Depression as a Consequence of Elder Mistreatment: A Case Report

Abstract

A 61-year-old elderly woman came to the emergency room in tertiary hospital in Jakarta, Indonesia due to epigastric pain for the past 7 months which was worsened in the past 4 days. Due to her illness, her daughters prevent her to do daily chores and her hobbies, such as singing and gardening. On admission, she had hypertension with moderate dependency, frail, cognitive impairment, malnutrition, risk of sarcopenia, and risk of depression. She was later diagnosed with poorly differentiated colon adenocarcinoma and adjustment disorders with anxiety and depressive reaction due to emotional elder mistreatment. There are a variety of forms of elder abuse, not only physical, but also emotional, sexual, financial, and neglect. The prevalence of elder mistreatment is projected between 5% and 10% all over the world and it is thought to be underdiagnosed. Among the consequences of mistreatment or abuse include social alongside, economic, physical, and mental (e.g., isolation, constrained relationships, and broken social networks). This is a case report of depression because of elder mistreatment.

Introduction

Elder abuse or elder mistreatment can present in many forms, not only physical, but also emotional, sexual, financial, and neglect. The prevalence of elder mistreatment is projected between 5% and 10% all over the world. Most common form of elder abuse is physical abuse, which is occurring more often in Western countries (Acierno et al., 2010). Physical abuse is one of the common forms of elder mistreatment, it is defined as intentional use of physical force that may result in bodily injury, physical pain, and/or impairment. Emotional abuse on the other hand, is the most prevalent form of elder mistreatment, as it comprised of verbal and/or non-verbal acts that can cause elderly to feel depressed, isolated, or even helpless. Neglect is a refusal to fulfill any part of elderly needs, whether it was intentional and/or unintentional. Financial or material exploitation can be in a form of illegal or improper use of the elderly assets, by stealing from them, coercing an elderly into signing contracts or wills especially those with palliative condition, and it can be done when the elderly is not capable to make his/her own decision due to health condition. The rarest form of elder mistreatment is sexual abuse, which is when an elderly person is being sexually assaulted and/or verbal sexual threat without giving consent (Rosen et al., 2018). However, it is still an underdiagnosed issue that can lead to physical, mental, and economic burden not only to the patients but also to the families and caregivers. Assessing elder mistreatment using comprehensive geriatric assessment (CGA) with several elder mistreatment tools can help doctors to detect and prevent the consequences, such as depression.

Case Illustration

The subject in this study gave consent to have her case to be published based on the Declaration of Helsinki. A 61-year-old elderly woman came to the emergency room in a tertiary hospital in Indonesia due to worsening epigastric pain for the past 4 days (Visual Analog Scale of 5–6). She felt the pain for almost 2 weeks. The pain was intermittent and usually worsened when she ate. She did not feel any nausea or vomiting but she had loss of appetite due to the pain. She also felt fatigue all over her body without neurological deficits. In the past 2 weeks, she also complained of having black stools once a day. She had no history of black or brownish vomiting.

Seven months ago, she reported to have started feeling pain. She had been going into several hospitals and underwent esophagogastroduodenoscopy. She was diagnosed with erosive esophagitis grade A with erosive gastroduodenitis. She was treated with proton pump inhibitor (PPI) and Sucralfate, but she reported that she continued to feel the pain even after treatment.

She was active and fit prior to the onset of pain 7 months ago. She was working as a cooker, and she sold several foods in her restaurant with the help of her daughters. She liked to go to singing places and mall with her friends if she had a free time. She never had any trouble in her two-story home. She can clean and take care of the households by herself. However, after she started feeling the pain, her daughters became anxious about her thus she was not allowed to perform any daily chores or even cook for her family. She was not allowed to go to the second floor as she once complained of feeling tired of going up the stairs. Her daughters took over the daily activities, including gardening and chopping the food. She spent her time mostly at her room, watching television and sleep. She ate the food that her daughters cook for her. She started to feel depressed because she was not able to perform all her routine activities. She reported to have lost 15 kg in the past 7 months.

Her initial physical examination showed high blood pressure (systolic blood pressure: 163 mmHg and diastolic blood pressure 93 mmHg) with normal body mass index. She had pale conjunctiva with tenderness in the epigastrium and right upper quadrant area (Visual Analog Scale: 3–4). There were no palpable mass, liver, and spleen. Her laboratory examination showed normocytic normochromic anemia (8.8 g/dL) with low serum iron (34), low transferrin saturation (13%). She had increase procalcitonin (0.12) and C-reactive protein (7) with CEA of 4.4. She had positive fecal occult blood test with normal amylase and lipase level and normal bilirubin test. Her fecal test showed positive bacteria result with no other positive results. She had negative hepatitis marker test.

Her Comprehensive Geriatric Assessment (investigated retrospective in order to conclude the subject was independent as reported) showed that before 7 months ago, she was categorized as independent subject. On admission, she had hypertension with moderate dependency, frail, cognitive impairment, malnutrition, risk of sarcopenia, and risk of depression. Further examinations showed she had a circumferential mass in the ascendens colon in the hepatic flexure region that has infiltrated pars descendent of the duodenum with multiple paracolica lymphadenopathy. Biopsy of the mass was performed during colonoscopy and found out that there was an adenocarcinoma with poor differentiation. Psychogeriatric assessment for the patient was adjustment disorder with anxiety mixed with depressive reaction. Rehabilitation medics helped her to start early mobilization and trying her maximum capacity to perform daily activities as much as she was able to.

Discussion

There was an increasing population of elderly in Indonesia and throughout the world as projected by the Indonesia Statistic Department (Badan Pusat Statistik, 2018). As the elderly population increase, not only they have increased risk of the health deterioration, but also increases the likelihood of elder abuse or elder mistreatment. Elder abuse or elder mistreatment is defined as “a single or repeated act 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,” of which the definition was adopted by The World Health Organization (WHO) in 2008 (Wang et al., 2015; World Health Organization, 2008). Elder mistreatment is not only defined by physical assault, but it can also be in the form of psychological abuse (emotional pain or injury, isolation or threats, treating the elderly like a child), financial exploitation, neglect (failure of the family or the caregiver to fulfill the basic needs of the elderly), and sexual abuse.

The prevalence of elder mistreatment is varied among the countries, with the highest of 40% to 50% in the United States, especially those with dementia or in low-income Latino immigrants (Acierno et al., 2010). In the United Kingdom, the prevalence was about 2.6% and most of them were neglect (Biggs et al., 2009). In Europe, the most common type of elder mistreatment was emotional abuse with sexual abuse was the less common form of elder mistreatment. However, this study was done in only 3,000 subjects, thus the prevalence may not reveal the exact percentages. In Asia, the prevalence of elder mistreatment was 6.3% and 27% both in South Korea and China respectively. In China, most common form of elder mistreatment was due to emotional abuse (Du & Chen, 2021). Data regarding elder mistreatment in Indonesia is still scarce as it is a new emerging topic in geriatric medicine here.

Besides routine history taking and physical examinations, comprehensive geriatric assessment (CGA) needs to be done in evaluating the condition of the elderly as we know that elder mistreatment can lead to several health and mental consequences. CGA consisted of several domains, including physical, functional, nutrition, mental, cognitive, frail, sarcopenia, and quality of life. By performing CGA to the patient, we can evaluate the level of dependency, any sign of malnutrition, risk of depression, decline in cognitive function, and the quality of life.

Specific in Asia, the prevalence may be quite low compared to the data in the Western countries. This may be because elder mistreatment is not reported to protect the dignity of the family. A longitudinal study done in Japan showed that older adults with suffered from elder mistreatment were 2.28 times more likely to have depressive symptoms during 3-year follow-up period (Koga et al., 2022). This is aggravated if the elderly has lack of social support and treating an elderly like a child. This is in line with this case where we found out that she was diagnosed with adjustment disorders with anxiety and depressive reaction. Physicians need to evaluate etiology since it is a general recommendation to evaluate the etiology of whether it is due to her illness or other predisposing factors. Further follow-up questions using the Elder Abuse Severity Index (EASI) showed that she was mildly dependent to perform the routine activities and she reported that she was not able to perform her routine daily activities as well as her hobbies, which was singing and gardening. There were several things that she was doing previously, and she was not able to undertake them under her daughters’ directions, such as cooking, gardening, and other daily chores. Her daughters want her to rest and not to perform any daily chores to make her feel comfortable and less fatigue. Treating an elderly like a child is the most common form of emotional abuse, whether the patient and/or the caregiver realize it or not. Besides the epigastric pain, emotional abuse is making the patient more helpless and felt that she was only making inconveniences to her family. Multidisciplinary approach is the most important management to treat elder mistreatment. By providing education and training to both the patient and family and/or caregivers through family conference, physician can provide reassurance to them. Even though the patient may have several limitations in her daily chores, but that does not mean that she was not able to perform anything.

Conclusion

Elder mistreatment can occur in many types, not only physical, but also emotional, sexual, financial, and neglect. Early detection of any type of elder mistreatment using comprehensive geriatric assessment is needed to prevent any physical, mental, social, and economic consequences, such as depression. Multidisciplinary approach is the most important way to treat elder mistreatment.