**4. Discussion**

To the best of four knowledge we are the first to highlight the association between COVID-19 and EA's occurrence in Poland in a hospital setting. In our study we confirmed the increase in the experience of abuse by the elderly during the COVID-19 pandemic. We emphasized that women, people aged 60–65, low socioeconomic status, chronic diseases, poor relationship with the family and lack of family, moderate and severe depression, ADL ≤ 3 and COVID-19 were factors that predispose mainly to EA and to increased susceptibility to abuse assessed using the VASS scale. Our reports additionally coincide with the evolving evidence of a surge in EA during a pandemic. Thus healthcare professionals must prepare themselves as best as possible to deal with this growing problem among their patients. We enrolled only hospitalized people. Therefore, the results of these studies cannot be strictly generalized to the entire Polish population. Further research is needed in the various settings of older adults. Our research during the COVID-19 pandemic showed that nearly 45% of the hospitalized elderly were victims of EA. On the other hand, in a cross-sectional study conducted by our team in the period before COVID-19 on a group of 200 older adults with similar inclusion criteria, it was shown that 38.5% of respondents had experienced abuse [13]. This means an increase of over six percentage points. Both the present and past findings indicate that psychological abuse is the most common form of EA [9,13]. On the other hand, Chang et al. [4] noted the occurrence of EA during the COVID-19 pandemic among 21.3% of respondents, an 83.6% increase compared to prevalence estimates prior to the pandemic. In addition, in China, a study by Du and Chen [23] found that 15.4% of the older adults were victims of EA. The conducted preliminary analyses of factors indicate an actual large increase in the percentage of victims of older adult abuse [24,25]. So far, however, only a limited number of studies have been published on the occurrence of EA during COVID-19. Therefore, our results could provide relevant and missing information in this area of research in a pandemic.

Before the pandemic, in the ABUEL study, conducted among seven European countries (Germany, Italy, Lithuania, Sweden, Portugal, Spain and Greece) among 4467 respondents aged 60–84 years old, the incidents of elder abuse and neglect was also assessed. It was shown that within 12 months, psychological abuse was experienced by 19.4% of respondents, financial exploitation—3.8%, physical—2.7%, and sexual—0.7% [26]. Interestingly, research conducted in Ireland found that the country has the lowest prevalence of EA— 2.2% [27]. In turn, the highest prevalence is found in Croatia—61.1% [28]. These results prove, that the prevalence rate of elder abuse varies widely. From the few studies conducted in Poland, it can be concluded that the EA rates in Poland also remains at a high level. Research conducted by a team of psychologists from the Institute of Psychology of the Polish Academy of Sciences in Poland shows that 59.7% of respondents reported the use of at least one form of EA outside their own family, and 30.1% in their own family [29]. In turn, the study by Kołodziejczak et al. [30] found that abuse affected 40.1% of older respondents living in rural areas. Our results are consistent with those presented by other authors from many different countries. For example, in a study by Hosseinkhan et al. [31] among 683 older adults it was found that 38.5% of the respondents were victims of EA. Subsequently, Anand [32] showed that out of 1435 respondents, 35% had experienced abuse. Torres-Castro et al. [33] reported a violence rate of 35.7%, and the study group was 487. If before the pandemic the EA rates in some countries were high and now increase even more, we will be faced with a serious social problem.

Interestingly, there are some common risk factors for both fraud susceptibility and COVID-19. Certainly, these factors include comorbidities that predispose to EA [34,35] and are associated with a higher mortality rate due to COVID-19 [36]. Following this trail, it can be safely stated that disability is also a significant risk factor for EA [37] and COVID-19 [38]. Moreover, COVID-19 itself predisposes to an increase in abuse among the elderly [4,24,25]. The remaining risk factors for EA during the pandemic do not differ from those that existed before the pandemic. And these include: female gender, younger age, economic problems, city living, comorbidities, depression, disability and dependence. Our results are consistent

with the results presented by other researchers [7,35,39–41]. Our research also indicates that statistically single people were more likely to experience abuse. In addition in the research conducted by Liu et al. [25], victims of older adult abuse reported a feeling of loneliness. Further more, a poor relationship with the family predisposes you to EA in a statistically significant way. Fraga Dominguez et al. [40] also showed that family relationships are a significant risk factor for abuse.

Research shows that the COVID-19 pandemic has added fuel to the fire in terms of EA. It turned out to be extremely harmful to the older adults. Many of the EA risk factors presented have increased during the course of the pandemic. For example, the need for isolation and social distancing have contributed to feelings of loneliness and neglect. In addition, the elderly are aware of the dangers of falling ill with COVID-19, and have experienced a real threat to health (and sometimes life) as a result of infection. It can be assumed that they may therefore be particularly prone to developing depressive and anxiety symptoms. Consequently, it is also associated with an increased risk of EA, as many studies have identified depression as a risk factor for abuse [33,42–46]. Depressive disorders cause further deterioration of mental and physical functioning, loss of social position, autonomy, and, as a result, the disappearance of social relations. All these factors increase the occurrence of acts of EA. Moreover, experiencing abuse aggravates depression and increases anxiety [42,43,45]. Further more, the older adults are a group particularly at risk of complications after contracting COVID-19, which in consequence often leads to increased dependence on other people and disability, which is a significant risk factor for EA [4,12,46]. Another leading factor in fraud is the financial problems that have worsened during the COVID-19 pandemic. Mass dismissals from work, forced leaves and isolation resulted in a decline in social status among the society. Due to the fact that pensions of the elderly in Poland are often insufficient, they require financial assistance from their children or family. The emerging economic pressure, stress and economic problems of the families of the elderly are the main cause of EA [23].

We are fully aware of the limitations. The study was conducted in a limited geographical area, so be careful in drawing conclusions on the entire population. In addition, the subjects are hospitalized people, therefore future research should be extended to include a research group from various environments and different regions.
