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Elder Abuse: A Determination of Death
Angela Lack, Science and Law Fellow

Introduction

Every year, nearly 700,000 to 1.2 million elderly people are subjected to mistreatment or abuse.1 People age 80 and older who are dependent on others for basic care, especially women, are particularly vulnerable to elder abuse.2 Many factors lead to the mistreatment of the elderly including: elderly persons’ need for caregiving; dependency of people on the elderly; mental impairments; isolation; inadequate living arrangements; inability to perform daily functions; frailty; family conflict; poverty; alcohol or drug abuse of the caregiver; or other socioeconomic issues.3

Definition of Elder Abuse

Elder abuse is a problem throughout the United States. Each state has its own guidelines and laws. Elder abuse is defined as doing something or failing to do something that results in harm to an elderly person, including, but not limited to (1) physical, sexual and emotional abuse, (2) neglecting or deserting an elderly person, or (3) taking or misusing an elderly person's money or property4. Elder abuse is manifested through visible signs such as abandonment, physical abuse, exploitation, and neglect5. Behavioral signs of elder abuse may manifest in the elderly individual avoiding eye contact, sitting at a distance from the caregiver, cringing or backing off, startling easily, and allowing the caregiver to answer for them all the time6. When a caregiver is unable to handle the pressures of caring for the elderly person or is unable to handle the needs of the elderly person, the caregiver may react with some form of elder mistreatment7.

“The abuser is typically a family member - an adult child or a spouse” or a relative who lives with or near the elder8 or acquaintances. Abusers demonstrate three characteristics which are known risk factors: a history of mental illness and/or substance abuse; excessive dependence on the elder for financial support; and a history of violence within or outside the family9. They often are unmarried, unemployed, and approximately 35% have a substance abuse problem or have psychological disorders.10 Some are caregivers for those they abuse11. “In institutions, such as nursing or group homes, professionals may be abusers.”12

Forensic Science Guidelines and Standards

Recently, the legal community raised concerns regarding the lack of research on the forensic aspects of elder mistreatment. This is due to the fact that the medical community lacks the ability and the information to easily determine whether injuries of the elderly are due to abuse, neglect, or natural effects of illness and aging13. Therefore, several jurisdictions have developed new methods to examine elder abuse and neglect, such as establishing “special elder abuse prosecution units, elder fatality review teams14, and the expansion and improvement of statutes that mandate abuse reporting for vulnerable adults.”15 The National Institute of Justice recently funded a study that “examined how medical examiners make determinations in cases of suspicious elder deaths and found that they rarely can differentiate symptoms of illness from signs of abuse in elderly decedents.”16 Signs of abuse in the elderly are usually missed and are rarely determined to be the cause of death; however, these signs are typically identified in younger decedents.17 Further research on these and other factors is required to determine abuse or neglect and to identify the forensic markers of mistreatment.18

Establishment of Forensic Markers of Abuse and Neglect

Forensic markers of elder abuse and neglect refer to factors used to determine whether an elderly person is suffering from age-related changes or other factors.19 The markers are being developed through the use of: (1) consistent, validated screening tools, (2) forensic centers, and (3) multidisciplinary teams.20 Researchers in Arkansas created four categories of markers for investigators.21

Potential Markers to Identify Elder Mistreatment:

Physical Condition and Quality of Care
  • Documented but untreated injuries
  • Undocumented injuries and fractures
  • Multiple, untreated, or undocumented pressure sores
  • Medical orders not followed
  • Poor oral care, poor hygiene, and lack of cleanliness of resident (e.g., unchanged adult diapers, untrimmed finger and toenails)
  • Malnourished residents that have no documentation for low weight
  • Bruising on non-ambulatory residents; bruising in unusual locations
  • Family has statements and facts concerning poor care
  • Level of care for residents with non-attentive family members
Facility Characteristics
  • Unchanged linens
  • Strong odors (urine, feces)
  • Trash cans that have not been emptied
  • Food issues (cafeteria smells at all hours; food left on trays)
  • Past problems
Inconsistencies between
  • Medical records, statements made by staff members, or what is viewed by investigator
  • Statements given by different groups
  • The reported time of death and condition of the body
Staff Behaviors
  • Staff members who follow the investigator too closely
  • Lack of knowledge or concern about a resident
  • Evasiveness, both unintended and purposeful, verbal and nonverbal
  • Facility's unwillingness to release medical records
Fourteen potential markers have been identified through research:22 These include: Abrasions and Lacerations; Bruises; Fractures; Sexual Abuse, Restraints; Decubiti;23 Malnutrition; Medication Use; Burns; Dehydration; Cognitive and Mental Conditions; Hygiene; Financial Fraud and Exploitation.24 The characteristics of these markers and the relationship between age-relatedness and abuse/neglect factors are discussed below.

Abrasions and Lacerations

Potential forensic markers include the presence of abrasions and lacerations but age-related changes may also account for them. As humans age skin thickness and elasticity decline making them more susceptible to trauma. Lacerations/skin tears generally occur on the forearms and occasionally on the legs, which usually occur no more than two at a time and usually heal completely without scarring.25

One indication of abuse is when there are skin tears on the body in places other than arms and legs.26 Multiple skin tears may also be signs of abuse.27 Abrasions and lacerations heal with scarring and are the most common in cases of physical abuse and sometimes in caregiver neglect.28 Health care professionals should document the abrasion pattern because it is an important way to identify the method of injury.29

Abrasions generally occur in elderly persons with minor trauma because as humans age, their skin thickness and elasticity decline making them more susceptible to trauma. Lacerations/skin tears generally occur on the forearms and occasionally on the legs, which usually occur no more than two at a time and usually heal completely without scarring.30 In one study of a large nursing home, the following statistics regarding the annual incidence of skin tears were that:
    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.31
Bruises

Bruising increases as people age, especially in women.32 However, bruising can be a sign of a serious abuse problem; bruising may occur at a site other than where the injury occurred.33 Sometimes, medications such as aspirin, Coumadin, corticosteroids, and Plavix, and dietary supplements such as fish oil, ginkgo, ginger and garlic increase the risk of bruising, since these medications and supplements thin the blood.34

While research exists on the site, patterns, and dating of bruising in children, research on the differentiation of bruising in the elderly population does not exist.35 Therefore, the National Institute of Justice funded a study to examine bruising, one of the most common indicators of abuse and neglect.36 A group of elderly individuals took part in a 16-month clinical study conducted by Laura Mosqueda, M.D.37 which documented the occurrence, progression, and resolution of accidentally inflicted bruising.38

Bruises are most commonly seen with physical abuse, but can be present in cases of neglect as well.39 To determine whether bruising is the result of abuse or natural occurrences, researchers conducted examinations of individuals analyzing normal bruising patterns and differentiating them from suspicious bruising.40 Mosqueda found that bruising followed patterns: (1) accidental bruises occurred in predictable patterns; (2) most accidental large bruises are located on extremities though 90% of all bruises are located on the extremities; (3) the initial color and appearance of bruises does not determine the age of the bruise and both change over time; (4) accidental bruising did not occur on the ears, neck, genitals, buttocks, or soles of the feet; (5) bruising is more severe in individuals on medications, and (6) individuals with compromised functional ability are more likely to have multiple bruises.41

A bruise lasts a shorter time in younger individuals than in elderly individuals.42 Generally, bruises keep the shape of the object which caused them.43 The location of the bruise is also an indication of abuse;44 bruising on the face, neck, chest wall, abdomen, soles of the feet, palms of the hands, and buttocks are considered signs of abuse rather than accidental injury.45 However, bruising can also be an indication of falling; circumstances regarding the fall should be evaluated to determine if it is a result of neglect.46

Fractures

The significance of the type of fracture and location requires more documentation and studies on the degree of impact to osteoporosis to determine the mechanism and degree of injury.47 Such studies and published information would be useful to forensic pathologists testifying in court in criminal and civil cases.”48

The bones of elderly persons are thinner and less dense due to poor nutrition, vitamin D deficiency, alcoholism, sex hormone deficiencies and bone diseases, causing bone to fracture more easily.49 Persons over age 75 typically fracture hip bones and persons under age 75 typically fracture wrist bones.50

While literature on fracture resolution in abused children exists, there is little or no data on fracture resolution in elders.51 Data pertaining to the resolution of fractures in children are invalid for older adults because their fractures heal much more slowly. Falls that lead to fractures should be analyzed along with an examination of the patient, their records, and/or their history before a determination of abuse is made.52 Indications of abuse include fractures on the head, spine, and trunk rather than limb fractures, sprains, strains, or musculoskeletal injuries,53 and spiral fractures of a large bone with no history of gross injury.54

Malnutrition

“Malnutrition often is a marker of caregiver neglect, especially in institutional settings.”55 Many factors can lead to malnutrition including a decline in smell and taste and poor health, inappropriate prescribing of medications, caregivers failing to maintain oral hygiene, not acknowledging cultural food preferences in group homes, and neglect due to inadequate numbers of staff to assist patients appropriately who cannot feed themselves.56

Sexual Abuse

Sexual assault is the most underreported, least perceived, least acknowledged, and least detected type of elder maltreatment. Due to the low rate of elder death investigation, sexual assault examinations are often not performed57 despite the fact that thousands suffer from sexual abuse. Not surprisingly, most victims are women.

Perpetrators of sexual abuse in nursing homes can include nursing home staff, other nursing home residents, and guests, but most sexual assaults occur at home. Trauma and stress from sexual abuse can lead to an untimely death.58 Unfortunately, evidence of sexual assault can be difficult to collect due to the decreased mental status, delayed reporting, and/or fear of retribution of the elder.59

An NIJ-sponsored study found that: (1) elderly sexual assault victims were not routinely evaluated to assess the psychological effects of an assault; (2) the older the victim, the less likelihood that the offender would be convicted of sexual abuse; (3) perpetrators were more likely to be charged with a crime if victims exhibited signs of physical trauma; and (4) victims in assisted living situations faced a lower likelihood than those living independently that charges would be brought and the assailant found guilty.60

Further studies must be conducted to better recognize elder sexual abuse. Caregivers should be trained to identify the signs of assault-related trauma.

Other Forensic Techniques for Determining Elder Abuse or Neglect

Forensic Entomology

One area of forensic science, which has become useful in determining whether elder abuse exists, is forensic entomology. Forensic entomology is defined as the “use of the insects, and their arthropod relatives that inhabit decomposing remains to aid legal investigations.”61 In several cases, entomologists have helped determine whether or not insects attacked the elderly individual before or after death.

Forensic Psychiatry

Another area of forensic science that has become useful in determining elder abuse or neglect is forensic psychiatry. Forensic psychiatry focuses on the interplay between law and mental health.62 Forensic psychological and psychiatric autopsies have been used in suspected suicide cases, but have not yet been used in the investigation of elder deaths.63 Autopsies can be critical tools in determining cause of death by looking at the associations of dementia, depression, and self-neglect to elder abuse and neglect.64 The ability to understand “the degree of cognitive impairment or decision-making capacity, even retrospectively, may be critical in investigating and classifying a death.”65 However, other limitations exist in classifying the death because the most important informants may be the person perpetuating the abuse or neglect, making them more likely to give false or subjective responses.66

The Role of Medical Examiners

The medical examiner or coroner determines the cause and manner of death through a physical examination and/or autopsy and an extensive investigation, review of medical records, toxicology testing, and other testing such as radiology, cultures, or serology.67

The medical examiner should examine the body for the potential markers of elder neglect and abuse just as they do in child abuse cases with regard to the location, extent, type and multiplicity of injuries which suggest repetitive abuse68. Explanations of injuries from falls and abrasions and skin tears are necessary and the decedent’s record should also be examined.69

After documenting an external examination of the body, the medical examiner conducts an internal examination to obtain additional evidence of abuse or neglect.70 This exam should include evaluation of the state of nutrition and hydration, and evidence of natural disease” including neuropathology which accounts for cognitive deficit disorders.

Prosecutions of Elder Abuse

Medical examiners have faced significant difficulty in getting elder abuse/neglect cases71 prosecuted due to lack of knowledge, ageist attitudes, and concerns about the standard of proof in criminal cases.72 Medical examiners stated that many prosecutors do not understand the nature of nursing home abuse and neglect. Medical examiners and coroners indicated that there were three reasons for the lack of prosecution, (1) the prosecutors did not view premature death of persons with multiple chronic diseases as necessarily a significant or easily “provable” crime; (2) the prosecutors did not necessarily know how to present the evidence and cases; and (3) prosecutors had difficulty determining whom to charge73 because up to 30 people may be involved in the care of the elderly person in a nursing home.74

Ageist Attitude

Medical examiners have seen an ageist attitude from some prosecutors illustrating a different standard for crimes against the elderly and crimes against children.75 One case involving the rape of a resident with dementia illustrates this double standard.76 In this case, the perpetrator was not prosecuted because the woman was demented. However, if the rape occurred to a child, it most likely would have been prosecuted.77 Additionally, the Attorney General’s office did nothing to rectify the situation, not even removing the known rapist from the nursing home.78

Standard of Proof in Criminal Cases

The standard of proof in criminal cases is proof beyond a reasonable doubt.79 Problems arise when the prosecution calls a witness to the stand and the witness must testify that something is possible. For example, “one forensic pathologist noted, when asked in court whether it was possible that the resident’s decline and death could have been caused by her underlying diseases, the pathologist had said that in her/his opinion, it was possible.”80 Another problem that prosecutors face is that there are few expert witnesses that can testify and limited data to bolster their cases.81

Conclusion

Elder abuse and maltreatment are growing concerns in the United States. As the Baby Boomer generation gets older, elder abuse will become a more prominent issue. Several organizations help elderly persons suffering from elder abuse, including the Administration on Aging,82 the National Center on Elder Abuse,83 and the National Institute on Aging.84 Organizations such as the National Institute of Justice continue to fund studies to provide more information to medical examiners, coroners, doctors, and the legal community on forensic markers for detection of elder abuse and neglect for both the living and the deceased.

Up
1American Geriatric Association, available at: http://www.healthinaging.org/agingintheknow/chapters_ch_trial.asp?ch=9, February 28, 2005. (Last accessed January 19, 2008)..
2Mayo Clinic Staff, http://www.mayoclinic.com/print/elder-abuse/HA00041/METHOD=print, January 12, 2007 (Last accessed January 19, 2008).
3Id.
4 Medline Plus, http://www.nlm.nih.gov/medlineplus/elderabuse.html (Last accessed January 19, 2008).
5 Abandonment will manifest as leaving the elderly person alone frequently. Physical abuse is generally detected with numerous trips to the emergency room, fractures or bruises (some old and some new), bruises on the inner thighs or inner arms, repeated falls, and unexplained loss of hair (possibly pulled out). Elderly people will also be exploited by the caregiver taking the elderly person’s possessions, lost Social Security or pension checks, sudden inability to pay for food, clothes, health care or other basic needs, or the caregiver’s unusual interest in the elderly person’s assets. Neglect is determined by unexplained skin rashes, irritations, or ulcers, inappropriate dress, no enegry or spirit, malnourishment, poor hygiene, being left in unsafe situations, and inability to get needed medication. MayoClinic Staff, supra at note 2. Other signs exhibited by the elderly person can include, exhibiting emotional distress such as crying, depression, or despair; nightmares or difficulty sleeping; a sudden loss of appetite that is unrelated to a medical condition; acts confused and disoriented (this may be the result of malnutrition); appears emotionally numb, withdrawn, or detached; exhibits regressive behavior; exhibits self-destructive behavior; exhibits fear toward the caregiver; or expresses unrealistic expectations about their care (e.g. claiming that their care is adequate when it is not or insisting that the situation will improve). National Committee for the Prevention of Elder Abuse, supra at note 8.
6The caregiver may also show the behaviors signs of elder abuse by acting nervous and fearful, or quiet and passive, by trying to prevent private conversation or examination of the elderly person, by providing explanations of elderly person’s injuries that don’t make sense, or by acting impatient, irritable, and make negative or demeaning statements about the elderly person. MayoClinic Staff, supra at note 2. Other signs observed in the caregiver/abuser include, expresses anger, frustration, or exhaustion; isolation of the elder from the outside world, friends, or relatives; obviously lacks care giving skills; is unreasonably critical and/or dissatisfied with social and health care providers and changes providers frequently; refuses to apply for economic aid or services for the elder and resists outside help. National Committee for the Prevention of Elder Abuse, http://www.preventelderabuse.org/elderabuse/neglect.html, March 2003 (Last accessed January 19, 2008)..
7American Geriatric Association, supra at note 1.
8Collins, Kim A., “Elder Maltreatment: A Review,” Archives of Pathology and Laboratory Medicine, Vol. 130, Issue 9, 2006 WLNR 15894522 (Last accessed January 19, 2008).
9Mayo Clinic Staff, supra at note 2.
10Collins, Kim A., supra at note 6.
11National Committee for the Prevention of Elder Abuse, http://www.preventelderabuse.org/elderabuse/physical.html March 2003 (Last accessed January 19, 2008).
12Mayo Clinic Staff, supra at note 2.
13National Institute of Justice (NIJ), “Elder Abuse,” http://www.ojp.usdoj.gov/nij/topics/crime/elder-abuse/welcome.htm. (Last accessed January 19, 2008)
14The American Bar Association Commission on Law & Aging has published a manual for elder fatality review teams. Lori A. Stiegel, Elder Abuse Fatality Review Teams: A Replication Manual, American Bar Association, Washington, D.C., 2005 available at http://www.abanet.org/aging/publications/docs/fatalitymanual.pdf (Last accessed January 19, 2008).
15NIJ, supra at note 47.
16Id.
17Id.
18Id.
19Bonnie, Richard J., and Robert B. Wallace, Eds., Elder Maltreatment: Abuse, Neglect, and Exploitation in an Aging America, The National Academic Press, Washington, D.C., 2002, available at http://www.nap.edu/openbook.php?record_id=10406&page=183 (Last accessed January 19, 2008).
20Bonnie, supra at 363. For more information on the Tools to identify forensic markers, see Bonnie, Richard J., and Robert B. Wallace, Eds., Elder Maltreatment: Abuse, Neglect, and Exploitation in an Aging America, The National Academic Press, Washington, D.C., 2002, available at http://www.nap.edu/openbook.php?record_id=10406&page=183 (Last accessed January 19, 2008).
21NIJ, supra at note 47.; see also, Lindbloom, E., J. Brandt, C. Hawes, C. Phillips, D. Zimmerman, J. Robinson, B. Bowers, and P. McFeeley, The Role of Forensic Science in Identification of Mistreatment Deaths in Long-Term Care Facilities, final report submitted to the National Institute of Justice, Washington, DC: April 2005 (NCJ 209334), available at www.ncjrs.gov/pdffiles1/nij/grants/209334.pdf (Last accessed January 19, 2008). A chart of individual markers and facility markers also portrays a list of markers to identify abuse and neglect in residential homes.
22Id. at 344.
23Decubiti are commonly known as bedsores. http://medical-dictionary.thefreedictionary.com/Decubiti (Last accessed January 19, 2008).
24See Bonnie, supra at 340-376.
25Id.
26Id.
27Id.
28Id.
29Id.
30Bonnie, 344-345.
31Id.
32Bruising is generally caused by (1) aging capillaries, which over time, become more fragile and prone to rupture when the supporting tissues weaken; (2) thinning skin, which becomes thinner and loses some of the protective fatty layer that helps cushion the blood vessels against injury; or (3) excessive exposure to the sun. Mayo Clinic Staff, “Easy Bruising: Common as You Age,” http://www.mayoclinic.com/print/easy-bruising/HQ00355/METHOD=print, May 25, 2007 (Last accessed January 19, 2008).
33Mayo Clinic Staff, supra at note 68.
34Id.
35NIJ, supra at note 47.
36Id.
37Laura Mosqueda, M.D. and her colleagues at the University of California, Irvine conducted the 16-month study. For more information on the NIJ-funded study on Bruising in the Geriatric Population, see Mosqueda, L., K. Burnight, and S. Liao, “Bruising in the Geriatric Population,” final report submitted to the National Institute of Justice, Washington, DC: June 2006 (NCJ 214649), available at www.ncjrs.gov/pdffiles1/nij/grants/214649.pdf (Last accessed January 19, 2008).
36NIJ, supra at note 47.
37Bonnie, supra at 346.
38NIJ, supra at note 47.
39Id.
40Bonnie, supra at 346.
41Bonnie at 346.
42Bonnie at 346.
43Bonnie at 346.
44Bonnie at 346.
45Bonnie at 346.
46Bonnie at 346.
47Bonnie at 346.
48Bonnie at 361.
49Bonnie at 347.
50Bonnie at 347.
51Bonnie at 347.
52Bonnie at 347-348.
53Bonnie at 348.
54Bonnie at 348.
55Bonnie at 350.
56Bonnie at 350.
57Collins, Kim A., supra at note 6.
58Hawks, Robert A. at 175, supra at note 53.
59NIJ, supra at note 47.
60Bonnie, supra at 372.
61J.H. Byrd, “What is Forensic Entomology,” http://www.forensicentomology.com/definition.htm (Last accessed January 19, 2008).
62W. Reid, “Frequently Asked Questions About Forensic Psychiatry,” http://www.reidpsychiatry.com/reidfaq.html#what1 (Last accessed January 19, 2008).
63Bonnie, supra at 362.
64Id. at 363.
65Id.
66Id.
67Id. at 344.
68Id. at 360.
69Id. at 361.
70Id.
71Lindbloom, supra at 38.
72Id. at 39.
73Id.
74Id.
75Id.
76Id.
77Id.
78Id.
79Id. at 40.
80Id. at 40-41.
81NIJ, supra at note 47.
82Contact the Administration on Aging at: Administration on Aging, Washington, DC 20201, Phone: 202 619-724 or visit the AOA online at http://www.aoa.gov (Last accessed January 19, 2008)
83Contact the National Center on Elder Abuse at: National Center on Elder Abuse, c/o Center for Community Research and Services, University of Delaware, 297 Graham Hall, Newark, DE 19716, Phone: 302-831-3525, Fax: 302-831-4225, E-mail ncea-info@aoa.hhs.gov or visit the NCEA online at http://www.ncea.aoa.gov/ncearoot/Main_Site/index.aspx (Last accessed January 19, 2008).
84Contact the National Institute on Aging at: National Institute on Aging, Building 31, Room 5C27, 31 Center Drive, MSC 2292, Bethesda, MD 20892, Phone: 301-496-1752, Fax: 301-496-1072 or visit the NIA online at http://www.nia.nih.gov/AboutNIA/ (Last accessed January 19, 2008).