Elder Abuse in the United States
by Catherine C. McNamee with Mary B. Murphy
To most people, Charles Cullen was an experienced nurse
attending to the elderly in hospitals and nursing homes.
The perception of Cullen as a devoted caretaker came to
an abrupt end in 2004, however, when he admitted that he
intentionally administered fatal doses of medication to
almost 40 patients in various institutions over a 16-year
period. Because most of Cullen’s early victims were
elderly and seriously ill, and because toxicology and other
tests were not done to detect whether there had been wrongdoing,
medical examiners did not classify the deaths as homicides. 
As a result, no criminal investigations were initiated for
several years, which resulted in the loss of valuable forensic
Cullen’s case is an extreme example of what happens
when professionals fail to recognize the signs of elder
abuse. Despite the wake-up call high-profile cases such
as Cullen’s should provide, little is known about
how to recognize, prevent, or prosecute incidences of elder
Early findings from NIJ-funded research projects on the
elderly are beginning to build a body of knowledge that
will help caretakers, medical personnel, and law enforcement
officers to recognize abuse indicators—known as forensic
markers—and isolate factors that place elderly individuals
Why Are We Behind the Curve?
One reason that so little is known about elder abuse is
that a “gold standard test” for abuse or neglect
does not exist. Those working
with elders who have been abused or neglected must rely
on forensic markers. The problem with this approach is that
caregivers, Adult Protective Services agencies, and doctors
are often not trained to distinguish between injuries caused
by mistreatment and those that are the result of accident,
illness, or aging.
Compounding the difficulty in diagnosis is the fact that
many elderly individuals suffer from diseases or conditions
that produce symptoms mirroring those resulting from abuse.
Because these symptoms may mask or mimic indicators of mistreatment,
their presence does not send up a red flag for treating
physicians or for medical examiners charged with determining
manner of death. In addition, doctors caring for elders
often fail to recognize how psychological conditions—such
as depression and dementia—place an individual at greater
risk of falling victim to elder abuse; such psychological
conditions themselves are indicators that abuse may be taking
Even if a doctor suspects abuse, police officers are rarely
trained to investigate elder abuse and thus may not know
how to interview an older adult, work with a person who
has dementia, collect forensic evidence, or recommend that
criminal charges be brought when responding to reports of
injuries at care facilities or in homes.
Successful prosecutions are further impeded by the absence
of a sufficient number of qualified experts to testify to
a reasonable medical certainty that the injuries were the
result of abuse or neglect. Medical testimony is crucial
in such cases because the victims are often too ill or incapacitated
to provide a coherent explanation of how the injury occurred.
And the absence of any standardized laws defining elder
abuse further constrains the ability of police, medical
professionals, and prosecutors to develop a systematic approach
to amassing evidence to prosecute offenders. (See “Impediments
to Pursuing Elder Justice.”)
Bruising: An Accident or a Consequence of Abuse?
In one NIJ-funded study, researchers are examining bruising,
one of the most common indicators of abuse and neglect.
Although there is a body of research on the site, pattern,
and dating of bruising in children, research on the differentiation
between accidental and intentionally inflicted bruising
in the geriatric population simply does not exist.
By following a group of elderly individuals for a 16-month
period, researcher Laura Mosqueda, M.D., of the University
of California, Irvine, and her colleagues, documented the
occurrence, progression, and resolution of accidentally
inflicted bruising on elderly persons. Researchers found
that accidental bruising occurred in predictable locations
in older adults: 90 percent of all bruises were on the extremities;
no accidental bruises were observed on the ears, neck, genitals,
buttocks, or soles of the feet. Contrary to a popularly
held belief that one can estimate the age of a bruise by
its color, this research found that the color of a bruise
at the time of its initial appearance is unpredictable.
More bruising was observed on those individuals who were
on medication known to have an impact on the blood clotting
system and on those older adults with compromised functional
This ongoing research is contributing to a body of data
that officials can use for comparison when they suspect
that an elderly person with bruising has been abused. The
data will also assist doctors and medical examiners in developing
a set of forensic markers for use in elder abuse cases.
Study of Elder Deaths Yields Markers
NIJ-funded researchers are also examining data on the deaths
of elderly residents in long-term care facilities to identify
potential markers of abuse. Led by Erik Lindbloom, M.D.,
of the University of Missouri-Columbia, the study examined
coroners’ reports of elderly nursing home residents
in Arkansas over a 1-year period.
Amassing data collected pursuant to an Arkansas law
requiring nursing homes to report all deaths to local coroners,
researchers studied the medical examiner’s investigative
process to gather impressions about markers that might indicate
mistreatment and identify barriers to accurate assessments
Although a majority of the coroner investigations did not
raise suspicions of mistreatment, researchers identified
four categories of markers that often led to referral to
the Arkansas Attorney General for further investigation:
- Physical condition/quality of
care. Specific markers include: documented
but untreated injuries; undocumented injuries and fractures;
multiple, untreated, and/or undocumented pressure sores;
medical orders not followed; poor oral care, poor hygiene,
and lack of cleanliness of residents; malnourished residents
who have no documentation for low weight; bruising on
nonambulatory residents; bruising in unusual locations;
statements from family concerning adequacy of care; and
observations about the level of care for residents with
nonattentive family members.
- Facility characteristics.
Specific markers include: unchanged linens; strong odors
(urine, feces); trash cans that have not been emptied;
food issues (unclean cafeteria); and documented problems
in the past.
- Inconsistencies. Specific
markers include: inconsistencies between the medical records,
statements made by staff members, and/or observations
of investigators; inconsistencies in statements among
groups interviewed; and inconsistencies between the reported
time of death and the condition of the body.
- Staff behaviors. Specific
markers include: staff members who follow an investigator
too closely; lack of knowledge and/or concern about a
resident; unintended or purposeful, verbal or nonverbal
evasiveness; and a facility’s unwillingness to release
Attitudes Hinder Investigations
Lindbloom’s multidisciplinary research team also
conducted focus group interviews with medical examiners,
coroners, and geriatricians across the United States to
assess the state of forensic investigation of nursing home
deaths and to determine ways to identify how abuse and neglect
leading to mistreatment deaths might be identified. Results
from the focus groups revealed that many professionals believe
that deaths due to mistreatment are rare, so forensic investigations
would be of little value in improving quality of care. Some
medical examiners and coroners felt that decedents’
families might resist such investigations, particularly
if a family member’s complaint had not initiated the
investigation. Researchers also identified a propensity
for medical examiners and coroners to exhibit ageism—a
belief that focusing on nursing home deaths was “a
waste of their time and resources…because of the poor
health status of most nursing home residents… [who]
would die anyway.”
These beliefs are major impediments to improvements in the
forensic identification of elder deaths.
Role of the Medical Examiner
Carmel Bitondo Dyer, M.D., of the Baylor College of Medicine,
is leading a team of researchers who are examining the deaths
of elders who reside in the community to isolate risk factors
and identify potential markers of abuse. Funding from NIJ
enabled Dyer and her colleagues to conduct research at the
Harris County Medical Examiner’s Office (HCMEO) in
Texas. They are surveying the medical examiners to determine
their practice in identifying forensic markers or risk factors
in elder death cases and in reporting elder abuse as a cause
of death. They are also viewing autopsies to observe and
offer geriatric consultation in elder death cases.
By cross-referencing data from the Texas Department of
Family and Protective Services–Adult Protective Services
databank with the HCMEO database, Dyer’s team has
discovered that since 1999, as many as 900 elder death cases
(autopsies, external exams, and inquests) had previously
been reported to Adult Protective Services. She and her
colleagues at Baylor College of Medicine are currently conducting
a pilot study by abstracting 30 cases from this dataset
to determine if forensic markers were identified by the
medical examiners or if elder abuse was suspected at autopsy.
Dyer is also promoting the creation of a Geriatric Toxicology
Registry to identify which drugs lead to death in elders.
Vulnerabilities of Victims Impede Detection of Abuse
Researchers are also examining how psychological conditions
place elders at risk for abuse—in particular, sexual
abuse. Ann Burgess, D.N.Sc., of Boston College, examined
20 nursing home residents who had been sexually assaulted
and found that the presence of a preexisting cognitive deficit
such as dementia not only impairs the ability of victims
to communicate but potentially compounds the trauma of the
sexual assault. The vulnerability
of this population places them at unusually high risk for
severe traumatic reactions to assault, researchers assessed,
noting that 11 of the 20 victims died within 12 months of
the assault. Many of
the victims remained silent about the attack—the incidents
came to light only after suspicious signs or evidence were
noted by a staff or family member.
The study highlighted the importance of training caregivers
to identify the signs of assault-related trauma, particularly
in those victims who are not likely to report the incident.
Researchers noted a disturbing propensity of nursing home
staff to diminish the gravity of assaults on residents.
Responses ranging from cynical disbelief to perverse amusement
The study recommended that guidelines be established for
conducting rape trauma examinations on elderly patients.
In many cases, researchers noted, doctors were unable to
perform the standard forensic rape examination because of
the elderly resident’s physical resistance to the
procedure or the examining physician’s inability to
effectively communicate with the victim. As a result, patients
were examined in only half the cases.
Because victims of elder abuse often suffer from physical
and mental disabilities, many cases must rely exclusively
on forensic evidence. NIJ’s portfolio of research
will help in the crucial task of identifying forensic markers
that can be used to identify cases of abuse and prosecute
IMPEDIMENTS TO PURSUING
In 2003, the National Research Council‘s Panel
to Review Risk and Prevalence of Elder Abuse and Neglect
estimated that between one and two million Americans
aged 65 and older have been harmed by a caretaker
in either an institutional or domestic setting.
Statistics indicate that the problem only stands to
grow as the population ages and life expectancy continues
But the data show that the science, education, and
clinical practice associated with elder abuse and
neglect are 30 to 40 years behind those associated
with other problems, such as child abuse and domestic
gap in knowledge and practice places an increasingly
large population of elders at risk and poses a huge
hurdle for prosecutors in bringing elder abuse cases,
notes Marie-Therese Connolly, Senior Trial Counsel
and Coordinator of the Elder Justice and Nursing Home
Initiative at the U.S. Department of Justice. And
the potential for effective research studies is further
diminished by a lack of reporting. The limited data
show that only 16 percent of abuse incidents are reported
to Adult Protective Services. The remaining incidents
are likely hidden by caregivers in homes and institutions
where the elderly reside.
Return to text
 Quigley, T., “Suspicions of
Cullen Arose in ’93,” The Express-Times,
May 30, 2004.
 On March 2, 2006, Cullen was sentenced
in Somerset County Superior Court in New Jersey to 11
consecutive life sentences for 22 murders and the attempted
murders of 3 others in New Jersey. He will be sentenced
at a later date for 7 murders and 3 attempted murders
in Pennsylvania. Source: CBS News, available at www.cbsnews.com/elements/2003/12/16/in_depth_us/
whoswho588843_0_1_person.shtml. (Retrieved from the
World Wide Web on March 9, 2006.)
 Researchers have identified 14 potential
markers of abuse or neglect. They include: abrasions,
lacerations, bruising, fractures, restraints, decubiti
(bedsores), weight loss, dehydration, medication use,
burns, cognitive and mental health problems, hygiene,
sexual abuse, and financial fraud and exploitation. Dyer,
C.B., M.T. Connolly, and P. McFeeley, “The Clinical
and Medical Forensics of Elder Abuse and Neglect,”
Elder Mistreatment: Abuse, Neglect, and Exploitation
in an Aging America, ed. R.J. Bonnie and R.B. Wallace,
Washington, DC: National Academies Press, 2003: 344–360
(reporting findings of the Panel to Review Risk and Prevalence
of Elder Abuse and Neglect).
 Ibid., 343.
 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.
 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
 P.L. 499, Arkansas Statutes .
 Ibid., 32.
 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,
a serious complicating illness, and even death. Burgess,
A., and N. Hanrahan, Identifying Forensic Markers in
Elder Sexual Abuse, final report submitted to the
National Institute of Justice, Washington, DC: 2006 (forthcoming).
 Ibid. Because more than half of the
victims were aged 80 to 95 years at the time of the assault,
it is impossible to determine if the death was a distal
effect of the assault. Although it is not possible to
determine whether in each case the assault accelerated
death, the fact that more than half of the victims died
not from the assault itself but within months of the assault
is clearly noteworthy.
 Reporting by victims accounts for
very few instances of elder abuse cases. A study by Jones,
J., J.D. Dougherty, D. Schelbie, and W. Cunningham, “Emergency
Department Protocol for the Diagnosis and Evaluation of
Geriatric Abuse,” Annals of Emergency Medicine
17 (1998): 1006–15, reported that 72 percent
of elder abuse victims did not complain of the abuse at
the time of presentation to an emergency center. Dyer
et al., “Clinical and Medical Forensics,”
Elder Mistreatment: 363.
 Ibid., 9, citing Pillemer and Finkelhor
(1998); Pavlik et al. (2001).
 Ibid., 9–10. In 2003, 13 percent
of the Nation’s population was over the age of 65.
The figure is expected to rise to almost 20 percent over
the next two decades. Burgess and Hanrahan, Forensic
Markers in Elder Sexual Abuse.
 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. Dyer et al., “Clinical and Medical
Forensics,” Elder Mistreatment: 339.
 Gallanis, T.P., A. Dayton, and M.
Wood, Elder Law: Readings, Cases, and Materials,
Dayton, OH: Anderson Publishing Co., 2000: 287.