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Medical Forensic Aspects of Elder Abuse and Neglect Dr. Kerry Burnight Professor, UCI Geriatric Medicine Director, Elder Abuse Forensic Center Founder, Ageless Alliance What is elder abuse? Intentional behavior that results in the physical, sexual, emotional or financial harm or injury or neglect or abandonment of an older person (65+) by a family member, friend, fiduciary or caregiver Types of Elder Abuse Emotional/Psychological Physical Sexual Financial Neglect Active or intentional Inactive or unintentional Risks Physical Abuse of the Elderly Use of physical force that may result in Bodily injury Physical pain Impairment Disease Results of Physical Abuse Wounds Bruising Burns Syndromes: medicinal misuse; shaking Fractures Decubitis ulcers (bedsores) Malnutrition Dehydration Difficulties in Detecting Abuse Hard to distinguish between A disease process An injury Often assumed that death was the result of old age Physical inspection not always done Deaths are often not evaluated in detail Autopsies rarely performed Forensic Markers of Physical Abuse Injuries Fractures Not properly cared for Delay in seeking medical treatment Unset broken bones Note: some injuries and fractures may be the result of a medical condition (e.g., osteoporosis) and/or medication (e.g., Coumadin) Medical Causes of Fractures Age Osteoporosis and other bone diseases Poor nutrition Vitamin D deficiency Alcoholism Cancer that invades bone (e.g., osteosarcoma) NYC Elder Abuse Training Project Sites of Fractures in the Elderly Hip in >75 years old Wrist in <75 years old Common site of fracture with falls Many use their hands to help break a fall Head (face, teeth, cheekbones) Trunk Spine NYC Elder Abuse Training Project Falls Added difficulty in detecting abuse Prevalence of falls Broken bones can be the result of a fall 30% of community-dwelling older persons 50% of nursing home patients Most persons who fall experience one to three falls a year Note: Detailed examination of the patient, medical records, and/or collateral history from caregivers is needed to determine abuse NYC Elder Abuse Training Project Bruising In the older adult Occurs more frequently Resolves more slowly (may last for months) Multiple bruises in different stages of healing may indicate abuse NYC Elder Abuse Training Project Sites of Bruising In abuse victims, most often seen on Knuckles and fingers Face and neck Chest wall Abdomen Buttocks Palms and soles of feet NYC Elder Abuse Training Project Inflicted NYC Elder Abuse Training Project Bruising Patterns Bilateral Different colors ranging from purple (recent) to yellow green (older) Shape and Pattern Facial distribution NYC Elder Abuse Training Project Bruising Distribution and Patterns Face & Neck Medial Surfaces Morphological Signs Bruises or burns shaped like an object Iron Curling iron Belt marks Fingers Cigarette burns Rope burns (e.g., resulting from restraints) NYC Elder Abuse Training Project Prevalence of Burns In healthy adults: rare In the frail elderly: rare in institutional settings 70% of all burns are the result of abuse/neglect NYC Elder Abuse Training Project Violent Shaking Possible results in the elderly: Whiplash Detached retinas Contusions Brain atrophy Brain hemorrhages NYC Elder Abuse Training Project Other markers Ruptured eardrums Boxing the victim’s ears Changes in hairstyle Cover up for Hair that may have been ripped out Bruises NYC Elder Abuse Training Project Decubitis Ulcers (bedsores) The result of circulatory failure due to pressure resulting in dead tissue (necrosis) May indicate that a bed-ridden patient is not being properly cared for and/or moved by the caregiver Note: can also result from insufficient circulation due to medical conditions (e.g. diabetes) Suspect neglect if: Deep decubiti, multiple sites Foul smelling dead tissue NYC Elder Abuse Training Project Decubitus Ulcers Bed sore Immobility Skin over bony surfaces Vasculature compression Vascular insufficiency Tissue necrosis Inflammation Infection Sepsis Shock NYC Elder Abuse Training Project Prevalence of Decubitis Ulcers In healthy adults: never In the frail elderly, risk factors include: Medical illness Cognitive impairment Incontinence Poor nutrition In abuse victims More frequent illnesses means victims dependent on others for proper skin care Neglect more likely NYC Elder Abuse Training Project Skin Ulcers in Diabetic with Severe Vascular Insufficiency General Condition •Edges •Centers •Smell •Surrounding Skin NYC Elder Abuse Training Project Malnutrition Poor health status due to the decreased intake of necessary nutrients Poor diet Malabsorption NYC Elder Abuse Training Project Medical Causes of Malnutrition Aging factors Decline of smell and taste reducing appetite Inappropriate medications, including psychotropic drugs Medical conditions (cancer, COPD, dementia, stroke, Parkinson’s Disease, disorders of the esophagus) NYC Elder Abuse Training Project Other Causes of Malnutrition Neglect Self-neglect Poor dentition Poor oral hygiene Loss of teeth Depression Loss of appetite NYC Elder Abuse Training Project Causes of Appetite Loss in the Elderly In the frail elderly: Depression Change in environment Change in medical condition Medication (over/under) In the abuse victim Inappropriate or excessive medications can affect swallowing and/or memory Ignoring of cultural food preferences Force feeding or other appropriate feeding NYC Elder Abuse Training Project Dehydration Loss of more fluids than are taken in Often caused by medical illness Neglect present if: Inadequate fluids are offered or provided Dehydration goes unrecognized for a long period of time by medical or nursing personnel NYC Elder Abuse Training Project Symptoms of Dehydration Dizziness Dry mouth and nose Decreased urine production NYC Elder Abuse Training Project Misuses of Medication Medications can be used as a tool for abuse Examples Giving a person too much or too little of an indicated drug Withholding a necessary medication Administration of unnecessary or inappropriate medication NYC Elder Abuse Training Project Misuses of Medications Over-medication Under-medication or withholding of medication To keep patients quiet and manageable Caregiver may use the drug him/herself Unnecessary or inappropriate medication Over/under-medication can result in medical or cognitive impairment NYC Elder Abuse Training Project Sexual Abuse of the Elderly Non-consensual sexual contact of any kind Sexual contact with any person incapable of giving consent Elderly are more vulnerable due to Cognitive impairment Physical inability to protect oneself NYC Elder Abuse Training Project Physical Forensic Markers of Sexual Abuse Torn, stained, bloody underclothing Difficulty in walking, standing and/or sitting Changes in bowel movement or bladder activity Pain, itching, bruising, burning in genital area Unexplained venereal disease NYC Elder Abuse Training Project Physical Forensic Markers of Sexual Abuse Bruising Palate (hard plate at roof of mouth) Genital area (75% of those who have been sexually abused) Sexually transmitted disease Signs of restraint NYC Elder Abuse Training Project ASK “Do you have other bruises, burns, or clusters of bruises on your body?” (May have come from repeated abuse) “How often do you go to the doctor?” “How many different doctors do you see?” “How often have you been to the emergency room in the past year?” “How many different hospital emergency rooms have you visited in the past year?” Consider: you see? Are the answers consistent with what NYC Elder Abuse Training Project Important Steps in Detecting Abuse Explore the use of medications Side effects Interactions Medications can be used as a tool for abuse Exploring the use of multiple medications Determine cognitive functioning and functional dependency of victim Refer to a psychiatrist for evaluation (e.g., Folstein mini-mental, Geriatric Depression Screen, PTSD symptom scale) NYC Elder Abuse Training Project Harry Bernard 46 NCEA Elder Abuse Overview 2013 Case Example Elaine Elder Abuse Forensic Center Elder Abuse Forensic Center Central Concept Unfettered collaboration of the various professionals to enable disparate systems (medical, legal, and social services) to effectively and comprehensively identify cases of elder abuse, facilitate prosecution where appropriate, and identify the appropriate legal course of action and service provision for these cases. What Makes it Work Director Doctor Geropsychologist Social Services Law Enforcement District Attorney Mental Health Public Guardian Long Term Care Ombudsman What We’ve Learned From 1000 Cases Of Elder Abuse