Download Markers of Physical and Sexual Abuse

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?
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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
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Emotional/Psychological
Physical
Sexual
Financial
Neglect
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Active or intentional
Inactive or unintentional
Risks
Physical Abuse of the Elderly
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Use of physical force that may result in
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Bodily injury
Physical pain
Impairment
Disease
Results of Physical Abuse
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Wounds
Bruising
Burns
Syndromes: medicinal misuse; shaking
Fractures
Decubitis ulcers (bedsores)
Malnutrition
Dehydration
Difficulties in Detecting
Abuse
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Hard to distinguish between
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A disease process
An injury
Often assumed that death was the result of old
age
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Physical inspection not always done
Deaths are often not evaluated in detail
 Autopsies rarely performed
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Forensic Markers of
Physical Abuse
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Injuries
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Fractures
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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
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Age
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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
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Hip in >75 years old
Wrist in <75 years old
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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
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Added difficulty in detecting abuse
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Prevalence of falls
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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
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In the older adult
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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
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In abuse victims, most often seen on
Knuckles and fingers
 Face and neck
 Chest wall
 Abdomen
 Buttocks
 Palms and soles of feet
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NYC Elder Abuse Training Project
Inflicted
NYC Elder Abuse Training Project
Bruising Patterns
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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
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Bruises or burns shaped like an object
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Iron
Curling iron
Belt marks
Fingers
Cigarette burns
Rope burns (e.g., resulting from restraints)
NYC Elder Abuse Training Project
Prevalence of Burns
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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
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Possible results in the elderly:
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Whiplash
Detached retinas
Contusions
Brain atrophy
Brain hemorrhages
NYC Elder Abuse Training Project
Other markers
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Ruptured eardrums
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Boxing the victim’s ears
Changes in hairstyle
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Cover up for
Hair that may have been ripped out
 Bruises
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NYC Elder Abuse Training Project
Decubitis Ulcers (bedsores)
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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:
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Deep decubiti, multiple sites
Foul smelling dead tissue
NYC Elder Abuse Training Project
Decubitus Ulcers
Bed sore
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Immobility
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Skin over bony surfaces
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Vasculature compression
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Vascular insufficiency
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Tissue necrosis
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Inflammation
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Infection
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Sepsis
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Shock
NYC Elder Abuse Training Project
Prevalence of Decubitis
Ulcers
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In healthy adults: never
In the frail elderly, risk factors include:
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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
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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
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Poor health status due to the decreased intake of
necessary nutrients
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Poor diet
Malabsorption
NYC Elder Abuse Training Project
Medical Causes of
Malnutrition
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Aging factors
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Decline of smell and taste reducing appetite
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Inappropriate medications, including
psychotropic drugs
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Medical conditions
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(cancer, COPD, dementia, stroke, Parkinson’s Disease,
disorders of the esophagus)
NYC Elder Abuse Training Project
Other Causes of Malnutrition
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Neglect
Self-neglect
Poor dentition
Poor oral hygiene
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Loss of teeth
Depression
Loss of appetite
NYC Elder Abuse Training Project
Causes of Appetite Loss
in the Elderly
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In the frail elderly:
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Depression
Change in environment
Change in medical condition
Medication (over/under)
In the abuse victim
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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
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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
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NYC Elder Abuse Training Project
Symptoms of Dehydration
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Dizziness
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Dry mouth and nose
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Decreased urine production
NYC Elder Abuse Training Project
Misuses of Medication
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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
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NYC Elder Abuse Training Project
Misuses of Medications
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Over-medication
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Under-medication or withholding of medication
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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
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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
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NYC Elder Abuse Training Project
Physical Forensic Markers
of Sexual Abuse
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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
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Bruising
Palate (hard plate at roof of mouth)
 Genital area (75% of those who have been
sexually abused)
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Sexually transmitted disease
Signs of restraint
NYC Elder Abuse Training Project
ASK
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“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
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Explore the use of medications
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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
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Refer to a psychiatrist for evaluation
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(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