12
The Clinical and Medical Forensics of Elder Abuse and Neglect

Carmel Bitondo Dyer, Marie-Therese Connolly, and Patricia McFeeley*

The medical forensic aspects of elder abuse and neglect are largely unexplored and undocumented. Those who work in the field of elder abuse and neglect believe that the state of medical knowledge and forensic science regarding elder abuse and neglect is approximately equivalent to that of child abuse and neglect three decades ago and domestic violence 10 to 15 years ago (Elder Justice Roundtable Report, 2000). Within the relevant victimized populations there are similarities and differences among the factors contributing to their vulnerability and victimization. Similarities include feared retaliation, perceived stigmatization at having been victimized, desire not to leave home, desire to protect the

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Carmel Bitondo Dyer, M.D., is an assistant professor of medicine at Baylor College of Medicine, Houston, Texas, and the Director of the Harris County Hospital District Geriatrics Program; Marie-Therese Connolly, J.D., is a senior trial counsel in the Civil Division, Department of Justice; Patricia McFeeley, M.D., is an associate professor in the Office of the Medical Investigator at the University of New Mexico.

The views expressed in Marie-Therese Connolly’s contributions to this paper are her own and do not necessarily reflect those of the Department of Justice.

The authors would like to acknowledge Samuel Riley and Rosa Torres for their technical assistance, and Jill Callahan for her editorial assistance. They are also grateful for review of the manuscript by Drs. Kenneth L. Minaker and Constantine G. Lyketsos and members of the National Academy of Sciences Panel on Risk and Prevalence of Elder Abuse and Neglect.



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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America 12 The Clinical and Medical Forensics of Elder Abuse and Neglect Carmel Bitondo Dyer, Marie-Therese Connolly, and Patricia McFeeley* The medical forensic aspects of elder abuse and neglect are largely unexplored and undocumented. Those who work in the field of elder abuse and neglect believe that the state of medical knowledge and forensic science regarding elder abuse and neglect is approximately equivalent to that of child abuse and neglect three decades ago and domestic violence 10 to 15 years ago (Elder Justice Roundtable Report, 2000). Within the relevant victimized populations there are similarities and differences among the factors contributing to their vulnerability and victimization. Similarities include feared retaliation, perceived stigmatization at having been victimized, desire not to leave home, desire to protect the *   Carmel Bitondo Dyer, M.D., is an assistant professor of medicine at Baylor College of Medicine, Houston, Texas, and the Director of the Harris County Hospital District Geriatrics Program; Marie-Therese Connolly, J.D., is a senior trial counsel in the Civil Division, Department of Justice; Patricia McFeeley, M.D., is an associate professor in the Office of the Medical Investigator at the University of New Mexico. The views expressed in Marie-Therese Connolly’s contributions to this paper are her own and do not necessarily reflect those of the Department of Justice. The authors would like to acknowledge Samuel Riley and Rosa Torres for their technical assistance, and Jill Callahan for her editorial assistance. They are also grateful for review of the manuscript by Drs. Kenneth L. Minaker and Constantine G. Lyketsos and members of the National Academy of Sciences Panel on Risk and Prevalence of Elder Abuse and Neglect.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America wrongdoer, other emotional harm, and as in some cases involving persons with diminished capacity, difficulties in communicating what transpired. Perhaps the starkest difference is that whereas children and younger victims of domestic violence are generally healthy and not expected to die, older people often have numerous underlying medical problems, and functional dependencies and are assumed to be more vulnerable to stressors causing death. Thus, when a younger person dies of unexplained causes, the cause of death is almost always carefully analyzed. The death of an older person, however, is rarely as carefully scrutinized, if at all, regardless of risk factors or indications of possible abuse or neglect. In addition, old age often brings medical conditions and physiological attributes that may mimic or mask the markers of elder abuse and neglect, further complicating the analysis and detection. Despite these many complexities, a recent study—one of the few in the area—most clearly underscores the importance of increasing our understanding of these phenomena. That study (Lachs et al., 1998) demonstrates that elder abuse and neglect significantly shorten older victims’ lives, even controlling for all other factors. Incidents of mistreatment that many would perceive as minor can have a debilitating impact on the older victim. A single episode of victimization can “tip over” an otherwise productive, self-sufficient older person’s life. In other words, because older victims usually have fewer support systems and reserves—physical, psychological, and economic—the impact of abuse and neglect is magnified, and a single incident of mistreatment is more likely to trigger a downward spiral leading to loss of independence, serious complicating illness, and even death. Unfortunately, there is a paucity of primary data relating to forensic markers of elder abuse and neglect, or even regarding the phenomena themselves. The ensuing discussion describes several potential forensic markers of elder abuse and neglect, including: abrasions, lacerations, bruising, fractures, restraints, decubiti, weight loss, dehydration, medication use, burns, cognitive and mental health problems, hygiene, and sexual abuse. We also are including financial fraud and exploitation because they often coexist with physical and emotional abuse and neglect. Some of the markers discussed are actual observations (such as bruises or fractures), whereas others are descriptions or conclusions based on underlying observations (for example, sexual abuse is a conclusion that might result from the observation of a vaginal tear or abdominal bruise, and a conclusion of neglect might result from the observation of poor hygiene and burns). Some of the markers are also potential risk factors (for example, self-neglect, cognitive and mental health problems, and financial abuse). But the current evidence regarding risk factors does not tell us the amount of risk conferred or by what mechanism. Where evidence-based data or other studies were found relating to the

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America forensic markers discussed in this paper, they are referenced. But the majority of information on this topic currently is derived from working hypotheses based on the experience of clinicians and pathologists. Discussion of each factor includes (a) a definition of the phenomenon, (b) a discussion of how it is affected by age-related changes, and (c) what we currently know of clinical and forensic markers indicating abuse and neglect. The term forensic is defined as pertaining to the law or employed in legal proceedings. Thus, medical forensic markers of elder abuse and neglect are factors that are relevant to medical and legal determinations of whether elder abuse or neglect has occurred. Consistent evidence-based medical definitions are urgently needed to assist health care and social service professionals in detecting, treating, responding to, referring, and better understanding this grave and increasingly important public health problem. Coherent legal definitions are needed for legal and public safety professionals to determine when the law may have been broken, what types of criminal, civil, or administrative cases may be pursued, and for lawmakers to determine what new laws should be proposed or enacted. Defining appropriate forensic markers will lead to more effective prevention strategies and medical, legal, social service, and public safety interventions. Expanding our medical forensic knowledge base is vital to all the myriad ways in which the law is expected to address elder abuse and neglect. Potential legal interventions include the following: federal, state, and local law enforcement entities (including prosecutors, investigators, and police) may pursue criminal and civil cases relating to allegations of elder abuse and neglect. The government generally pursues such cases in its police power capacity—to punish, deter, remediate, and/or redress wrongdoing. Government also may use the law in its parens patrie capacity—pursuing guardian and commitment cases, primarily intended to protect those who cannot care for themselves. Almost all cases brought by government entities in this field rely on medical forensic evidence. Some government entities (such as the Departments of Justice and Health and Human Services) have resources to fund projects relevant to medical forensic issues. Private plaintiffs may file civil suits against health care providers depending on available medical forensic evidence. Federal and state legislative bodies can enact laws that provide for funding, create new entities, establish civil and criminal causes of action, and provide for other measures to address the problem. Federal and state regulatory bodies determine and/or enforce reimbursement, licensure, and administrative enforcement rules. Each legal aspect of this issue would benefit from being informed by more and better research. Elder abuse and neglect are often not detected or diagnosed, precluding any intervention, including prosecution. Thus research aimed at improving

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America detection is crucial to law enforcement. Furthermore, even when there is detection or diagnosis, cases will not be prosecuted unless the suspected abuse or neglect is reported (which often is not the case even where there are mandatory reporting laws). Criminal and civil elder abuse and neglect prosecutions are pursued for many reasons, including to stop, redress, punish, and deter the wrongdoing, and to recoup government monies provided for care that was not rendered. However, the current state of legal, social science, and medical knowledge does not include an evaluation of which types of prosecution and which remedies and punishments best address these goals. By providing the tools necessary to detect and prove these cases, research on the forensic markers of elder abuse and neglect can help law enforcement make appropriate cases a priority. DETECTING ABUSE AND NEGLECT IN ELDERS The American Medical Association (1996) has defined physical abuse as an act of violence that may result in pain, injury, impairment, or disease. Neglect is the failure to provide the goods or services necessary for functioning or to avoid harm. A caregiver may be a family member, a friend, or an employee of the elder or of a nursing or other type of facility, or it may be the entity responsible for providing care. Definitions and intent standards may vary depending on discipline, entity, location, or jurisdiction, as well as the relationship of the victim and the perpetrator. Furthermore, intent in a legal proceeding is the province of the fact finder (judge or jury) and therefore opened to argument by both the plaintiff/prosecutor and the defendant. Thus, the above-provided descriptions are intended as a general guide and a way to frame the discussion, but not as specific legal definitions. Actual abuse or neglect is rarely directly observed by medical, legal, or protective service professionals. In the absence of eyewitness testimony, law enforcement must rely on other circumstantial evidence to prove the existence of abuse or neglect. In most instances the experience of other direct observers is sought or the circumstances are deduced through investigation or physical examination. The state of current knowledge, however, does not always allow health care and social science professionals to link physical signs with a diagnosis of abuse or neglect. Further research will help identify and define useful forensic markers to help practitioners detect and treat elder abuse and neglect victims. How, when, why, and by whom injuries have been inflicted on elderly victims are all important questions to be answered before actors in the legal system take any affirmative action to protect the victim and deter future wrongdoing. Thus, a fractured bone may heal and a bruise may resolve regardless of whether a practitioner can identify the cause. And yet, the

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America cause of the break or the bruise is the starting point for any legal action. Thus, even where there are clear bad outcomes (harm to an older person), absent a causal link and evidence to support a hypothesis of illegal abuse or neglect, the law will provide no remedy or accountability. The most extreme cases of abuse and neglect are not diagnostic dilemmas. In some cases—gunshot wounds, knife wounds, or rope burns, for instance—it is clear that the older person has been abused. In other cases multiple large decubiti or starvation may indicate severe neglect. Bite marks, too, are established evidence of abuse (Rawson et al., 1984; American Board of Forensic Odontology, 1986). But most cases fall into a gray area where abuse and neglect are not so nearly clear-cut, often because of subtle physiologic and psychological changes that occur in old age. No gold standard test for abuse or neglect exists, and those working with abused or neglected elderly victims rely on forensic markers. The difficulty with this approach is that there is often a great overlap among the markers of disease and neglect (and sometimes abuse). Although abuse often is considered to require an overt act, whereas neglect is considered to require an omission, it sometimes is difficult to distinguish between the two. There are cases in which neglect is so profound and widespread, and the caretaker is knowledgeable of what was needed but not provided, that many would consider it abuse. For example, if a case includes apparently preventable decubiti, neglect may be indicated. The line between abuse and neglect becomes murkier, however, when a person presents with multiple serious decubiti, and the caregiver was aware of the decubiti and of what care was needed but still failed to render adequate care. The ambiguity between abuse and neglect is similarly demonstrated in scenarios where caregivers, particularly those who know better, either withhold necessary medication or fail to perform needed care (for example, fail to change a bandage and cause the loss of part of a limb and/or sepsis, or cause illness and death by not giving needed insulin). The absence of clear and consistent legal definitions of neglect limit our ability to address the phenomenon. Liability for neglect is dependent on the ability to assign blame, and blame is easier to assign with acts of commission than acts of omission (Phillips, 1988). Definitional (and legal) distinctions also are necessary in determining when self-neglect evolves into caregiver neglect. This is a combined medical-legal inquiry: Is the person physically or mentally incapacitated? At what point does the legal responsibility for the care of that person shift from self to another? What are the legal responsibilities of a caregiver under law such that failure to render such care in a home or community setting subjects the caregiver to civil or criminal liability? What types of documentation must exist to justify a failure by caregivers to intervene in the face of self-neglect (e.g., refusal to eat) in an institutional setting? The answers to these questions, to the

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America extent that such answers exist, vary from state to state, and sometimes from community to community, complicating the analysis and any research of the issue. Resolution of these difficult distinctions is beyond the scope of this paper. It is worth noting, however, that whether elder abuse and neglect has occurred is a conclusion drawn from a constellation of factors—some are medical (the individual’s medical condition), and some are legal (the jurisdiction’s definition of caregiver neglect). Developing consistent definitions and laws relating to elder abuse and neglect is critical to (a) developing useful forensic markers, (b) effective detection and diagnosis by health care professionals, (c) law enforcement’s determination of a violation of law and of what cases to prosecute, and (d) researchers’ and policy makers’ determination of the scope of the problem and of what new laws (including causes of action and remedies) and other measures are needed to adequately address it. To the extent that the term forensic is defined as “pertaining to the law,” medical forensic markers also are relevant to guardianship, involuntary commitment, power of attorney, and other types of parens patrie cases. Because this panel is examining abuse and neglect, however, those applications of forensic markers are not specifically discussed in this paper. Abuse and neglect may occur in community or institutional/residential settings. For most of the markers described, there is no literature describing the relevance of various settings to the medical forensic analysis. This, too, is a topic in need of study. POTENTIAL MARKERS OF ABUSE AND NEGLECT Fourteen potential markers of elder abuse and neglect are discussed below, including for each a brief definition, a description of age-related changes, and a review of what is known about each as a medical forensic marker of elder abuse and neglect. Most of the forensic markers discussed in this section apply both to living persons and to postmortem evaluations. Factors pertaining peculiarly in the postmortem context are discussed in the next section. Abrasions and Lacerations Abrasions are superficial injuries involving the outer layer of skin; lacerations are characterized by full-thickness splitting of the skin. Abrasions are caused by movement of the skin over a rough surface; lacerations are the result of blunt force (Crane, 2000). Skin tears are a very common type of laceration seen in the elderly and are defined as a splitting of the

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America epidermis (superficial layer of the skin) from the underlying connective tissue resulting in a flap of skin (Malone et al., 1991). Age-Related Changes Skin thickness and elasticity decrease with age. Tensile strength also declines, increasing the susceptibility to shearing-force trauma (Griffiths, 1998). Abrasions can occur in older persons with minor trauma. Common lacerations in elderly persons are the skin tears that occur most frequently on the forearms and occasionally on the legs. Persons usually have no more than one or two skin tears at a time, and skin tears often heal completely without scarring. A primary data study revealed that the annual incidence of skin tears in a large nursing home was a little less than one per year per resident. The majority of tears were approximately 0.75 inches in length, though nearly 6 percent were 1.6 inches or longer. Eighty-five percent of the lacerations occurred on the arms. A known cause was identified in less than half the cases (47 percent), and most known causes were attributed to falls or bumping into something; wheelchairs accounted for 30 percent of the injuries (Malone et al., 1991). In cases in which the cause was unknown (53 percent), the skin tears may have occurred accidentally and may not have been noticed or may have been forgotten by the elder, or they could have been due to rough handling or worse by staff members and others. This study included no analysis of the cases with known causes as compared to those with unknown causes. Clinical and Forensic Markers Indicating Abuse or Neglect Abrasions retain the pattern of the causative agent better than any other type of injury, and careful documentation by health care personnel is important for identification of the mode of injury. Skin tears in sites other than the arms and legs or multiple tears or abrasions should raise suspicion. Lacerations often heal with scarring (Knight, 1997), as opposed to skin tears, which heal without scarring. Abrasions or lacerations are most commonly seen in cases involving physical abuse, although they can occur in cases of caregiver neglect. Bruises A bruise is the result of blunt force with concomitant rupture of small blood vessels under the skin. Blood escapes to the surrounding tissues propelled by the muscular contractions of the heart. Bruises are most

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America commonly seen in physical abuse but can be a result of caregiver neglect. Bruises can surface hours to days after an initial insult, depending on the depth of the wounds. Blood can track through fascial planes and result in bruises distant from the site of injury. The eyelids, neck, and scrotum are very susceptible to bruising. Age-Related Changes Bruises often occur more frequently and resolve much more slowly in older persons than in younger persons and can last for months instead of the usual one to two weeks (Knight, 1997; Crane, 2000). Langlois and Gresham (1991) prospectively studied bruising by collecting over 200 photographs of bruises occurring in persons over the age of 65. They concluded no bruises less than 18 hours old demonstrated yellow coloration (p < 0.001). The opposite was, however, not true; some bruises did not develop a yellow color until much later. This primary data study is included in the Appendix to Chapter 1. Clinical and Forensic Markers Indicating Abuse or Neglect The pattern of the bruise may suggest the cause of the injury. Bruises may retain the shape of knuckles or fingers. Parallel marks, called tramline bruising, indicate injury from a stick (Knight, 1997; Crane, 2000). The site of the injury may also indicate abuse. The most common locations for nonaccidental injury are the face and neck, the chest wall, the abdomen, and the buttocks (Crane, 2000). Intentional injury was determined in a retrospective review of random charts in New Zealand to be 13 times more likely to involve the head than other areas of the body. In this study internal injuries were two times as common in the assault victims (Fanslow et al., 1998). Bruising on the palms and soles may serve as forensic markers since the tissue at those sites is made of tough fibrous tissue and is not usually injured accidentally (Knight, 1997). The color of the bruise is usually unhelpful for dating because two bruises in the same person may heal at different rates. Reddish blue, blue, or purplish bruises are more likely to be recent while bluish green, greenish yellow, and brown bruises are more likely to be in some stage of healing (Crane, 2000). Multiple bruises in various stages of healing may indicate physical abuse (Knight, 1997). Bruises are common sequelae of falls, the most common cause of injury in older persons. Abusive or neglectful caregivers often attribute intentional bruises to a fall. Falls, however, cannot always be prevented and have multiple causes, such as poor vision and transient ischemic attacks. The causes of any given fall in an elder should be evaluated and the results

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America of the fall, such as the type of bruising or fracture, may be forensic markers worthy of study and provide useful information about whether abuse or neglect was involved. Fractures Fractures are broken bones and include a frank severing of the bone or a compression of intact bone. Age-Related Changes The bones of older persons are thinner and less dense, making them more susceptible to fractures as the result of bone disease or injury. Poor nutrition, vitamin D deficiency, alcoholism, and age-related sex hormone deficiencies also contribute to an increased propensity to fractures (Francis, 1998). Other bone diseases such as osteoporosis and all its causes, such as chronic steroid use, osteomalacia, and Paget’s disease, make the bones more brittle. Any type of cancer that invades bone weakens the osseous structure, making the patient more prone to fractures—these are called pathological fractures. The most common sites of fracture are the hip in those over the age of 75 and the distal wrist in persons younger than 75 (Francis, 1998). The wrist is a common site of fracture with falls in older individuals because many use their hands to help break the fall. Older women in particular are susceptible to vertebral fractures. Alcoholics are prone to multiple falls with resulting fractures of the arms, legs, and ribs. Two types of bone fractures are known to occur spontaneously: vertebral fractures in osteoporotic older women, and hip fractures. There are two series that report cases of hip fracture in which abuse was suspected but subsequently attributed to medical causes (osteomalacia or soft bones, prolonged bed rest, Paget’s disease) (Kane and Goodwin, 1991; Connolly et al., 1995). Prolonged bed rest, chronic limb paralysis, or non-weightbearing status put elderly persons at increased risk for spontaneous fracture (Kane and Goodwin, 1991). Clinical and Forensic Markers Indicating Abuse or Neglect A sizable literature on the resolution of fractures in abused children exists, but there are little or no data on fracture resolution in elders. Elders’ bones, however, heal at much slower rates, making the child abuse data on fracture resolution invalid for older adults. Also, 30 percent of community-dwelling older persons and 50 percent of nursing home patients fall; therefore, falls alone should not necessarily increase suspicion of abuse. Most persons who fall experience one to three falls per year. A person who falls

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America once has joined a grouping prone to frequent falls. A detailed examination of the patient, records, and/or collateral history from caregivers is needed to determine if fractures in frail elders constitute physical abuse. Dentists and oral surgeons often see physically abused patients with fractured, subluxed, or avulsed teeth or fractures of the zygomatic arch (the bony structures around the eyes) or the mandible and maxilla (jaw bones) (Fenton et al., 2000). Fanslow and colleagues (1998) showed in a retrospective chart review that fractures of the head, spine, and trunk are more likely to be assault injuries than limb fractures, sprains or strains, or musculoskeletal injuries in adults. A spiral fracture of a large bone with no history of gross injury is diagnostic of abuse, as are fractures with a rotational component (Medical Tribune, 1995). Fractures in nonalcoholics at sites other than the hip, wrist, or vertebrae should raise suspicions of abuse. Restraints Restraints are means of controlling the behavior of older persons, especially in hospitals and nursing facilities. There are two forms of restraints, mechanical and chemical. The following discussion refers to mechanical restrains, such as Posey vests, and wrist and ankle restraints made of leather, plastic, or cloth. Standards of Care for Elders The only acceptable reason for restraining an elder is to prevent significant harm (Knight, 1997). Appropriate restraints help stop the agitated patient from pulling out a tube that is a conduit for life-saving treatments such as an endotracheal intubation for mechanical ventilation, oxygen replacement, or intravenous fluids and medications. Clinical and Forensic Markers Indicating Abuse or Neglect Abuse or neglect occurs whenever a person is restrained in a noncritical situation and without a concomitant evaluation by a medical practitioner. If restraints are determined to be necessary, the restrained patient must be monitored closely and frequently. The restraints must not be so tight as to completely restrict movement. Proper bedding must be used to prevent decubiti (bedsores). In many studies, physical restraint is very strongly associated with increased injury and death (Miles, 1996; Mohr and Mohr, 2000). Restraints, in fact, often do not control behavior and instead may result in a worsening of behavioral problems. Despite this evidence, many health professionals still believe that restraints will help prevent injury due to

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America falling. Restraints can be a form of neglect when used in lieu of adequate caretaking because they render persons “easier” to care for. They can be a form of physical abuse, for example, when they leave scars or result in wrist wounds or decubiti. Decubiti The breakdown of skin integrity resulting in an ulcer is known as a decubitus, or bedsore. Decubiti are the result of circulatory failure due to pressure; shearing forces cause thrombosis of the microcirculation (clotting or blockage of blood in small blood vessels), resulting in tissue necrosis (Barton and Barton, 1981). Most decubiti occur over the sacrum; the hip and the heels are also common locations. Although decubiti may be divided into four stages, in general they are either deep or superficial. Age-Related Changes and Standards of Care Normal aging skin has relatively well-preserved blood flow. The elderly are more susceptible to decubiti because of disease states and not on the basis of age alone (Bennett and Bliss, 1998). Decubiti most often occur in medically ill or cognitively impaired individuals. Intrinsic causes such as acute illness, neurological disease, peripheral vascular disease, incontinence, and poor nutritional status place individuals at higher risk (Bennett and Bliss, 1998). Although poor nutrition is a risk factor, improving nutritional status doesn’t always reverse or prevent the process (Henderson et al., 1992; Finucane et al., 1999). The healing may take weeks to months, depending on the underlying comorbidities and the extent of the decubiti. Risk factors for decubiti were found not to be predictive where appropriate care was provided; however, when the standard of care was not met, risk factors were found to be predictive (Berlowitz et al., 2001). The standard of care for decubitus ulcers is to prevent them from occurring, particularly in high-risk patients. Prophylactic measures include turning patients regularly, range-of-motion exercises, appropriate nutritional supplementation, and bedding. New therapies available for treatment including hydrocolloid dressings and hydrogel preparations, are superior to wet-to-dry dressings and the use of povidone iodine in wounds (Patterson and Bennett, 1995). Clinical and Forensic Markers Indicating Abuse or Neglect There are divergent views regarding which decubiti are due to illness and which are due to neglect or even abuse. The failure to adhere to the standard of care could be due to medical, institutional, or caregiver neglect.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America elder abuse and neglect. Mortality rates associated with each marker also should be evaluated. This research, among other things, should determine in a scientific manner the difference between age and unavoidable disease-related changes versus abuse and neglect. Very few studies of any of the 14 factors listed below have been done; more are needed. For example, descriptive studies of skin tears are needed that compare those with known causes to those with unknown causes. Burnight (2000) has suggested a national database of witnessed injuries. Many forms of trauma could be studied, beginning with witnessed falls, which occur commonly in hospitals and nursing homes. Research protocols should be designed to provide information applicable to minority populations and to both genders. The study by Langlois and Gresham (1991) was limited to whites; a study of bruising is needed for people of color. A few suggestions (there are many more) for research needed relating to the markers discussed in this paper include the following: Fractures The significance of type and location of fractures is not well understood relative to mechanism and degree of injury. Objective documentation of the degree and ensuing impact of osteoporosis is needed. Research into osteoporosis to determine its objective documentation postmortem and how it affects fracturing, mechanisms (i.e., degree of force required) would be useful to the forensic analysis. Burns The findings on burns and elder abuse or neglect are intriguing and could be further studied at U.S. burn centers. The high incidence of burns in cases of self-neglect raises the question: When does a history or propensity of an elder to set fires give rise to a duty by a caregiver to intervene? This inquiry would benefit from research to develop forensic markers to guide the analysis. The high mortality rates in elders as a result of burns make this public health issue a compelling research topic. Cognitive and Mental Disorders The existing data on cognitive and mental disorders raise many research questions. What is the impact of cognitive and mental disorders in cases of abuse or neglect? What is the prevalence of dementia, depression, and psychosis in abused or neglected individuals or perpetrators? Are mortality and morbidity higher in persons with cognitive or mental disorders? Because dementia and alcoholism are treatable and depression and

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America psychosis are curable, interventions derived from trials may decrease or even reverse some cases of elder abuse and neglect. Elder Sexual Abuse To improve recognition of elder sexual abuse, researchers need to develop precise anatomic diagnostic criteria, something that is yet to be determined for child sexual abuse (Kerns, 1998). Studies are needed comparing anogenital examination findings and psychological characteristics in sexually abused elders with findings in examinations of those who participate in consensual sexual relations. Studies in each of the additional categories below should be conducted to determine what physical and behavioral signs should catalyze further examination, inquiry, and possible reporting by caregivers. The categories include: abrasions and lacerations, bruises, restraints, decubiti, malnutrition, dehydration, medication use, self-neglect, and financial fraud and exploitation. Additional studies should be conducted to determine what other markers should be added to the list (for example, contractures). Research on Distinctions in Medical Forensic Markers in Home Versus Residential Settings The study of these forensic markers in caregiver neglect is difficult because so many variables are involved. Some caregivers may neglect patients because of a lack of knowledge, resources, training, assistance, and available time due to competing responsibilities. Others may neglect intentionally or sadistically. In the institutional context, a corporate decision maker may order cutbacks that result in neglect. Research is needed to develop appropriate standards of care for caregivers that are meaningful and achievable regardless of socioeconomic status. Most of the adverse events that happen to frail elders are not the result of abuse or neglect. Tracking of data on adverse and unexpected events is important in determining standards for such incidents and is already performed by state and federal agencies. Intermingled with data on, for example, falls, may be data on bruises and fractures that occurred because of abuse or neglect unbeknownst to investigators. Gurwitz and colleagues (1994) have collected data on adverse and unexpected events in long-term care settings. A study in which investigators collect a single stream of data, screen data for abuse and neglect, and compare positive cases to negative cases may give results that are more accurate.

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America Assessment Tools The lack of statutory or well-studied screening instruments can result in highly subjective standards by mandated reporters, leaving prosecutors with very little hard evidence on which to base their cases (Loue, 2001). Health care providers and social services agencies may not reach the people who need them most if cases of abuse and neglect cannot be adequately identified. Research is vital to creating validated, uniform screening tools. The lack of a gold standard requires using alternative methods for validating tools, such as a lead standard. One lead standard might be an expert consensus panel. Consideration should be given to developing (a) a form with a short format for busy environments, such as emergency centers, with questions applicable to all elders; (b) a form applicable to community-dwelling elders; and (c) a form suited to residents of institutions. These various forms are required because we do not know what risk different settings confer. A second form with a long format, also validated and uniform, should be developed with a structure similar to that of a, b, and c above. The long form would be intended to be used by those who historically take a lengthy interview, such as protective service specialists or ombudsmen. The long form could serve as a research tool in conjunction with the short form if the individual appears to be at high risk for abuse or neglect. Screening for all elders, coupled with targeted comprehensive assessment in high-risk populations, may be the most practical and fruitful approach. Finally, comprehensive geriatric assessment is already a well-validated procedure for assessing and intervening in the care of frail elders and merits study in populations of abused or neglected individuals. Just as in the evaluation of potential abuse and neglect in living persons, there is a need for development of screening or evaluation tools that are specifically useful in the postmortem setting. For example, research could compare the number, location, and type of fractures incurred in documented accidental situations versus those encountered in the setting of inflicted injury. It is intriguing to think that there might be biological markers of elder abuse or neglect. While the need for epidemiological research on screening and assessment tools is clear, it does not preclude searching for other objective laboratory measures. Mortality Data for Abused and Neglected Elders Although a 100 percent autopsy rate, including proper investigation, review of medical records, consultation with specialists, including geriatri-

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America cians, odontologists, radiologists, and other specialists would be ideal to obtain baseline information, it is not practical financially and would overwhelm most medical examiner/coroner systems. Consideration should be given to a pilot study using statistically selected cases for investigation and autopsy to determine the prevalence of abuse and neglect and their contribution to death in an autopsied elderly population. Medical examiners and coroners should exchange information with geriatricians and others, including being active members of multidisciplinary teams to review deaths, review reporting mechanisms, and identify system issues that work for and against adequate reporting and intervention. Development of additional scientific literature on all markers would be useful to support a medical examiner’s diagnoses and conclusions when challenged in court. It would be useful to study what number or percent of cases of elder abuse and neglect contributing to death are not investigated or autopsied. This research likely will require predicate research into the markers to enhance detection in the first instance. Research Regarding Certification of Elder Deaths To ensure better certification of elders’ deaths, researchers should document aspects of aging that are natural and compare them with features of injury due to accidental mechanisms and to malevolence. Training in recognizing signs and typical features of abuse and neglect is important for medical examiners, coroners, death investigators, law enforcement, and those who first respond to emergency calls reporting deaths, and should be enhanced. Policy makers should consider expanding elder death mandatory-reporting laws beyond institutional cases. Development of standardized protocols for examination of deaths in elders, particularly when there is a suspicion of abuse or neglect, is fundamental and could benefit from the expertise of all health care professionals concerned about fatal abuse and neglect of the elderly. Legal Issues for Study Research is needed to determine what types of criminal, civil, and administrative cases best protect elders in all settings. To date, there has been no research on the efficacy of current laws and existing remedies or how to develop more effective ones. Reporting There is a wide divergence of views regarding whether reporting of elder abuse and neglect should be mandatory, whether mandatory-report-

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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America ing laws should be aggressively enforced, and regarding the efficacy, in general, of mandatory reporting. In addition, some states have specific reporting requirements, such as the Arkansas law requiring immediate reporting of deaths of nursing home residents. Research protocols should be developed that inform this debate and to track the impact and efficacy of reporting laws. Developing Experts in Forensic Geriatrics Development of a group of forensic pediatricians has reportedly improved detection, diagnosis, reporting, and prosecution of child abuse and neglect. Pilot programs to train a group of forensic geriatricians, and to identify what types of programs are most effective, should be developed and tested. Screening Tools, Forensic Centers, and Multidisciplinary or Interdisciplinary Teams As discussed earlier in this paper, each of these potential tools should be the subject of study to determine how best to construct screening tools, forensic centers, and multidisciplinary/interdisciplinary teams (including fatality and serious-injury review teams), likely including several pilot or demonstration projects in several sites. A predicate for such research would be to examine and evaluate what is known about screening tools, forensic centers, and multidisciplinary/interdisciplinary teams used in other areas, such as child abuse and neglect, sexual abuse, and domestic violence. There are many more areas of needed study and many more recommendations could be made. The reader is directed to Elder Justice Roundtable Report (2000). CONCLUSION Evidence-based forensic markers of elder abuse and neglect have attracted little research interest and therefore remain largely unidentified. No data exist regarding the number of documented forensic markers or prosecuted cases. A comprehensive research agenda should be developed that will provide the information needed to help derive accurate clinical and forensic markers for elder abuse and neglect in both living and deceased persons, in home and residential settings alike. The significantly increased mortality rate for elder victims of abuse and neglect underscores the pressing need for a national research agenda and extensive study by the relevant disciplines to address this growing issue.

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