Elder Abuse Roundtable: Detection and Diagnosis

What Are the Forensic Markers for Identifying Physical and Psychological Signs of Elder Abuse and Neglect?

Mark Lachs, M.D., M.P.H., Co-Chief, Geriatrics and Gerontology
Weill Medical College, Cornell University

First Responder:
Ian Hood, M.D., J.D., Deputy Medical Examiner, Philadelphia Medical Examiner's Office

Elder abuse and neglect are significantly underdiagnosed and underreported.

Abuse and neglect can contribute to many common maladies, including depression, malnutrition, and decubitus ulcers (bedsores), but physicians often do not ask their patients the questions necessary to detect abuse. The similarity between symptoms of chronic disease and signs of abuse, a physician's own reluctance to investigate abuse, ageism, and reduced reimbursement issues all contribute to the failure to recognize abuse and neglect. Dementia in older people also reduces physicians' confidence in their patients' reports of abuse and neglect. Even when there are clear indications of abuse or neglect, physicians are reluctant to report them—because of the lack of research, physicians' unwillingness to investigate possible abuse and neglect, and the risk of having to testify in court when evidence is confusing or unclear.

"The state of medical science and forensic science in elder abuse and neglect in the year 2000 is about where child abuse was in 1970, when we began to look at whether or not there were diagnostic injuries in child abuse and neglect," said Dr. Mark Lachs, co-chief of geriatrics and gerontology at Cornell University's Weill Medical College. To stop abuse and neglect, communities need to establish multidisciplinary teams to examine abuse and neglect allegations, and these teams must make themselves easily available to concerned health workers who lack the expertise or time to investigate abuse themselves.

Many common ailments and disturbances among the elderly may be the result of abuse and/or neglect. Malnutrition can occur when an older person has cancer—or it could be a sign of neglect. "I think we should have an increased index of suspicion in individuals who have dementia, who have depression, who have psychosis, who can't otherwise take care of themselves [who are malnourished]," said Dr. Carmel Bitondo Dyer of Baylor College of Medicine.

Other types of data also may help in the detection of elder abuse and neglect. "If you look at the minimum data set (MDS) data (resident-level information submitted by Medicare and Medicaid recipients) from nursing homes, you will find the rates of malnourishment for people without an explicit terminal prognosis range from 8 percent of the residents to 27 percent of the residents. And there are facilities where nearly one-third of the residents have severe undernutrition. So, the suspicion ought to be just not individual cases, but also patterns of care," said Dr. Catherine Hawes, professor at the Texas A&M University School of Rural Public Health. Similarly, emergency room staff might be aware of patterns of problems at a particular facility; such knowledge could facilitate detection of individual cases.

There are few explicit "markers" for elder abuse, but certain symptoms should raise suspicions. Symptoms of disease can either cause a "false negative" by masking abuse or a "false positive," where symptoms appear to be the result of neglect. "There is, unfortunately, no absolute pathognomonic condition that says this person was abused, absent outright assault. But fractures of long bones [and] fractures of ribs almost always should be investigated further. A fracture of the hip or a fracture or a collapse fracture of vertebrae may not," said Dr. Ian Hood, deputy medical examiner with the Philadelphia Medical Examiner's Office.

Patterns of injuries can indicate neglect, said Dr. Carl Eisdorfer, chairman of the Department of Psychiatry and Behavioral Sciences at the University of Miami. "Clearly, falls in older people are more likely to lead to broken bones, but if you have a pattern of falls in a nursing home, then you know that there is some kind of neglect because patients should not keep falling," he added.

Sexual abuse of the elderly has a battery of symptoms as well, but again, these are not pathognomonic, said Ann Burgess, a professor of psychiatric mental health nursing at the University of Pennsylvania School of Nursing. Nursing home residents who have sexually transmitted diseases may be victims of abuse. Urinary tract infections also can indicate abuse, particularly if all the infected patients are housed in one room or taken care of by one aide. Vaginal bleeding is suspicious, as are certain patterns of bruising to the abdomen and pelvis. "It is a particular patterning," said Burgess. "It's really to the abdomen, where a massive amount of force has been used, and you'll see the pattern."

Older victims of sexual abuse also show psychological symptoms. They may be fearful—especially of men—or display new sexualized behavior. Other victims may withdraw by sleeping excessively (hypersomnolence) or by becoming depressed. "It is almost traumatic shock. They just go into a very different mode after the abuse," said Burgess.

Pressure ulcers are another area of concern. "Pressure ulcers in areas that are easily protected, like knees, heels, or near urinary catheters, indicate poor nursing care and possible abuse," said Dr. Hood. "Severe decubitus in a nursing home should raise everybody's index of suspicion, since it can actually be lethal," said Dr. Eisdorfer. Pressure ulcers in areas that may be hard to move or access, however, such as the hips or lower spine, may not be a sign of neglect even if they get progressively worse if they have been documented and appropriately cared for.

At present, healthcare workers avoid and ignore signs of elder abuse. Physicians simply do not like to believe that family members would abuse their aged relatives. "The belief . . . on the part of physicians—and it was true of all of us, including pediatricians, 35 or 40 years ago—was that families do not abuse their own. Child abuse, for example, we keep trying to forget, is relatively recent as something that is under suspicion on the part of emergency room [and] family practitioners," said Dr. Eisdorfer.

Ageism also prevents physicians from detecting neglect. "If an older person dies, someone says, `Older people die. They must've died from old age, from whatever it is,' " said Dr. Wendy Wright of Children's Hospital in San Diego, California.

One study showed that normal 75-year-olds who were not victims of elder abuse or neglect had a 13-year survival rate of 40 percent, while victims of elder abuse and neglect had a survival rate of 9 percent. Dr. Lachs said: "When I present this sort of data to internists, they say things to me like, `Mark, didn't these individuals have metastatic cancer, horrible, chronic congestive heart failure, terrible emphysema?' " When the data are adjusted for these diseases, the risk of dying after a period of abuse is still three times higher than that of normal older people. None of the death certificates from the abused group ascribed death to injury or poisoning. "There was a slightly higher prevalence of symptoms of ill-defined conditions," said Dr. Lachs.

Physicians need to learn to ask hard questions and think about the possible environmental causes for their patients' symptoms. "Any kind of bruising in an elderly, fragile individual does not necessarily mean neglect or abuse," said Dr. Hood. "One of the toughest calls to make is, first off, is it a bruise, and if it is a bruise, was it obtained innocently? Frequently, clinicians never even think to address that issue."

Clinicians also may fail to investigate emotional symptoms of neglect. In many cases, doctors simply prescribe medication for depression instead of probing for the syndrome's cause. Depression is common in older adults, but it also is a natural response to abuse or neglect. "If you don't ask, you don't find out," said Dr. Lachs. Similarly, Alzheimer's patients frequently have delusions that people are breaking into their homes and stealing their possessions. "Well, maybe they are," said Dr. Lachs. "I think we really need to get on the stick and recognize that patients are telling us something. I think we are ignoring those cries."

Even in clear cases of abuse, medical personnel are often reluctant to report abuse. "We recently had a situation where, in one month's time, two very demented, bedbound women in the same facility showed up with vaginal bleeding and tearing. And the conclusion of the charge nurse was that it was self-induced. One wonders how that can happen," said Joanne Otto, an adult protective services (APS) administrator with the Colorado Department of Human Services.

Despite the fact that 44 States require reporting of elder abuse, fewer than 10 percent of referrals to APS come from physicians and other healthcare professionals—even though, noted Otto, "almost every elderly person goes to the physician more often than probably he or she goes to his preacher."

This underreporting may be due to physicians' discomfort with the legal system. "I think there is a process going on [where physicians say] `I suspect these are indicators, but I'm not going to make the report, because then I get brought into the system and I may have to testify,' " said David Hoffman, an assistant U.S. attorney in Philadelphia.

This lack of data makes it difficult to determine the true incidence of elder abuse. "It's like in child abuse. It's important to look at and to evaluate the deaths because you learn something about the less significant injuries. But until you do that, you're not going to have a real handle on what the incidence is," commented Dr. Patricia McFeeley, assistant chief medical investigator at the University of New Mexico. The forensic markers of abuse are unknown. "I think that just like Sudden Infant Death Syndrome or Shaken Baby Syndrome, until we started doing autopsies on children who died, we did not realize there was a difference between the two. There could be a constellation or a pattern of injuries in elderly people that could be a forensic marker but currently is not being recognized because of the lack of information after death," said Dr. Wright.

Unfortunately, physicians consistently fail to order autopsies, even in cases where the death is suspicious. Dr. Erik Lindbloom, a geriatrician and assistant professor of family medicine at the University of Missouri, examined every 1997 Missouri death certificate where dehydration and malnutrition were listed as the primary or secondary causes of death. "I found no postmortem exam or other investigation after the fact," said Dr. Lindbloom. Deaths in nursing homes are not investigated unless there is some substantial cause for suspicion.

Some simple procedural changes can protect patients. "Where you have had one incident in a particular nursing home or chain of nursing homes, as a form of monitoring you can now say you're not allowed to sign your own death certificates. Anyone who dies in that institution must now be referred to the medical examiner's office," said Dr. Hood. "It is relatively easy to start a case file, and it is remarkably effective at maintaining awareness in that nursing home or personal care facility that it is being monitored, and that alone is all you need."

This state of affairs must change. Primary care physicians are important gatekeepers for abused elders. "For an older person, that annual visit to a physician may be the only contact that the individual has with someone outside the abusive situation," said Dr. Lachs. Even patients who do not come to their appointments may be communicating vital information. "[Look at] the lack of contact, frequent missed appointments, for example, or mildly demented elders coming to a clinic alone, maybe put on public transportation to get to their clinic appointment with no one accompanying them," noted Dr. Lindbloom.

Improved screening by emergency departments, primary care practices, and other medical specialties will help detect elder abuse and neglect, as will efforts that effectively involve law enforcement personnel. In South Carolina, researchers have put together an adult abuse protocol for healthcare workers. "It provides a structured way for physicians to screen for possible suspected cases of abuse or neglect," said Randolph Thomas, a police officer and law enforcement instructor with the South Carolina Department of Public Safety. The protocol also takes advantage of South Carolina's existing child abuse protocols. "Our law enforcement people are familiar with the forensic package that goes with this. They are familiar with the fact that it is an evidence-collection issue and has to be handled properly," said Thomas. "I think a vital component can come from law enforcement and a prosecution arm so that people know where to call, or when they have a suspicion know whom to contact," said Bill Gambrell, assistant deputy attorney general with the South Carolina Attorney General's Medicaid Fraud Control Unit. Social workers and nurses who engage in home healthcare also could help identify abuse and neglect.

At present, law enforcement and APS workers are not working together efficiently. "Law enforcement needs to be included in this process. While in Philadelphia, it may go to a detective, I can tell you I have ridden with beat officers who get calls on a regular basis to go out to homes because some neighbor dials 911 and says, `Do something.' And that beat officer spends 4 hours at a home waiting for APS to show up because it takes that long for an APS worker to get notified that they need to do an emergency investigation," said Dr. Gregory Paveza, an associate professor at the University of South Florida's School of Social Work.

Part of the problem is that in many States, there is no good system for dealing with elder abuse. In the case of child abuse, doctors have an easy alternative. Dr. Wright, a pediatrician, commented: "What they can do is call me in a heartbeat. I will see the child, do the whole forensic evaluation, and then do the reporting, do the documentation, go to court. So, it eliminates their responsibility to follow up. It increases the reporting because they feel like they have some backup in terms of medical expertise." The lingering question is, who will pay for these forensic services—for children or for older people? "If we're going to legislate reporting of elder abuse, we have to also include in it funding and some streams of resources to the people who are going to have to do that work," said Dr. Wright.

There may be support for forensic evaluations of older people from an unexpected ally: fraud investigators. "They are starting to investigate whether the person is being physically neglected as a way of hastening their death," said Lisa Nerenberg, M.S.W., consultant, elder abuse prevention.

Date Created: October 18, 2000