Alessandra Pastorino, MD Francesca Greppi, MD Daniele Bergamo, MD Geriatric Division, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy Elisabetta Versino, MD Epidemiology, Department of Clinical and Biological Sciences, AOU San Luigi, University of Turin, Orbassano, Turin, Italy Mario Bo, MD Geriatric Section, Department of Medical and Surgical Disciplines, San Giovanni Battista Hospital, Orbassano, Turin, Italy Maria S. Pezzilli, MD Elisabetta Furno, MD Sokol Rrodhe, MD Gianluca Isaia, MD Geriatric Division, University of Turin, San Luigi Gonzaga Hospital, Orbassano, Turin, Italy

ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Pastorino, Greppi, Bergamo: preparation of manuscript, acquisition of subjects and data. Versino: analysis and interpretation of data. Bo: study concept and design. Pezzilli, Furno, Rrodhe: acquisition of subjects and data. Isaia: study concept and design, preparation of manuscript. Sponsor’s Role: None.

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10. Jarchow-MacDonald AA, Mangoni AA. Prescribing patterns of proton pump inhibitors in older hospitalized patients in a Scottish health board. Geriatr Gerontol Int 2013;13:1002–1009.

INSIGHT INTO ELDER ABUSE AMONG URBAN POOR OF KUALA LUMPUR, MALAYSIA—A MIDDLE-INCOME DEVELOPING COUNTRY To the Editor: Malaysia’s population is aging rapidly because of rising life expectancy, a lower crude death rate, and a falling birth rate.1 Sensitivity regarding the problems of elderly adults is necessary. Social problems such as elder abuse and neglect must be identified now to ensure that vulnerable older adults are protected and that Malaysia progresses as an aging society. Well-established child protective services serve as an example of how to do so.2 Research in developed countries is now focusing on a vulnerability index to identify such individuals within the community.3 Because these social problems have multiple contributing factors, a proper screening method and a broad multidisciplinary intervention approach are required.4 In Malaysia, the National Policy for the Elderly 20115 outlines six strategies centered on promotion and advocacy, safety and protection, and intergenerational involvement, among others. It emphasizes that elderly adults should be able to live with respect and self-worth, to be safe and free from oppression and abuse, and to continue living with their family within society as long as possible. This is a common attitude in Asian cultures, where filial piety toward elderly adults and preserving the integrity of family structure is valued, and institutionalization of elderly adults is frowned upon.

METHODS REFERENCES 1. Batuwitage BT, Kingham JG, Morgan NE et al. Inappropriate prescribing of proton pump inhibitors in primary care. Postgrad Med J 2007;83: 66–68. 2. Ahrens D, Behrens G, Himmel W et al. Appropriateness of proton pump inhibitor recommendations at hospital discharge and continuation in primary care. Int J Clin Pract 2012;66:767–773. 3. FDA Drug Safety Communication. Low Magnesium Levels Can Be Associated with Long Term Use of Proton Pump Inhibitor Drugs (PPIs). Washington, DC: U.S. Food and Drug Administration, 2011. 4. Gau JT, Yang YX, Chen R et al. Uses of proton pump inhibitors and hypomagnesemia. Pharmacoepidemiol Drug Saf 2012;21:553–559. 5. Danziger J, William JH, Scott DJ et al. Proton-pump inhibitor use is associated with low serum magnesium concentrations. Kidney Int 2013;83: 692–699. 6. Isaia G, Bo M, Aimonino N et al. Functional decline two weeks before hospitalization in an elderly population. Aging Clin Exp Res 2010;22: 352–355. 7. Isaia G, Maero B, Gatti A et al. Risk factors of functional decline during hospitalization in the oldest old. Aging Clin Exp Res 2009;21: 453–457. 8. Martin BJ, Black J, McLelland AS. Hypomagnesaemia in elderly hospital admissions: A study of clinical significance. Q J Med 1991;78: 177–184. 9. Arinzon Z, Peisakh A, Schrire S et al. Prevalence of hypomagnesemia (HM) in a geriatric long-term care (LTC) setting. Arch Gerontol Geriatr 2010;51:36–40.

A pilot study among the urban poor in the capital city of Kuala Lumpur was conducted in December 2012. The researcher and trained enumerators interviewed 291 individuals aged 60 and older living in low-cost government subsidized flats face-to-face using an instrument developed based on recent work in a national Irish elder abuse and neglect prevalence survey.6 This instrument was first validated locally in an expert panel of social workers and public health experts in the field of violence and geriatrics and subsequently tested in a small subset of elderly adults. Sufficient content validity and face validity was declared before interviews were conducted on this sample of 291 elderly adults.

RESULTS Of 291 elderly persons interviewed, 28 (9.6%) reported experiencing some form of abuse or neglect in the preceding 12 months. Abuse refers to overall abuse, which may be a combination of one of more of its subtypes (physical, financial, psychological, sexual, neglect). Financial abuse was most common (6.2%), followed by psychological


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Table 1. Proportions of Elderly Respondents Reporting Abuse in the Past 12 Months Overall



Instances of Abuse

0 1 to 2 ≥3 Total abused




n (%)

263 20 8 28

(90.4) (6.9) (2.7) (9.6)

263 13 5 18

(90.4) (4.5) (1.7) (6.2)

(4.5%), physical (1.6%), and sexual (1.0%) abuse, and neglect (0.3%). Two thirds of people abused had experienced two or more incidents of abuse in the preceding 12 months (Table 1). Being female, divorced, younger (60–64), and of Indian ethnicity; being poor, depressed, or currently employed; living alone; and having a primary school education or less, poor social support, or cognitive impairment were associated with greater odds of abuse. Further statistical analysis using SPSS version 21.0 (SPSS, Inc., Chicago, IL) and forward step-wise multiple logistic regression to analyze the above factors while controlling for age, sex, marital status, education, ethnicity, and income revealed that individuals who were depressed were three times (odds ratio (OR) = 3.26, 95% confidence interval (CI) = 1.02–10.43) as likely to report being abused than those who were not and that individuals who were currently employed were three times (OR = 3.25, 95% CI = 1.10–9.58) as likely to disclose abuse.

DISCUSSION Almost 10% of elderly adults interviewed disclosed that they had been abused in the past 12 months. This figure corroborates prevalence rates found in other Asian countries, which range from 14.0% to 27.5%.7 Previous local studies had also identified a lack of awareness of elder abuse within the wider community, including healthcare workers.8–10 There is also a lack of detection measures or screening, and even when cases are identified, there are no established frameworks for elder abuse reporting, which in turn hampers early intervention to protect elderly adults. Depressed elderly adults were more likely to be abused than others, which is a finding that was common to eight of the 26 studies reviewed previously.7 Currently employed elderly adults earn little, with most being in manual categories of work. This contributes to what little the family earns. Many studies relate lower levels of family income to higher odds of abuse,7 which may explain why older adults who are employed are more vulnerable to financial abuse.

CONCLUSION This preliminary study highlights elder abuse as a public health problem in Malaysia, and it is hoped that it will sensitize healthcare workers and academia toward it, in addition to underscoring why longitudinal studies are needed to study this phenomenon to guide effective screening and intervention, interagency collaboration, laws, and policies for vulnerable elderly adults, which are currently lacking.

263 4 1 5

(90.4) (1.3) (0.3) (1.6)

263 9 4 13

(90.4) (3.1) (1.3) (4.5)

263 2 1 3

(90.4) (0.7) (0.3) (1.0)

263 1 0 1

(90.4) (0.3) (0) (0.3)

Rajini Sooryanarayana, MPH Julius Centre University of Malaya, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia Wan Yuen Choo, PhD Noran N. Hairi, PhD Karuthan Chinna, PhD Awang Bulgiba, PhD Julius Centre University of Malaya, Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

ACKNOWLEDGMENTS The questionnaire used was developed based on that used in the recent Irish national elder abuse and neglect prevalence survey and the New York study with permission from Dr. Corina Naughton, School of Nursing, Midwifery and Health Systems, Health Sciences Centre, University College Dublin Belfield, Dublin, Ireland. Presented as a poster at Faculty of Medicine, University of Malaya Research Week, March 24–28, 2014. Conflict of Interest: Rajini Sooryanarayana’s work on this study was supported by the Public Service Department of Malaysia and University of Malaya and Ministry of Higher Education High Impact Research Grant E000010–20001. Ethical approval was received from the University of Malaya Medical Centre Institutional Review Board (UMMC IRB 902.2, February 21, 2012). Author Contributions: Sooryanarayana: literature search; study design, data collection, entry, analysis, interpretation; writing, submission. Choo, Hairi: study design, data analysis and interpretation, writing, editing. Bulgiba: data interpretation, writing, editing. Chinna: data analysis and interpretation, writing, editing. Sponsor’s Role: None.

REFERENCES 1. Department of Statistics Malaysia. Population by Age Group 2010 [on-line]. Available at www.statistics.gov.my Accessed December 5, 2011. 2. Lancet T. Preventing elder abuse: Can we learn from child protection? Lancet 2011;377:876. 3. Dong X, Simon MA. Vulnerability risk index profile for elder abuse in a community-dwelling population. J Am Geriatr Soc 2014;62:10–15. 4. Lachs MS, Pillemer K. Elder abuse. Lancet 2004;364:1263–1272. 5. Ministry of Women Family and Community Development. National Policy for the Elderly, 2011 [on-line]. Available at http://www.kpwkm.gov. my/dasar1 Accessed June 12, 2014.



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6. Naughton C, Drennan J, Lyons I et al. Elder abuse and neglect in Ireland: Results from a national prevalence survey. Age Ageing 2012;41:98–103. 7. Sooryanarayana R, Choo W-Y, Hairi NN. A review on the prevalence and measurement of elder abuse in the community. Trauma Violence Abuse 2013;14:316–325. 8. Esther E, Shahrul K, Low WY. Elder abuse: A silent cry. Malaysian J Psychiatry 2006;14:29–34. 9. Aishath M, Harun MH. Elder Abuse in Malaysia. Malayan Law J Articles 2010;6:viii. 10. Hamid TA, Za SF, Mansor M et al. Cohort Differences in Perceptions of Elder Maltreatment. South East Asian Conference on Ageing 2010, July 17–18, 2010, Grand Millenium Hotel, Kuala Lumpur, Malaysia [on-line]. Available at http://seaca2010.files.wordpress.com/2010/07/ microsoft-powerpoint-perception-tah-sfza-et-al-17-July-2010.pdf Accessed October 3, 2011.

LOWER GLOMERULAR FILTRATION RATE ASSOCIATED WITH WHITE MATTER HYPERINTENSITIES MORE IN VASCULAR DEMENTIA THAN IN ALZHEIMER’S DISEASE To the Editor: White matter hyperintensities (WMHs) from cerebral small vessel disease (SVD) can indicate greater risk of stroke and dementia. Aging and hypertension are major risk factors for cerebral SVD, but these fail to account for all of the risk. Chronic kidney disease (CKD), defined according to estimated glomerular filtration rate (eGFR), is widely recognized as an independent risk factor for stroke and subclinical vascular diseases, such as SVD.1 Moreover, recent research has supported a causal role of inflammation, endothelial dysfunction, and oxidative stress in the development of vascular disease.2 These processes are all characteristic of CKD3 and may also be found in vascular dementia (VaD) and Alzheimer’s disease (AD).4 Data regarding the role of low eGFR in the development of WMHs in AD and VaD are limited.5 It was hypothesized that lower eGFR would be more strongly associated with WMHs in VaD than AD, independent of vascular risk factors.

METHODS This study formed part of the ongoing Clinical Research Center for Dementia of South Korea Study (CREDOS), a large, prospective, hospital-based cohort study designed to


assess the occurrence of and risk factors for cognitive disorders, established in November 2005. Further information regarding CREDOS has been previously published.6 Data from 952 CREDOS participants with measurements of eGFR, hemoglobin, and albumin were retrospectively analyzed. All participants had a clinical interview and blood test on the same day. All blood parameters were analyzed according to the standard protocols of the biochemistry laboratories that participated in the study, which operate under a rigorous quality control program. Kidney function was indicated according to eGFR, which was calculated in mL/min per 1.73 m2 using the simplified Modification of Diet in Renal Disease equation (186.3 9 (serum creatinine) 1.154 9 age 0.203, multiplied by 0.742 for women).7 Anemia was defined according to World Health Organization criteria as hemoglobin concentrations less than 12 g/dL for women and 13 g/dL for men.8 A standardized neuropsychological battery, the Seoul Neuropsychological Screening Battery—Dementia version, was used to assess all participants. Magnetic resonance imaging (MRI) was conducted in accordance with an acquisition protocol developed for CREDOS. MRI scans included transaxial T2, T1-weighted, gradient-echo, fluid-attenuated inversion recovery (FLAIR), and coronal T1-weighted images. The severity of WMHs was evaluated according to modified Fazekas9 and Scheltens10 criteria, using the T2 axial or FLAIR images. WMHs were examined separately in the periventricular white matter and deep white matter. Logistic regression analysis was conducted in individuals with normal cognitive function, mild cognitive impairment (MCI), AD, and VaD to evaluate the effect of eGFR on severity of WMHs. Age, sex, history of hypertension, diabetes mellitus, hyperlipidemia, and ischemic heart disease were included as covariates.

RESULTS Of 952 older adults, 162 had normal cognitive function, 237 had MCI, 330 had AD, and 224 had VaD. The prevalence of hypertension and stroke was higher in participants with VaD. Logistic regression analysis indicated that the association between age, hypertension, and moderate WMHs was statistically significant in participants with normal cognitive function. Multivariate logistic regression analysis showed a significant association between hypoalbuminemia and moderate WMHs after adjustment for age,

Table 1. Moderate White Matter Hyperintensities (WMHs) in Normal Cognitive Function, Mild Cognitive Impairment (MCI), and Alzheimer’s Disease (AD), and Severe WMHs in Vascular Dementia (VaD): Multivariate Logistic Regression Analysis Normal Cognitive Function Risk Factor

Chronic kidney disease Hypoalbuminemia Anemia Hypertension Age P < a.01, b.05.




Odds Ratio (95% Confidence Interval)

4.50 1.03 0.31 3.74 1.13

(0.66–30.64) (0.30–3.48) (0.05–2.01) (1.58–8.81)a (1.05–1.21)a

0.97 2.39 0.72 1.07 1.09

(0.39–2.41) (1.12–5.08)b (0.28–1.85) (0.54–2.14) (1.04–1.15)a

1.63 1.79 0.48 0.59 1.11

(0.83–3.17) (1.01–3.18)b (0.22–1.04) (0.33–1.05) (1.07–1.16)a

2.28 0.67 1.08 1.40 1.02

(0.95–5.48) (0.32–1.37) (0.48–2.46) (0.71–2.77) (0.98–1.07)

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Insight into elder abuse among urban poor of Kuala Lumpur, Malaysia-a middle-income developing country.

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