Abuse of Older Chinese With Dementia by Family Caregivers

Abuse of older Chinese with dementia by family caregivers:
an inquiry into the role of caregiver burden

Elsie Yan
1
and Timothy Kwok
2
1
Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong
2
Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
Correspondence to: Dr E. Yan, E-mail: elsieyan@hkucc.hku.hk
Objective: This study examined the prevalence and risk factors for elder abuse in older Chinese with
dementia by their family caregivers in Hong Kong.
Methods: A sample of 122 family caregivers of older persons with dementia was conveniently recruited
from local community centers for the elderly. Participants provided information on their demographic
characteristics, care recipients physical functioning and agitated behavior, caregiver burden, and
whether they had directed any abusive behavior at the care recipients in the previous month.
Results: Sixty-two and 18 per cent of the caregivers reported having verbally or physically abused the care
recipients in the past month. Family caregivers who spent more days co-residing with the care recipients,
lacked any assistance from a domestic helper, observed more agitated behaviors in the care recipients,
and/or reported a higher level of caregiver stress, reported more abusive behaviors. The results of
hierarchical regression analysis showed that the number of co-residing days ( p <0.001), lack of any
assistance from a domestic helper ( p <0.05), and caregiver burden ( p <0.01) were signicant predictors
of verbal abuse. Care recipient agitated behavior ( p <0.01) also predicted verbal abuse, with its effect
mediated by caregiver burden. For physical abuse, the number of co-residing days ( p <0.01) was the
only signicant predictor.
Conclusions: Verbal and physical abuse were highly prevalent among this population of older Chinese
with dementia. A higher level of caregiver stress is related to a higher level of verbal, but not physical
abuse inicted by the caregivers of these older persons with dementia. Copyright #2010 John Wiley &
Sons, Ltd.
Key words: elder abuse; dementia; Chinese; family caregivers
History: Received 9 October 2009; Accepted 29 April 2010; Published online 5 August 2010 in Wiley Online Library
(wileyonlinelibrary.com).
DOI: 10.1002/gps.2561
Introduction
Elder abuse refers to actions that cause harm or create
a serious risk of harm, whether or not intended, to a
vulnerable elder by a caregiver or other person who
stands in a trust relationship to the elder, or failure by a
caregiver to satisfy the elders basic needs or to protect
the elder from harm" (US National Research Council,
2003: p. 40).
Older adults with cognitive or physical impairments
are more likely to be abused by their caregivers
than other older adults (Choi and Mayer, 2000). Older
people with dementia, in particular, have been descri-
bed as a group at high risk for domestic violence (Dyer
et al., 2000; Hansberry et al., 2000; Wang, 2006).
Estimates of the prevalence of the abuse of older
persons with dementia range from 5 to 55%, far exce-
eding the 3.227.5% prevalence rates typically cited for
all older adults (Cooper et al., 2008). According to the
caregiver stress model, a family stressor may lead to
the occurrence of a family crisis, but appraisal of the
stressor can inuence the stressor effects on the occu-
rrence of a crisis (McCubbin and Patterson, 1983). In
the context of dementia and elder abuse, a cognitively
RESEARCH ARTICLE
Copyright # 2010 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2011; 26: 527535.
or physically impaired older person in the family is a
stressor that can lead to elder abuse. The caregivers
appraisal of the stressor, i.e. their perceived burden,
moreover, can inuence the effects of the dementia on
the likelihood of elder abuse. In line with the caregiver
stress model, research has shown that in a shared living
environment (Hansberry et al., 2000; Shugarman et al.,
2003), cognitive or physical impairments of the care
recipients (Choi and Mayer, 2000), behavioral disturb-
ance exhibited by the care recipients (Bredthauer et al.,
2005), and caregiver stress (Quayhagen et al., 1997)
were all associated with elder abuse in older persons
with dementia.
The aim of the present study was to determine the
prevalence of and risk factors for verbal and physical
elder abuse among older Chinese with dementia by
their family caregivers in Hong Kong. The conceptual
model was based on the caregiver stress model and
included variables selected from the literature, includ-
ing the living arrangement, kinship, care-recipient phy-
sical functioning and agitated behavior, and caregiver
perceived burden in relation to care giving. In testing
this model, we will also examined the impact of
the caregiver lial piety, a traditional cultural value in
Hong Kong which prescribes that younger family
members take care of older family members. We hyp-
othesized that after controlling for the demographic
characteristics, agitated behavior (an objective stres-
sor) would have an impact on elder abuse (the family
crisis). The relationship between agitated behavior and
abuse, however, would be mediated by caregiver bur-
den (i.e. caregivers appraisal of the stressor).
Methods
The protocol of this study was approved by the ethical
committee of the University of Hong Kong.
Sampling
We recruited family caregivers of older Chinese with
a clinical diagnosis of dementia who were living in
the community and were existing service users or new
referrals of a local non-governmental organization.
The organization runs 31 community centers covering
all districts in Hong Kong and provides services for
older people and their families including home care,
day care, and respite services. Of the 135 family care-
givers referred to the present study, 122 were succ-
essfully interviewed, yielding a response rate of 90%.
Having explained the study and condentiality issues,
written consent was obtained from all participants.
They were then individually assessed on a battery of
instruments by a trained female research assistant.
Interviews took place at a time and place convenient to
the caregiver, usually at their own homes.
Measures
Demographic variables. Data were collected on the
caregiver age, gender, education level, marital status,
employment status, number of months since rst assu-
ming the caregiving activities, use of community ser-
vices in relation to elder care (total number of days per
month using any form of community service including
respite care, home help, and day care services), as well
as the care recipient age, gender, chronic condition,
and living arrangements, and whether they had recei-
ved any training in dementia care.
Physical functioning. Care recipient physical function-
ing was measured by the Lawton Instrumental Acti-
vities of Daily Living (Lawton IADL; Lawton and
Brody, 1969).
The Chinese version of the Lawton IADL demon-
strated satisfactory internal consistency (Cronbachs
a0.86) and had an overall prediction accuracy of
78% in discriminating residents in hostels and care-
and-attention homes (Tong and Man, 2002). Partici-
pants rated the care recipients ability to carry out
various tasks on a 3-point scale ranging from totally
independent to totally dependent, with a higher score
indicating a greater ability to perform everyday acti-
vities independently. The IADL has an internal
consistency a of 0.90 in this study.
Agitated behaviors. Care-recipient agitated behaviors
were assessed by the 29-item caregiver rating Cohen-
Manseld Agitation Inventory (CMAI, Cohen-Mans-
eld, 1986, 1996). The Chinese version of the CMAI
has shown satisfactory reliability across methods and
raters (Chronbachs a ranged from 0.63 to 0.86) (Lin
et al., 2007). Participants indicated on a 7-point scale
the frequency of which the care recipients display each
of the cited behaviors in the preceding month, with a
higher score indicating a greater frequency of agitated
behaviors. The CMAI has an internal consistency a of
0.81 in this study.
Filial piety. The 10-item Filial Piety and Ancestral
Worship subscale of the Chinese Individual Tradition-
ality Scale (Yang and Huang, 1991) was used to assess
family caregiver attitudes toward lial piety. Partici-
528 E. Yan and T. Kwok
pants indicated on a 4-point scale the degree to which
they agree or disagree with each item, with a higher
score indicating a stronger adherence to the traditional
Chinese value for intergenerational relationships. The
scale has an internal consistency a of 0.64 in this study.
Caregiver burden. Family caregiver perceived burden
of care-giving was assessed by the 22-item Zarit Burden
interview (BI; Zarit et al., 1985), the instrument most
consistently used in dementia care-giving research
(Bedard et al., 2000). The BI (comprises) is comprised
of 22 items with 5 answers ranging from never (0) to
nearly always (4). A higher total score indicates a hig-
her level of perceived burden. The Chinese BI has good
inter-rater reliability and internal consistency, with an
intra-class correlation coefcient of 0.99 and split half
correlation coefcient of 0.81 (Chan et al., 2005). The
BI has an internal consistency a of 0.84 in this study.
Assessment of abuse. Items from the two subscales of
psychological aggression and physical assault from the
Revised Conict Tactic Scale (CTS2; Straus et al.,
1996) were used to assess the extent and nature of
abuse. The 12-items from the physical assault subscale
encompasses a wide range of violent behavior,
including slapping, grabbing, and using a knife against
the older person. The 6 items from the psychological
aggression subscale covers items such as insulting,
humiliating, or intimidating the older person. The
Chinese version of the CTS2 scale has demonstrated
good reliability, with an internal consistency a of 0.81
for psychological aggression and 0.82 for physical
assault, in previous studies of elder abuse in Chinese
(Yan and Tang, 2001). For the present study, family
caregivers indicated whether they had displayed each of
the cited behaviors to the care recipient in the past
month. The psychological aggression and physical
assault sub-scales have an internal consistency a of 0.64
and 0.69, respectively, in this study.
Data analysis
Data was analyzed using the statistics package SPSS
16.0. Chi-square tests and Correlation analyses were
conducted to reveal associations among variables. Mul-
tiple regression analyses were used to further examine
the impact of agitated behavior and caregiver burden
on caregivers reports of abuse. Sobel text was cond-
ucted to examine (the) any mediating effect of the
caregiver burden between agitated behavior and abuse.
For the above analyses, a p value less than 0.05 was
considered signicant.
Results
Sample characteristics
The participants were 122 family caregivers providing
care to older Chinese with dementia. The majority of
the family caregivers were female (76.2%, N93), and
their age ranged from 17 to 85, with a mean of 56.72
(SD13.03). The care recipients were mostly female
(74.6%, N91), and their age ranged from 59 to 103,
with a mean of 82.59 (SD8). All of the care recipients
had received a diagnosis of dementia from local medi-
cal practitioners. The majority of them also were
suffering from other chronic conditions in addition to
dementia at the time of the study (75.4%, N92).
The majority of the family caregivers were the adult
children of the care recipients (62.3%, N76), while
the rest were spouses (26.2%, N32), grandchildren
(2.5%, N3), or other family relatives (9%, N11).
The households in this study generally came from a
high income group, considering that the median
household income was USD 2200 (Hong Kong Census:
Government of Hong Kong SAR, 2006). Half of the
participants had a monthly household income of less
than USD 2500 (55.7%, N68), a quarter of them had
between USD 2500 and 5000 (N31, 25.5%) and
14.8% above USD 5000. Participants co-resided with
the care recipients on an average of 17.72 days per
month (SD14.81). The majority of care recipients
used community services (80.3%, N98). These inclu-
ded: home help (2.5%, N3), respite care (16.39%,
N20), and day care services (62.3%, N76). More
than one-third also received assistance from domestic
help (37.7%, N46).
The participants demographic characteristics and
descriptive statistics for the major variables are dis-
played in Table 1.
Prevalence of verbal and physical abuse among
older persons with dementia
The results show that verbal and physical violence
directed towards older persons with dementia by their
family caregivers is common in this population.
Among the 122 participants, 76 (62.3%) admitted to
displaying some form of abusive behaviors towards the
older care recipients within the past month. Verbal
abuse was the most common, with 62.3% acknowled-
ging at least one incident of verbal aggression. The
more common forms of verbal abuse included shout-
ing at the older person (57.4%, N70) and calling
the older person fat, ugly or other bad things (40.2%,
Dementia and elder abuse 529
N49). Physical abuse was less common, but was
reported by one-fth of the respondents (18%, N
22). The more common forms of physical abuse were
grabbing the older person (12.3%, N15) and beat-
ing up the older person (10.7%, N13). The preval-
ence of the different forms of verbal and physical abuse
is summarized and displayed in Table 2.
Demographic and psychosocial correlates of abuse
The results of the x
2
tests showed that the caregivers
kinship to the care recipients was not related to reports
of verbal or physical aggression ( p >0.05), nor was the
presence of chronic illness, or training in dementia care
related to the incidents of abuse ( p >0.05).
Correlation analyses results revealed that verbal
aggression and physical assault were highly correlated
(r 0.41, p <0.01). The two forms of abuse, however,
were associated with distinct variables. Verbal abuse
was related to a large number of co-residing days
(r 0.37, p <0.01), a lack of any assistance from a
domestic helper (r 0.26, p <0.01), a high level of
caregiver burden (r 0.33, p <0.01), a young age of
the care recipient (r 0.18, p <0.05), and a high
level of agitated behavior (r 0.25, p <0.01). Physical
abuse, conversely, was only related to a larger number
of co-residing days (r 0.24, p <0.01).
Care recipient agitated behavior was related to a high
level of caregiver burden (r 0.42, p <0.01), while
assistance from a domestic helper and a higher house-
hold income were (also) related to a lower level of
caregiver burden (r 0.20 and 0.29, p <0.05 and
0.01, respectively).
The caregivers education level, number of months
since rst assuming care-giving duty, sense of lial
piety, care-recipients chronic condition, and IADL
were not related to reports of verbal or physical abuse
( p >0.05), nor were they related to caregiver burden
( p >0.05). The detailed results of the correlation ana-
lyses are summarized in Table 3.
Regression analyses
Hierarchical regression analyses were performed to
ascertain the relative contribution of the various risk
factors in predicting caregivers reports of abuse. For
subsequent analyses, demographic variables, including
care recipient age, number of days the caregivers co-
Table 1 Scale performance and descriptive statistics for the major
variables
a
Situational Variables
No. of co-residing days 17.72 (14.81)
Assistance from domestic helper 46 (37.7%)
Caregivers Characteristics
Caregivers age 56.73 (13.03)
Caregivers gender
Female 93 (76.2%)
Kinship to care recipient
Spouse 32 (26.2%)
Adult children 76 (62.3%)
Grandchildren 3 (2.5%)
Family relatives 11 (9%)
No. of months assuming
care duties
66.83 (40.84)
Caregivers burden (range 088) 36.81 (14.39)
None/little burden 18 (14.8%)
Mild burden 51 (41.8%)
Moderate burden 48 (39.3%
Severe burden 5 (4.1%)
Caregivers sense of lial
piety (range 1040)
27.10 (3.1)
Care Recipients Characteristics
Care recipients age 82.59 (8.00)
Care recipients gender
Female 91 (74.6%)
Care recipients chronic illness 92 (75.4%)
Care recipients IADL (range 018) 1.27 (3.11)
Care recipients agitated behavior
(range 29203)
61.67 (17.99)
a
Data presented as number (%) or mean (SD).
Table 2 Prevalence of elder abuse
Prevalence
N122
Verbal elder abuse
Insulted or swore at 22 (18%)
Shouted at 70 (57.4%)
Threaten to hit or throw something
at the elder person
21 (17.2%)
Destroy things belonging to the elder person 1 (0.8%)
Said something to spite the elder person 5 (4.1%)
Call the elder person fat or ugly 49 (40.2%)
Subtotal (one or more of the above) 76 (62.3%)
Physical elder abuse
Kicked, bit, or punched 5 (4.1%)
Slapped 3 (2.5%)
Beat up 13 (10.7%)
Punched or hit with something
that could hurt
1 (0.8%)
Choked 0 (0%)
Slammed against a wall 0 ( )
Grabbed 15 (12.3%)
Threw something at the elder person
that could hurt
0 ( )
Used knife on 0 ( )
Pushed or shoved 6 (4.9%)
Twisted arm or hair 2 (1.6%)
Burned or scalded on purpose 0 ( )
Subtotal (one or more of the above) 22 (18%)
Overall elder abuse (one or more
of the subtypes)
76 (62.3%)
resided with the care recipient, and the availability of
assistance from a domestic helper were entered as
Block 1. Care-recipient agitated behavior was entered
as Block 2. Caregiver burden was entered as Block 3.
The results of the regression analysis are summarized in
Table 4.
For verbal abuse, the three blocks of predictor
variables accounted for 30% of the variance. The beta
values indicated that verbal abuse was best predicted
by a larger number of co-residing days, lack of any
assistance from a domestic helper, and a high level of
caregiver burden (b0.34, 0.16, and 0.23, p <0.001
and 0.01, respectively). A high level of agitated beha-
vior was also predictive of verbal abuse (b0.22,
p <0.01), but the effect diminished when caregiver
burden was entered into the model. The results of the
Sobel test conrmed that the effects of agitated beha-
vior on verbal abuse were mediated by caregiver bur-
den (Sobel test statistics 3.06, p <0.01). For physical
abuse, the three blocks of predictor variables accounted
for 7% of the variance. The beta values indicated that
physical abuse was only predicted by a larger number
of co-residing days (b0.24, p <0.001).
Hierarchical regression analyses were also perfor-
med to unearth the relationship between community
service use and co-residence, and their relative contri-
bution in predicting caregiver burden and reports of
abuse. For subsequent analyses, total number of days
per month using community service and number of
co-residing days per month were entered as Block 1. An
interaction term between the number of days co-
residing and the number of days using community
service was computed and entered as Block 2. The
results of the regression analysis are summarized in
Table 5.
The model accounted for 13 and 9% of the variance
in verbal abuse and physical abuse, respectively. The
beta values indicated that verbal and physical abuses
were predicted only by a larger number of co-residing
days in these models (b0.43 and 0.26, p <0.001 and
0.01, respectively). None of the variables were signi-
cant in predicting caregiver burden.
Discussion
Verbal and physical abuse is common in older Chinese
with dementia in Hong Kong. Sixty-two per cent of the
caregivers in this study admitted to displaying some
form of violence towards the older care recipients in
the past month. This rate is much higher than those
observed in cognitively competent older Chinese in
Hong Kong (27.5% in Yan and Tang, 2004), Taiwan T
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(22.6% in Wang, 2006), and the Peoples Republic of
China (35.2% in Dong et al., 2007). This rate, however,
is comparable to those reported in dementia patients
in western societies (52% in Cooper et al., 2009 and in
Cooney et al., 2006). Previous studies have shown
that people generally perceive abusive behavior as less
abusive when the victim has dementia (Matsuda,
2007). It is possible that such an attitude contributes
to the occurrence of abuse against older persons with
dementia.
Similar to the ndings from previous investigations
(Yan and Tang, 2004; Wang, 2006; Dong et al., 2007;
Table 4 Results of hierarchical multiple regression analyses
Verbal abuse Physical abuse
Standardized
coefcients
beta
t-value R
2
F change Standardized
coefcients
beta
t-value R
2
F change
Block 1: Demographics 0.21 10.36*** 0.06 2.41
Care recipients age 0.13 1.52 0.02 0.21
No. of co-residing days 0.35 4.24*** 0.24 2.65**
Assistance from domestic helper 0.23 2.72** 0.03 0.34
Block 2: Agitated behaviors 0.25 9.94*** 0.06 1.88
Care recipients age 0.14 1.68 0.02 0.24
Assistance from domestic helper 0.19 2.32* 0.04 0.42
Agitated behaviors 0.22 2.66** 0.05 0.57
Block 3: Caregivers Burden 0.07 1.78
Care recipients age 0.13 1.58 0.30 9.72*** 0.02 0.17
Assistance from domestic helper 0.16 1.99* 0.05 0.58
Agitated behaviors 0.13 1.45 0.01 0.06
Perceived caregivers burden 0.23 2.62** 0.12 1.16
*p <0.05. **p <0.01. ***p <0.001.
Table 5 Interaction between co-residence and use of community service on caregiver burden and abuse
Standardized
coefcients beta
t-value R
2
F change
Caregiver Burden 0.00 0.13
Block 1: Main Effect 0.03 0.32
Use of community service 0.04 0.43
No. of co-residing days
0.00 0.16
Block 2: Interaction Effect 0.01 0.08
No. of co-residing days 0.08 0.46
Community serviceco-residing days
Verbal Abuse
Block 1: Main Effect 0.13 9.19***
No. of co-residing days 0.35 0.43***
Block 2: Interaction Effect 0.13 6.09**
No. of co-residing days 0.35 2.33*
Community serviceco-residing days 0.03 0.18
Physical Abuse
Block 1: Main Effect 0.08 4.99**
No. of co-residing days 0.26 2.89**
Block 2: Interaction Effect 0.09 3.69*
No. of co-residing days 0.13 0.83
Community serviceco-residing days 0.17 1.05
*p <0.05. **p <0.01. ***p <0.001.
Cooper et al., 2009), the present study found that
verbal abuse is more prevalent than physical abuse.
While 62.3% of the respondents reported verbal abuse,
only 18% reported physical abuse. Distinct predictors
were noted for the two forms of abuse. Verbal abuse
was predicted by a larger number co-residing days, lack
of any assistance from a domestic helper, a high level of
agitated behavior, and a high level of caregiver burden,
whereas physical abuse was only predicted by a larger
number co-residing days.
The result that a larger number of co-residing days
was associated with both verbal and physical abuse
supports previous nding which showed the shared
living environment to be a major factor related to the
abuse of older persons with dementia (Hansberry et al.,
2000; Shugarman et al., 2003). Living in a shared living
environment, the caregiver and the care-recipient are
exposed to increased opportunities for interpersonal
conicts, which can give rise to incidents of elder
abuse.
The nding that a high level of agitated behavior
predicts verbal abuse is also in line with previous
studies, which showed that care recipients behavioral
disturbances were associated with both caregiver bur-
den (Coen et al., 1997; Arai et al., 2004) and abuse by
caregivers (Sasaki et al., 2007). The present results
supplement the existing literature by delineating the
relationship between agitated behavior, caregiver burden,
and abuse. Specically, our results show that agitated
behavior may have an impact on the elicitation of
abusive behaviors through its effect on caregiver
burden.
Assistance from a domestic helper was related to a
lower level of verbal abuse. A possible explanation for
this is that the assistance from a domestic helper can
mitigate the daily chores that the caregiver would need
to otherwise need to carry out on his or her own, and
thus minimizes caregiver burden and conicts between
the caregiver and the care recipient. Another plausible
explanation is that the presence of a non-family
member in the household may increase the caregivers
sense of self-awareness. Under the impression that one
is constantly observed and evaluated by someone
outside of his or her own family, the caregivers may be
less likely to engage in verbally abusive behaviors.
Limitations
This study has several limitations, and caution should
be taken in interpreting and generalizing the results.
First, the present sample was recruited from local non-
governmental organizations. Caregivers who did not
receive any service or did not have any contact with
local services were not represented in this study. It thus
remains unclear the extent to which the present sample
represents the general population of family caregivers
to older Chinese with dementia. Second, this study
relied solely on self reports of family caregivers regard-
ing incidents of abuse, which were subjected to recall
and social desirability biases. It is likely that the pre-
valence of elder abuse in this study is underreported in
terms of the real cases, but the magnitude of this failure
is unclear. Third, this was a cross sectional study and its
results represented associations between variables
only, so no conclusive statement on casual effects
can be inferred from the present ndings. Fourth, in
investigating elder abuse, the present study focused on
verbal aggression and physical assault; other forms of
elder abuse, including abandonment, neglect, social
and nancial abuse were not included. Finally, it
should be noted that the use of various factors acco-
unted for the minimal variance in the reported physical
abuse. It is possible that there are different mechanisms
underlying physical and verbal abuse. In fact, various
factors that may have important implications for elder
abuse, including cognitive impairment, premorbid
relationship, personality, substance use, and history of
psychiatric illness were not assessed in this study.
Further studies are needed to address these issues.
Implications
Although the present sample consisted of a highly
self-selected group and thus the results may not be
generalizable to the whole of Hong Kong, this study
does provide certain insights into the scale of elder
abuse problem in older people with dementia and shed
light on some of the associated risk factors. The results
of this study have important implications for public
policy on dementia care and the design and implem-
entation of elder abuse intervention programs. First of
all, intervention programs should be targeted to miti-
gating the caregiver stress experienced by family caregi-
vers. Community services should be designed to better
t the needs of family caregivers. Case management
supported by multidisciplinary efforts have been sho-
wn to be effective in not only improving symptom
severity in persons with dementia, but also relieving the
psychological distress experienced by family caregivers
(Chien and Lee, 2008), and may be useful in this area.
Second, education should be provided to family care-
givers to heighten their awareness of the rights of
older care recipients, as well as the behaviors that are
considered to constitute elder abuse. Education
programs should inform family caregivers of the
prognosis of dementia, and to advance their under-
standing of the reasons for care recipients occasionally
agitated behaviors. The use of psychoeducation groups
with caregivers have demonstrated some success in
alleviating the agitation and anxiety of demented older
persons (Haupt et al., 2000) as well as the caregivers
perceived burden in relation to these problems (Hebert
et al., 2003). Such training can potentially mitigate
elder abuse through its positive inuence on caregiver
stress and reaction to the agitated behaviors of those in
their charge.
Conclusions
Despite considerable research in elder abuse and dem-
entia, few studies have reportedly examined the abuse
of elder persons with dementia. The present study
indicates that verbal and physical abuses are quite
prevalent among older Chinese with dementia in one
population in Hong Kong. The caregiver stress model
is useful in understanding verbal aggression, but not
physical assault. Further study will be needed to both
explore the mechanisms underlying the physical abuse
of older persons with dementia and to determine
whether these ndings are representative of a general
pattern in Chinese society.
Conflicts of interest
None declared.
Acknowledgements
The authors would like to express thanks to all of the
family caregivers who kindly participated in this study.
Their gratitude is also extended to the staff in the
anonymous non-governmental organization who
helped them recruit the participants and Miss Grace
Leung who assisted them in data collection and
management. Dr Chun Fan Lee for his advice on
statistical analysis. Pacic Edit reviewed the manu-
script prior to publication. This study was supported
by the Seed Funding Research Program of the
University of Hong Kong, Hong Kong.
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among older Chinese with dementia in Hong
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Co-residence, lack of any assistance from
domestic helper, care recipient agitated behavior
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abuse.
Co-residence is associated with physical abuse.
Intervention programs should be targeted to
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