influence personally
defining abuse,
suspicion and dependence for each individual health care
professional.
Relevance to clinical practice: Critical care unit protocols
and/or policies and procedure for reporting elder abuse are
needed in critical
care settings and are warranted for providing quality of care.

Key words: Critical care • Elder abuse • Mandatory reporting •
Qualitative study
A recent national study found 1 in 10 of 5777
respondents, persons 60 years and older, reported
emotional, physical or sexual mistreatment or potential
neglect in the last year (Acierno et al., 2010). It is difficult
for persons who are older to report mistreatment.
Victims have many reasons for not reporting elder
mistreatment, including fear of retaliation, being
afraid of institutionalization, being ashamed, lack of
information on who to contact for reporting and
thinking no one can help (National Research Council
of the National Academies, 2003).
In the critical care setting, patients are treated for
brief but severe episodes of illness, and the intensity of
the situation may not allow for exploration or thoughts
of elder abuse. Barriers for health care providers in
the critical care setting for reporting elder abuse are
Authors: JM Daly, RN, PhD, Associate Research Scientist,
Department of
Family Medicine, University of Iowa, Iowa City, IA, USA; AN
Schmeidel
Klein, BA, Medical Student (M4), Carver College of Medicine,
University of
Iowa, Iowa City, IA, USA; GJ Jogerst, MD, Professor/Associate
Head,
Department of Family Medicine, University of Iowa, Iowa City,
IA, USA
Address for correspondence: JM Daly, Department of Family
Medicine, University of Iowa, 01290-F PFP, 200 Hawkins
Drive, Iowa City,
IA 52242, USA
E-mail: [email protected]

varied and include the patient as potential victim,
patient’s family/significant others and the health care
provider. High patient acuity and lack of consciousness
are important factors that hinder reporting of abuse
by the patient and when alert and responsive, the
typical barriers exist, i.e. fear of retaliation, fear of being
placed in a nursing home, powerlessness and wanting
to protect their family (Beaulaurier et al., 2008). Family
members may know or actually be the perpetrators and
they deny the abuse (Krueger and Patterson, 1997). For
the health care provider, reporting barriers may be
lack of knowledge about the law, not wanting to be
involved in court cases and not routinely screening for
abuse (Clark-Daniels et al., 1990; Taylor et al., 2006).
In some states, health care professionals are not
obligated to report elder abuse to adult protective
services, but in 44 states and the District of Columbia
they are required by law to report elder abuse
(Daly et al., 2003). Guidelines from the American
Medical Association note that a physician may be
the only person outside the family whom an elder
sees regularly, and is therefore in a key position
to report elder abuse (Aravanis et al., 1993). Health
care professionals attest to viewing cases of suspected
elder abuse but fail to report those cases (Daly
172 © 2012 The Authors. Nursing in Critical Care © 2012
British Association of Critical Care Nurses • Vol 17 No 4
Perspectives on elder ebuse
and Jogerst, 2005). In a retrospective medical record
review of 28 thermally injured patients 60 years and

older, findings indicated that the patients were poorly
screened for elder abuse and 7 persons were victims
of abuse, neglect or self-neglect; but only two cases
had intervention by adult protective services (Bird
et al., 1998). In another study, physicians were found to
report only 2% of all suspected cases (Rosenblatt et al.,
1996). In the same study, a substantially larger number
of cases were reported by social workers (18%) and
nurses (26%).
From 2010 to 2050, the US population is expected
to grow from 310 to 439 million, and by 2030 one
in five persons will be 65 years and older. Health
care professionals in all settings will need to become
increasingly aware of elder abuse and reporting
mechanisms (Vincent and Velkoff, 2010). From 2010
to 2030, the dependency ratio (number of persons
65 years and older to every 100 persons of traditional
working age) will increase from 22 to 35 persons. The
higher the dependency ratio, the greater the potential
burden on health care (US Census Bureau, 2011).
Reasons for lack of reporting are understudied.
While laws require reporting regardless of mitigating
circumstances, most health care professionals consider
the broader context of the patient before reporting,
including patient autonomy and rights, patient-
physician confidentiality, quality of life and future
patient-health care professional relationships (Daly
et al., 2003). Rodriguez et al. (2006) interviewed a
convenience sample of 20 family and general internal
medicine physicians to identify their perspectives on
mandated reporting of elder abuse. They reported
that physicians worry about future physician-patient
rapport and trust, patient quality of life and physician
control when deciding to make an elder abuse report

(Rodriguez et al., 2006). Schmeidel and colleagues
expanded that study and interviewed nurses and
physicians in primary care settings with a main
conclusion that pragmatic elder abuse education
is necessary and the reporting system may need
reorganization (Schmeidel et al., 2012).
This study continues the author’s earlier work
and examines the perspectives of other health care
professionals, critical care nurses. It has been noted
that there is sparse research regarding critical care
nurses and their perceptions of elder abuse (Burgess
et al., 2006; Daly et al., 2011). The purpose of this study
was to explore through interviews of critical care
nurses their perspectives on elder abuse, to achieve
a better understanding of the problems of reporting
and to generate ideas for improving the process.
This qualitative approach using in-depth interviews
is appropriate for exploring a complex domain that is
not fully understood – in this case, perspectives on and
barriers to mandatory reporting of elder abuse – and
is meant to be hypothesis generating rather than
hypothesis testing.
METHODS
The methods for this project were approved by
the Institutional Review Board of the University of
Iowa. Methods are described for subject recruitment,
instrument, interviews and qualitative analyses.
Subject recruitment
A list of critical care nurses was obtained from the Iowa
Board of Nursing. All nurses employed in critical care
settings were selected from three counties in Iowa. A
cover letter with the list of interview questions was

sent to all 396 nurses. Also included in the envelope
was a form to complete and return in a postage-paid
envelope indicating the respondent would participate
in this study. Contact information was provided on
the form. After receipt of agreement to participate, a
researcher contacted the respondent and set up a time
and place for interview. Thirty-eight envelopes from
nurses were returned as undeliverable. No further
attempts were made to engage non-responders after
the initial invitation letter.
Instrument and interviews
An interview guide developed by Rodriguez and
colleagues (2006) was used for this study. The guide
had 13 open-ended interview questions (Appendix A)
and was developed from literature review and expert
input. The questions were developed for physicians
and were modified for the critical care nurses. No
demographic information was collected because of
the sensitivity of the topic. Anonymity was protected
because a respondent could indicate they were aware
of an elder abuse incident and had not reported it,
which would be in violation of Iowa laws.
One interviewer (A. S.) was trained in ethnographic
techniques, and she has conducted similar research.
The interviews were conducted in the respondent’s or
interviewer’s office. At the beginning of the interview,
respondents were reminded not to indicate who they
were or the names of any of the abuse victims.
Interviews lasted from 20 to 50 min, were all tape-
recorded, and transcribed verbatim.
Qualitative analysis
A multi-step process of thematic analysis was used
to identify the core themes that represent the per-

ceptions of nurses and physicians about elder abuse
© 2012 The Authors. Nursing in Critical Care © 2012 British
Association of Critical Care Nurses 173
(Crabtree and Miller, 1999; Rice and Ezzy, 1999). All
transcriptions were entered in N’Vivo (QSR Interna-
tional, Victoria, Australia), a qualitative software pro-
gram that allows for coding and systematic searching
of interview data. After development of a prelimi-
nary codebook, initial coding was conducted by the
interviewer (A. S.) to identify general themes in the
responses of all persons interviewed. A second-coding
step entailed members of the research team repre-
senting each profession (MD and RN) interactively
reading through interview transcripts. All members
of the research team concurred on themes identified
during the transcript review.
RESULTS
Twelve nurses who worked in intensive care units
agreed to participate in the interviews. During the
project 10 nurses were interviewed, for an overall
interview rate of 83% and 2·7% of those initially
contacted to participate. The nurses all worked in
hospital-based critical care units in three Iowa counties.
Interview responses are provided within the concepts
of types of elder abuse, suspicions of elder abuse,
reporting of elder abuse, barriers to reporting elder
abuse, legislation and improvement in practice.
Types of elder abuse

Nurses reported the kinds of abuse they may encounter
as emotional abuse, financial exploitation, neglect
and physical abuse. None of the nurses reported
sexual abuse, and one nurse stated: ‘I’m trying to
think. . .I don’t think we’ve ever seen sexual. . .not to
my knowledge’. Another nurse stated, ‘I’ve worked in
the surgical intensive care unit for over 20 years and
I haven’t seen any signs of any physical abuse, partly
because as a nurse in the ICU, you’re usually so busy
you don’t have time to scratch your nose’.
Neglect issues were frequently mentioned and
described as the patient having many sores on the
body, bruises, needing hygiene care and looking
malnourished. One nurse reported, ‘They will be very
filthy. They’ll have sores. It’s obvious they haven’t been
bathed or shampooed for a long time. So we see a lot
of that type of thing’.
An example of financial exploitation was provided.
‘The patient was on a ventilator, controlled life support,
and the family wanted us to wake him up to sign his
social security check. And that was kind of like a red
flag right there. And the patient was in for 3 months,
and the only time we saw the family was the first of
the month when the check came in’.
A report of actual abuse occurring in the intensive
care unit was depicted by a nurse. ‘I had one case
where the wife would come in every day and sat for
3 hours next to her husband’s bed, and shortly after
she left the ventilator alarm would always go off, and
we could never figure out why, and we always ended
up changing the tubing. Well, we sat and watched her
one day, and she sat there with her sewing needles

and was poking all these holes in the ventilator tubing.
And she’d called in later, asking, ‘‘Oh, is he still alive’’?
So, that was something we did report’.
Suspicions of elder abuse
Nurses report being suspicious of elder abuse if the
patient (a) depicts being malnourished and unkempt;
(b) has bruising or other marks on the body with
no reasonable explanation; (c) has burn marks in
places where the patient can not reach; (d) can not
provide a clear explanation/reluctance to answer
questions; or (e) if a family member hovers or appears
uncomfortable with health care professionals present.
Many reported suspicions because of evidence such as
sores on their body and the patient being hungry.
Two nurses reported their admission questionnaire
asks about their care at home and if they are safe.
One reported, ‘The joint commission standards have
mandated that we ask people, you know, have you
been sexually abused, have you ever been physically
abused, and that sort of thing. So, my particular
situation, it’s rare. . .we ask those questions to an
awake and oriented person. Well, most of our people
come to us completely anesthetized from the operating
room, and by the time they do wake up they’re pretty
disoriented’.
A nurse described one situation as, ‘an elderly
gentleman came in with cigarette burns on his back,
and he did not smoke, and a step-son who was a
primary care giver did. We just kind of figured that
had to be the son. There was no logical explanation for
it [other] than that. And it wasn’t a single burn; it was
multiple burns on his back’.

An example of establishing rapport to confirm
suspicions was provided. ‘Ultimately my goal is to
be able to have time alone with that patient. If we have
a good rapport going on, the family will leave. If we
force them to leave, a lot of times that really frightens
the patient and that puts up more defenses because
then they really think they are going to get in trouble’.
Thus suspicions of elder abuse lead to the reporting of
an allegation of abuse.
Reporting of elder abuse
Similar themes were found from all the nurses where
reporting of abuse is conducted in the hospital setting
according to hospital policy. In most instances, the
British Association of Critical Care Nurses
nurses reported suspected abuse to the patient’s
physician or the unit’s social worker. And in a VA
hospital, one nurse reported, ‘I know in the hospital I
work in right now that we aren’t supposed to report
it directly to the Department of Human Services. We
are supposed to go to the federal before we go to state,
as this is a federal hospital. We have to report it to
the manager and then the social worker, and then she
takes it further’.
One nurse said, ‘I would report, because there’s
not a penalty to reporting, unless you are doing it
to be malicious. There’s no penalty and there’s no
harm to the patient by me saying, something doesn’t

seem right here’. Stressing the importance of physical
injuries, one nurse would find the physician probably
first, so that the physical conditions can be dealt with,
and then we have our nurse managers, and the nurse
managers’ then are required to notify appropriate
people’.
Nurses generally seemed to let someone else do
the actual reporting to the state’s adult protective
services agency. ‘No, I’ve never reported the abuse.
I’ve told them what I’ve noticed, and then the social
worker does the report’. And another similar response,
‘We’ve got the chain of command: our charge nurses,
or supervisor, and so on. It’s always worked. We have
an excellent social worker’.
Another similar theme to reporting was that the
nurses did not know what happens after the allegation
is reported to the social worker. A nurse described,
‘I’m not sure how the system works as far as reporting
up past the social worker. . .where it’s supposed to
go, but I’d always go to the social worker’. Similarly,
nurses did not know the end result of the case, if it was
founded or not. A nurse conveyed, ‘I don’t really know
whatever happens afterwards. It goes to the manager,
it goes to the social worker, and then it goes to. . .I
don’t know, like a safety officer or something and then
it goes. . .I don’t know where it goes. It goes to some
federal officer and then state gets notified. So, it’s like,
where does it go? It’s like out there in virtual space or
something’. Another nurse said, ‘We never find out a
result’.
In emergency situations, a nurse reported, ‘If it was
severe enough you would have to call the authorities.
Absolutely, call the police and make sure whoever

the perpetrator was had no access to the patient’. And
because of the shift changes and staffing, another nurse
conveyed, ‘. . .because we do 12-hour shifts, but there
are a lot of nurses that take care of these patients, so
you always want to make sure to give your thoughts
and your feedback to give it to the next nurse to be
sure it doesn’t fall through the cracks. Because you’re
not going to come back a week later and be like, Well
you know I thought there could potentially be. . .You
don’t want that’.
Barriers to reporting elder abuse
Reasons provided by the nurses why patients are
reluctant to report being abused include being scared,
feeling they deserve the abuse, it may get worse when
they get home, fear of being relocated to a nursing
home or different institution, fear of abandonment or
they do not want to get their children in trouble. One
nurse stated, ‘You have an inverse ratio of power in that
relationship, whether it’s with a spouse, or a neighbor,
or a child, or whoever the perpetrator is. These people
are older. They are dependent on who ever or at
least their perception is that they are dependent on
that person for whatever, shelter, food, clothing, care,
money, or whatever. I think they are afraid to disrupt
it’. Another nurse reiterated the same thought, ‘people
that are co-dependent on other people tend to need
that other person and tend to justify [the abuse]’.
A similar thread across interviews was that the
perpetrator was a relative and they did not want to
get them in trouble. The nurse felt the patient thinks,
‘Oh, I brought this child up, this is how I brought them
up to be. They get real touchy when it’s their kid’.

Legislation
Nurses provided mixed responses about the state’s
legislation, including the following: we don’t need a
law, the law should be better enforced, and health
care professionals’ education should be more frequent
and content expanded. A nurse responded about Iowa
legislation that, ‘I don’t really think we even need the
law, because we do it anyway’. And another nurse
provided a different opinion, ‘Oh, I think it definitely
needs to be there, because, you know, without that,
some people when they notice it, well, that’s too bad,
but it’s not me’.
Health care professionals in Iowa are required to
report allegations of elder abuse. A nurse’s perception
about this reporting was, ‘I think that if people feel
like its mandatory, they have to, they are more likely
to do it than if they think, Oh, I don’t really have to
do it. I know it’s wrong, but I don’t really want to
get involved’. Whereas, another said, ‘the nurses that I
know anyway take that seriously and realize that they
have made an oath, so that if they feel that something
is going on with someone that it is their moral and
ethical duty to step up and say, This isn’t right and I’m
not going to let it continue’.
Completion of a dependent adult abuse curriculum
is required for health care professionals, beginning
when they enter a health care profession and every

5 years thereafter. Additional content to this curricu-
lum was suggested, as ‘more education about it [report-
ing abuse], what we can and cannot do. And our legal
liability, are we putting ourselves up for a lawsuit’.
Another complaint about the law was ‘the law doesn’t
lay out the signs and symptoms [of abuse], doesn’t tell
you when you see it. It doesn’t give you that way of
noticing the abuse. It just gives you a way of contacting
the law enforcement. It doesn’t give you a way of recog-
nizing the abuse or. . .how to recognize the symptoms’.
I think it’s adequate, but like I said I’d like to have some-
thing on elderly abuse and just abuse in general annu-
ally. Because I don’t think every 3 years is enough’.
In response to the law needing to be better enforced,
one nurse stated, ‘we don’t have investigators out
there’. Indicating that the law should provide for
additional investigators for conducting investigations
of alleged abuse. Another final thought on the law was,
‘in the best of all worlds, we wouldn’t have abuse [and
then wouldn’t need the law]’.
Improvement in practice
Various ideas were suggested for improving nursing
practice for elder abuse in critical care. Suggestions
included the following: conduct health history in
private, ask safety questions on admission assessment,
readdress the issue of elder abuse at discharge from the
unit, establish the reporting of elder abuse as a priority
for the unit and offer elder abuse education in addition
to that required by law.
One nurse reports, ‘On admissions, we ask questions
like, Are you in a relationship where you feel unsafe?
Are you in a relationship where you are being harmed

by someone? Do you want to harm yourself’? Those
kinds of things. We ask those questions, and that
gives them an opportunity to say, ‘Yes’. Emphasizing
the need for admission assessment, another nurse
responded, ‘You know, I think probably. . . , you have
to identify that there is truly a problem, and for
example, a problem there. Epidemiology comes up,
documents transmission of one bacteria from one
patient to another that can be stopped by washing
your hands. And they show that there is a problem.
And if there is problem that it can be changed by doing
this. So, I think that if you could document that there
is some type of abuse going on, then I think there is
more motivation, and maybe that’s how to change’.
Additional education was suggested by providing
information about the seriousness of elder abuse. A
nurse suggested, ‘I think it should almost be like an
annual thing that they cover in the hospital. Because,
I don’t know, I think with the way the economic
situation is out there. . . .I just think things are going
to get worse instead of better and I think we need
to be more aware of that’. Another nurse stated, ‘Just
keeping the education going’.
In conclusion to the interviews, one nurse stated, ‘I
just really think we’re on top of it. Not to toot our own
horn, but I really do, I really think that we’re on top
of it. . .any admission, I mean, we’re really looking at
those things whether you realize it or not’.
DISCUSSION
The purpose of this study was to explore the
perspectives of critical care nurses on elder abuse
to achieve a better understanding of the problems of

reporting and generate ideas for improving the process.
A variety of responses emerged, some responses
similar for a particular concept and dissimilar for other
concepts.
Intensive care nurses are aware of the different types
of elder abuse. They described different scenarios
regarding emotional abuse, financial exploitation,
neglect and physical abuse and noted that none were
aware of sexual abuse. Being aware of abuse is the
first step in caring for persons who are at-risk or
are victims of abuse. Burgess and colleagues (2006)
emphasize the importance for critical care nurses of
having protocols in place to detect and manage elder
sexual abuse. Protocols would allow nurses to detect
abusive instances but also identify risk factors that
may contribute to abuse and establish a mechanism for
reporting the suspicion or allegation of abuse.
These nurses want to do the right thing: i.e. to
ensure that victims of elder abuse are identified and
properly cared for during their ICU stay and after
discharge. ICU policies and procedures must be an
integral part of the standards of care. Hoyt provides
a compliance checklist for forensic issues in the ICU
that includes the following: (a) staff orientation for use
of abuse and neglect screening tools with appropriate
documentation, (b) forensic case management criteria,
(c) management of sentinel events (such as death from
neglect), (d) equipment and supplies for evidentiary
specimens available in a dedicated, locked storage
area, (e) references and resources available to all staff
members and (f) procedures that include collection
of specimens, photo documentation, chain-of-custody
and reporting/referral (Hoyt, 2006).

These nurses did have the intuition for being
suspicious of abuse. Winfrey and Smith describe a
phenomenon called the ‘suspiciousness factor’ which
is an intuitive sense of heightened alertness based on
knowledge and experience that compels a nurse to take
action in response to a given circumstance or series of
events (Winfrey and Smith, 1999). Nurses described
reasons for being suspicious, and in one instance the
suspicion became real when the nurse realized the
ventilator tubing was being damaged. Nurses need to
continually be aware, to act on their suspicious feelings
and to obtain additional information from the patients
or respective family members/significant others who
can provide needed information. This extra intense
probing must continue until their curiosity is satisfied.
As noted by one of the interviewees, the opportunity
for obtaining information is sometimes short-lived in
the intensive care setting.
The nurses indicated the process for reporting
elder abuse in the critical care setting is vague and
unknown. They collect some of the information, or
enough information to raise concern and pass that
information on to the patient’s physician or the
unit’s social worker. The actual mechanism of calling
adult protective services has not been performed by
this group of nurses, as they are following hospital
protocol. As a result, they never know the results of

the report. No feedback is provided to them about
further investigation by the state’s adult protective
services unit. This lack of feedback may be a reason
why one nurse thought there were not enough
investigators in the state. Hospital social services
could implement a protocol that provides feedback
to reporters when they are notified of the decision
by adult protective services to accept the report and
provide an outcome of the investigation. Having such
a mechanism in place would raise awareness of elder
abuse and provide the reporter with more confidence
that the extra work of investigating was worth the
effort.
No new information was gleaned from the nurses’
perceptions regarding the older person’s rationale for
not reporting elder abuse. The nurses described the
law for dependent elder abuse on a continuum, from
not being necessary to the need for it to be in place. As
health care professionals in Iowa, nurses are required
by law to be mandatory reporters. A suggestion from
nurses in critical care units is that they be notified when
the abuse they have reported to hospital employees is
actually reported to adult protective services. Hospital
employees who report the allegation of abuse receive
the results of adult protective services investigations
and should report those results to the health care
professionals involved in the collection of relevant
information.
While Iowa is currently the only state with manda-
tory training on dependent adult abuse, confusion still
persists as to the actual law surrounding both abuse
and mandatory reporting, especially by nurses (Jogerst
et al., 2003). Differing institutional requirements and
chains of command may contribute to this confusion.

However, when asked what changes or improvements
could be made, many people from all groups sug-
gested more frequent and more practical education.
While currently mandated for every 5 years in Iowa,
participants requested refreshers to be given as often
as yearly. They also desired content to focus on specific
cases, how to identify elder abuse, as well as how to
best respond.
Some novel and useful suggestions were offered for
improving critical care practice in relation to elder
abuse. Assessment for abuse or risk factors of abuse is
acknowledged on admission to a unit; however, one
nurse thought this assessment should also occur at
discharge from the unit. Persons admitted to critical
care are in critical condition and usually not of
sound mind to answer questions or provide relevant
information, but at discharge their health has improved
and useful information may be obtained.
Even though Iowa law requires dependent adult
abuse education, the numbers of elder abuse inves-
tigations and substantiations have not changed since
1988, when this law was implemented (Jogerst et al.,
2003). These nurses believe education is valuable and
indicated they want more education than that which is
required every 5 years.
While this sample size was small, it was appropriate
in order to fulfil our study purpose which was to
identify the range and complexity of issues and barriers
perceived by critical care nurses in relation to elder
abuse and within the sample size range for similar
exploratory qualitative studies (Rice and Ezzy, 1999).
Our sample was limited to three counties in Iowa which

report to the Iowa Department of Human Services,
whose elder abuse legislation is different from other
states (Daly and Jogerst, 2001; Jogerst et al., 2003).
Nurses who agreed to participate may have particular
interest in elder abuse from prior experience, and
responses may be different from those who did not
participate.
CONCLUSION
Critical care nurses are aware of elder abuse
and somewhat systematically evaluate for abuse at
admission to their unit. They recognize signs and
symptoms of abuse and are suspicious when it
is warranted. They are aware of why an older
person does not want to report abuse and take this
into consideration when soliciting information. Facts,
values and experience impact personal approaches to
defining abuse, suspicion and dependence for each
individual health care professional. Promoting the
inclusion of elder abuse reporting and investigations
in unit protocol and/or policies and procedures is
warranted for providing quality of care.
ACKNOWLEDGEMENTS
The research fellowship for Amy Schmeidel to conduct
this project at the University of Iowa was funded from
the NIH 5 T35 HL007485-28 award entitled, Short-Term

Training for Students in Health Professions Schools
and the University of Iowa Carver College of Medicine.
WHAT IS KNOWN ABOUT THIS TOPIC
• Elder abuse presents in any health care setting, including
critical care.
• In Iowa, health care providers are required to report
suspicions of elder abuse.
WHAT THIS PAPER ADDS
• Protocols for reporting elder abuse are needed in critical care
settings.
• Barriers for older patients in critical care not reporting abuse
are similar to other settings, including fear of retaliation,
perpetrator is a
relative and physical injury.
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APPENDIX A: OPEN-ENDED INTERVIEW
QUESTIONS
Instructions: Remember, during the interview, I will be
taping our conversation. Please provide no information
that would identify yourself or any of your patients.
We are interested in understanding nurse’s thoughts on
addressing elder abuse in the outpatient clinical setting.

1. Please tell me about the kinds of elder abuse
that an intensive care unit/critical care unit nurse
might encounter in the inpatient setting?
2. Please tell me about any patient situations
(provide no names or patient identifiers) in which,
for whatever reason, made you think that there
may be risk of or probable elder abuse?
3. What might make you suspicious that a patient
of yours was experiencing elder abuse?
4. What would you do if you become suspicious?
5. Is there anything else that a nurse might consider
doing once there is suspicion of elder abuse?
6. Under what conditions if any would you report
abuse?
7. Under what circumstances if any would you
consider only monitoring?
8. Why do you think that patients who have been
victims of elder abuse might be reluctant to bring
this up with their nurse?
9. Why do you think nurses may not address the
topic of elder abuse, even if suspected?

10. How do you feel about the law that requires
nurses to report suspected elder abuse?
11. What do you think could be carried out in your
practice to help improve the effectiveness of nurse
efforts to address elder abuse?
12. What changes can be made to the clinic (inpatient)
setting or environment that will help improve the
effectiveness of nurse efforts to address elder
abuse?
13. Is there anything else that we haven’t talked about
that you would like to say about improving nurse
effectiveness in addressing elder abuse?
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279 Indian Journal of Community Medicine/Vol 40/Issue
4/October 2015

Introduction
In India, the phenomenon of population ageing has
resulted in various challenges on family and the society.
With changes in the family system, older people are no
longer considered an asset to the family. Individualistic
attitude and craving for personal achievements leads
to intergenerational tension and elder abuse within the
family.
‘Elder abuse is a single or repeated act of, or lack of
appropriate action, occurring within any relationship
where there is an expectation of trust which causes harm
or distress to an older person’.(1) Abuse usually occurs
at two sites—home and institution. Abuse occurring at
home is usually not reported either due to unawareness
of the victims regarding different legal provisions or
due to fear of grave consequences by the abuser or due
to social taboo.
The impact of abuse on physical and psychological
healt h of the victims as well as quality of life
is enormous. Abuse can exacerbate chronic and
d i s a b l i n g c o n d i t i o n o f o l d e r p e r s o n a n d
m a k e
t h e p e r s o n m o r e d e p e n d e n t , v u l n e r a b l e , a
n d
marginalized.(2)
Indian data are limited. Lack of well-validated
s c r e e n i n g t o o l m a y b e o n e r e a s o n f o r p o o r
documentation. Hwalek–Sengstock Elder Abuse
Screening Test (H-S EAST) is a tool with 15 items
which targets three domains: violation of personal
r i g h t s o r d i r e c t a b u s e a n d c o n t e x t u a l f a c

t o r s
contributing of vulnerability and potentially abusive
situations.(3) The present study was conducted to
assess the prevalence and type of abuse among
community dwelling elderly and to study the various
risk factors associated with it.
Prevalence and Risk Factors of Abuse among
Community Dwelling Elderly of Guwahati City,
Assam
Anku Moni Saikia, Neelakshi Mahanta1, Ajaya Mahanta2,
Ashok Jyoti Deka3, Arupjyoti Kakati4
Departments of Community Medicine, 1Medicine, 2Neurology,
and 4Physiology, Gauhati Medical College, Guwahati,
3Department of Community
Medicine, Fakhruddin Ali Ahmed Medical College, Barpeta,
Assam, India
ABSTRACT
Background: In spite of tremendous impact on health, elder
abuse is still an underreported and unrecognized issue.
Objectives: To
assess the prevalence of abuse among community dwelling
elderly and to identify the various risk factors. Materials and
Methods:
This community-based cross-sectional study was conducted in
10 randomly selected wards of Guwahati city. A total of 331
elderly (60 years and above) were interviewed. Abuse was
screened by Hwalek-Sengstock Elder Abuse Screening Test (H-
S EAST).
Results: The study revealed 9.31% prevalence. Neglect was the
most common type of abuse reported. Age, sex, socioeconomic
status, living status, and functional status were found to be
significantly associated with abuse. Conclusion: Abuse is
prevalent

among elderly population.
Keywords: Elderly abuse, Hwalek–Sengstock Elder Abuse
Screening Test, maltreatment, risk factors
Address for correspondence:
Dr. Anku Moni Saikia, Department of Community Medicine,
Gauhati Medical College, Guwahati - 781 032, Assam, India.
E-mail: [email protected]
Received: 19-06-14, Accepted: 05-11-14
Access this article online
Quick Response Code:
Website:
www.ijcm.org.in
DOI:
10.4103/0970-0218.164406
Short Communication
Saikia, et al.: Prevalence and risk factors of elder abuse
Indian Journal of Community Medicine/Vol 40/Issue 4/October
2015 280
Materials and Methods
This community-based cross-sectional study was
carried out in Guwahati City from 1st April 2013
to 30th June 2013. This capital city is the gateway
to northeastern states with a population of 968,549

according to 2011 census. Considering the fact
that prevalence of abuse varies with sociocultural
context of the study setting and there is no authentic
prevalence available, sample size was calculated
using the formula; n = 4PQ/L2, where P was taken as
50%(4) and allowable error as 10% of P. The calculated
sample size was 400. After applying the exclusion
criteria, 69 were excluded, the final sample size became
331. Elderly above 60 years of age and both sexes
were included in the study. Elderly with known or
diagnosed psychiatric illnesses including dementia,
scoring ≥5 on 15-item Geriatric Depression Scale, and
also who failed to comprehend the interview were
excluded considering the fact that screening tool
used in the study is based on direct questioning of the
elderly. Approval from Institutional Ethics Committee
was obtained for the study.
Out of 31 municipality wards of the city, 10 wards
were selected randomly. From each ward, 40 elderly
were selected. House-to-house visits were made until
the desired sample was met. From each household, all
eligible elderly were included in the study. Information
w a s c o l l e c t e d o n a p r e d e s i g n e d a n d p r e t e
s t e d
schedule. Modified Kuppuswamy’s Scale was used
for assessment of socioeconomic status. Functional
status was assessed by Barthel Index. Financially
independent elders were those who had one or other
means of current income which was sufficient for self-
maintenance. H-S EAST was used to detect the elders
at risk of abuse. The instrument was translated into
the local language and again retranslated to reassure
validity. The person showing suggestive scoring was
again asked more on type of abuses and perpetrators
of abuse. Attempts were made to identify types of

abuse. The working definitions of these types of abuse
are based on the World Health Organization (WHO)
definitions. The study focused on abuse of elderly in
the home settings only. No attempt was made to verify
the signs of abuse.
Results
Out of the total 331 elderly interviewed, abuse was
found in 31 (9.36%). Statistically significant association
was observed between age, gender, living status,
socioeconomic status, and functional status with
abuse [Table 1]. However, financial dependency was
not found to be significantly associated with abuse
(P < 0.05).
Neglect was reported by all males and females followed
by verbal abuse. Physical abuse was reported by two
(9.09%) elderly and significantly both were females
[Figure 1].
Table 2 depicts the perpetrators of abuse in the family. It
was seen that, the main perpetrator of abuse was son
(51.61%) and followed by daughters-in-laws (48.39%).
Table 1: Prevalence of abuse according to certain variables
Age (in years) Abuse χ2 and
P - valueYes
(n = 31)
No
(n = 300)
Total
(n = 331)

60-74 15 (5.38) 264 (94.62) 279 (100) χ2 = 43.591
75-84 12 (26.09 34 (73.91) 46 (100) P = 0.000
> 85 4 (66.67) 2 (33.33) 6 (100)
Sex
Female 22 (14.19) 133 (85.81) 155 (100) χ2 = 8.005
Male 9 (5.11) 167 (94.88) 176 (100) P = 0.005
Living status
Living with spouse 4 (28.57) 10 (71.43) 14 (100) χ2 = 38.228
Living with spouse
and children
6 (2.65) 220 (97.35) 226 (100) P = 0.000
Living with children/
relatives without
21 (23.08) 70 (76.92) 91 (100)
Spouse
Functional status
Intact 10 (3.97) 242 (96.03) 252 (100) χ2 = 36.235
Non-intact 21 (26.58) 58 (73.42) 79 (100) P = 0.000
Socioeconomic
status
Upper 2 (25) 6 (75) 8 (100) χ2 = 21.502
Upper-middle 8 (11.76) 60 (88.24) 68 (100) P = 0.000
Lower-middle 5 (16.13) 72 (83.87) 77 (100)
Lower-lower 9 (5.70) 149 (94.30) 158 (100)
Lower 7 (35) 13 (65) 20 (100)
Financial status

Independent 18 (13.33) 117 (86.67) 135 (100) χ2 = 4.228
Dependent 13 (6.63) 183 (93.97) 196 (100) P < 0.05
22 (100%)
20 (90.9%)
18 (81.82%)
2 (9.09%)
9 (100%) 9 (100%)
6 (66.67%)
0
5
10
15
20
25
NEGLECT VERBAL FINANCIAL PHYSICAL
ABUSE
FEMALE MALE
Figure 1: Bar diagram showing different types of abuses in male
and
females

Saikia, et al.: Prevalence and risk factors of elder abuse
281 Indian Journal of Community Medicine/Vol 40/Issue
4/October 2015
Discussion
The prevalence of elder abuse in the present study
could be viewed as a tip of an iceberg. However,
t h e p r e s e n t f i n d i n g w a s s o m e w h a t l o w e r t
h a n
that reported by Skirbekk and James.(5) The range
of abuse reported by different studies was wide
(3.2-27.5%), possibly reflecting true variation in
above rates across cultures as well as defining and
measuring abuse.(6) Various studies across the globe
have shown higher prevalence of elder abuse in the
community.(7-10) HelpAge India in their study found
a national prevalence of 23%. However, Sivsagar
District from Assam was included and abuse was not
reported at all.(11) Higher prevalence in the present
study than reported by HelpAge India could be
attributed to the urban setting of the study. Regarding
the types of abuse, our findings were in conformity
with other studies.(7-9)
Son, being the main perpetrator of abuse, could be partly
due to fact that living with son was the most favored
option in the study area.
A statistically significant association was observed
between age, sex, living status, functional status, and
socioeconomic status [Table 1]. Age, sex, poverty,
functional dependency, and low socioeconomic status
were identified as risk factors for reported elder

mistreatment by various authors.(3,7,11) Women were
found to be more at risk. This could be due to their
status in the society as well as their economically
disadvantageous position.
The present study could be an eye-opener for policy
makers to institute appropriate interventions. The issue
needs to be fully explored.
Acknowledgment
We deeply acknowledge the elders for participating in the
study. We also acknowledge Anjana Moyee Saikia, Statistician,
Department of Community Medicine, Gauhati Medical College
for statistical inputs.
References
1. Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R.
Editors.
World report on violence and health. Geneva: WHO;2002:123-
45.
Available from: www.who.int/violence_injury/violence/world_
report/en/. [Last accessed on 2013 Feb].
2. Gupta R, Chaudhuri A. Elder abuse in a cross-cultural
context:
Assessment, policy and practice. Indian J Gerontol
2008;22:373-93.
3. Perel-Levin S. Discussing screening for elder abuse at
primary
health centre level. Geneva: WHO. 2008:129. Available from:
www.who.int ageing/publications/discussing_Elder_Abuseweb.
pdf. [Last accessed on 2013 Feb].
4. Sarmukaddam SB, Garad SG. On validity of assumption

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