Elder Mistreatment Abuse, Neglect, and Exploitation in an Aging America (2003) / Chapter Skim
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12. The Clinical and Medical Forensics of Elder Abuse and Neglect
12. The Clinical and Medical Forensics of Elder Abuse and Neglect
Pages 339-381
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From page 339... ...
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 (Elder Justice Roundtable Report, 2000~. Within the relevant victimized populations there are similarities and differences among the factors contributing to their vulnerability and victimization.
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From page 340... ...
The ensuing discussion describes several potential forensic markers of elder abuse and neglect, including: abrasions, lacerations, bruising, fractures, restraints, decubiti, weight loss, dehydration, medication use, burns, cognitive and mental health problems, hygiene, and sexual abuse. We also are including financial fraud and exploitation because they often coexist with physical and emotional abuse and neglect.
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From page 341... ...
Defining appropriate forensic markers will lead to more effective prevention strategies and medical, legal, social service, and public safety interventions. Expanding our medical forensic knowledge base is vital to all the myriad ways in which the law is expected to address elder abuse and neglect.
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From page 342... ...
However, the current state of legal, social science, and medical knowledge does not include an evaluation of which types of prosecution and which remedies and punishments best address these goals. By providing the tools necessary to detect and prove these cases, research on the forensic markers of elder abuse and neglect can help law enforcement make appropriate cases a priority.
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From page 343... ...
No gold standard test for abuse or neglect exists, and those working with abused or neglected elderly victims rely on forensic markers. The difficulty with this approach is that there is often a great overlap among the markers of disease and neglect (and sometimes abuse)
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From page 344... ...
and other measures are needed to adequately address it. To the extent that the term forensic is defined as "pertaining to the law," medical forensic markers also are relevant to guardianship, involuntary commitment, power of attorney, and other types of parens patrie cases.
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From page 345... ...
This study included no analysis of the cases with known causes as compared to those with unknown causes. Clinical and Forensic Markers Indicating Abuse or Neglect Abrasions retain the pattern of the causative agent better than any other type of injury, and careful documentation by health care personnel is important for identification of the mode of injury.
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From page 346... ...
Clinical and Forensic Markers Indicating Abuse or Neglect The pattern of the bruise may suggest the cause of the injury. Bruises may retain the shape of knuckles or fingers.
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From page 347... ...
Clinical and Forensic Markers Indicating Abuse or Neglect A sizable literature on the resolution of fractures in abused children exists, but there are little or no data on fracture resolution in elders. Elders' bones, however, heal at much slower rates, making the child abuse data on fracture resolution invalid for older adults.
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From page 348... ...
Clinical and Forensic Markers Indicating Abuse or Neglect Abuse or neglect occurs whenever a person is restrained in a noncritical situation and without a concomitant evaluation by a medical practitioner. If restraints are determined to be necessary, the restrained patient must be monitored closely and frequently.
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From page 349... ...
preparations, are superior to wet-to-dry dressings and the use of povidone iodine in wounds (Patterson and Bennett, 1995~. Clinical and Forensic Markers Indicating Abuse or Neglect There are divergent views regarding which decubiti are due to illness and which are due to neglect or even abuse.
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From page 350... ...
Clinical and Forensic Markers Indicating Abuse or Neglect Malnutrition often is a marker of caregiver neglect, especially in institutional settings. More than 40 percent loss of body weight can result in death (Knight, 1997~.
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From page 351... ...
Clinical and Forensic Markers Indicating Abuse or Neglect In general, in moderate climates, the loss of water results in death within 10 days (Knight, 1997~; this time frame is likely to be much shorter in the case of older persons. Although most commonly caused by a medical illness, dehydration and volume depletion can serve as forensic markers for abuse or neglect when withholding food and water or insufficient care is part of the history.
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From page 352... ...
Conversely, needed medications, such as cancer chemotherapy, are withheld from older people for fear of side effects. Standards of care for specific disease states, such as a three-drug regimen for persons with heart failure or a two-drug regimen for Alzheimer's disease, have been established.
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From page 353... ...
Nongeriatricians may not be as attuned as geriatricians or geriatric nurse practitioners to the signs of drug overdose in elders because they often use the same drug dosages with impunity in younger adults. Increasing credentialing for medical practitioners requires proof of age-reliant continuing education and certification during the licensing procedures.
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From page 354... ...
In addition, although burn survival has improved for most age groups, there have been relatively few gains in burn survival for elderly persons in the past decade. Clinical and Forensic Markers Indicating Abuse or Neglect The association of burns and child abuse or neglect is well documented (Bowden et al., 1988; Andronicus et al., 1998; Evasovich et al., 1998; Hultman et al., 1998~.
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From page 355... ...
Self-neglect often accompanies dementia and mental health problems in older people. It is an important issue that requires additional research, but it is not addressed in this paper except to the extent that it constitutes a risk factor for or sign of elder abuse and neglect inflicted by others in effect, a forensic marker.
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From page 356... ...
In a preliminary analysis by the Texas Department of Protective and Regulatory Services, self-neglect and medical neglect (failure to obtain or have obtained appropriate medical care) cases were more likely to be associated with other types of elder mistreatment than were cases of physical or sexual abuse (Dyer et al., 2000a)
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From page 357... ...
Persons with psychotic disorders are likely to neglect themselves and to be unable to care for themselves as a result of their delusions and hallucinations (Lachs and Pillemer, 1995; Dyer and Goins, 2000~. Alcohol Abuse.
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From page 358... ...
Age-Re~ted Changes Women experience a number of physiologic changes in the genital tract as they age. Both progesterone and estrogen levels decline with aging (American Geriatrics Society Review Syllabus, 1998~.
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From page 359... ...
Age-Relate`1 Changes There is never a situation in which financial exploitation is considered normal, regardless of the age or functional status of the individual. Clinical and Forensic Markers Indicating Abuse or Neglect Paveza and his colleagues (1997)
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From page 360... ...
Documentation of bruising, skin lacerations, and fractures should include a detailed description of the size, color, extent, and location of these injuries. The lessons learned in the examination of child abuse may also apply here.
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From page 361... ...
A complete neuropathology examination, preferably in conjunction with an experienced neuropathologist, is necessary to correlate clinical dementia or paralysis with documented gross and microscopic changes in the brain. How Postmortem Forensic Markers May Differ from Those Applicable to Living Persons Postmortem examination in many cases provides less information than would a complete physical examination in a living person.
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From page 362... ...
As in evaluations of other types of domestic violence, maxillofacial injuries should prompt suspicion of abuse. Injuries suggestive of defensive maneuvering, such as those on the back of the arms and hands, and injuries related to grasping, squeezing, or forcible restraint should also prompt suspicion (Brogdon, 1998~.
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From page 363... ...
. OTHER FORENSICS CONSIDERATIONS Three additional tools could be tremendousiv useful in developing and/ or identifying forensic markers of elder abuse and neglect: t1' consistent, validated screening tools, (2)
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From page 364... ...
Current Screening Tools Numerous types of screening tools relevant to elder abuse and neglect exist, but most professionals collect information on the observations of others and assess risk factors. The very proliferation of different types of tools amidst the paucity of evidence-based data is evidence both of the desire to improve detection and measurement and of the lack of uniformity among the approaches to this issue.
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From page 365... ...
They often do not assess for neglect or address the difference between disease and abuse. The Mount Sinai/Victim Services Agency Elder Abuse Project Questionnaire.
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From page 366... ...
Diminished decision-making capacity is a complex factor faced by law enforcement, adult protective service specialists, and medical personnel who deal with abused or neglected older persons, for example, when a patient with diminished capacity decides against hospital transport, resulting in inadequate
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From page 367... ...
Screening tools designed for use in nursing homes and other care facilities (where the onus is less on family and friends and more on health professionals and institutional culture) have a different focus from screening tools for those cared for at home.
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From page 368... ...
Forensic Centers Overview of Forensic Centers Forensic centers have been developed to address and study numerous categories of illegal conduct usually associated with complex social problems as diverse as child abuse and neglect, sexual abuse, terrorism, food tampering, and computer crime. These centers are intended to bring together multidisciplinary groups of leading experts in their fields; to use state-of-the-art science, analytic tools, and techniques; to identify wrongdoing; to support law enforcement; to provide diagnostic resources; to conduct research and training; and to advance understanding in the specific field.
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From page 369... ...
A national forensic center would bring together leading experts in geriatrics, gerontology, forensic pathology, nursing, law enforcement, and other relevant fields. Time and funding would be dedicated to the diagnosis of and response to elder abuse and neglect, to research and training in its related fields, and to its prosecution.
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From page 370... ...
Research to Establish Forensic Markers The need for research to develop medical forensic markers of elder abuse and neglect is urgent. That research is the threshold to detection and diagnosis, without which reporting, intervention, and prosecution are impossible.
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From page 371... ...
This inquiry would benefit from research to develop forensic markers to guide the analysis. The high mortality rates in elders as a result of burns make this public health issue a compelling research topic.
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From page 372... ...
. Research on Distinctions in Medical Forensic Markers in Home Versus Residential Settings The study of these forensic markers in caregiver neglect is difficult because so many variables are involved.
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From page 373... ...
Screening for all elders, coupled with targeted comprehensive assessment in high-risk populations, may be the most practical and fruitful approach. Finally, comprehensive geriatric assessment is already a well-validated procedure for assessing and intervening in the care of frail elders and merits study in populations of abused or neglected individuals.
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From page 374... ...
Research Regarding Certification of Elder Deaths To ensure better certification of elders' deaths, researchers should document aspects of aging that are natural and compare them with features of injury due to accidental mechanisms and to malevolence. Training in recognizing signs and typical features of abuse and neglect is important for medical examiners, coroners, death investigators, law enforcement, and those who first respond to emergency calls reporting deaths, and should be enhanced.
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From page 375... ...
A predicate for such research would be to examine and evaluate what is known about screening tools, forensic centers, and multidisciplinary/interdisciplinary teams used in other areas, such as child abuse and neglect, sexual abuse, and domestic violence. There are many more areas of needed study and many more recommendations could be made.
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From page 376... ...
Journal of the American Dental Association 1 12:383-386. i, , American Geriatrics Society Review Syllabus 1998 A Core Curriculum in Geriatric Medicine, Fourth Edition 1999-2001.
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From page 377... ...
Baylor College of Medicine, Houston, TX. Elder Justice Roundtable Report: Medical Forensic Issues Concerning Abuse and Neglect 2000 The Department of Justice medical forensic roundtable discussion, Washington, DC, October 18, 2000.
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From page 378... ...
Hood, I 2000 Elder Justice: Medical Forensic Issues Concerning Abuse and Neglect.
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From page 379... ...
2000 Elder Justice Roundtable: Medical Forensic Issues Concerning Abuse and Neglect. Paper presented at the Department of Justice medical forensic roundtable discussion, National Institute of Justice, Washington, D.C., October 18, 2000.
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From page 380... ...
1991 Elder sexual abuse: Preliminary findings. Journal of Elder Abuse and Neglect 3(3)
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From page 381... ...
Duke, and M Kim 2000 Sexual abuse of older adults: Preliminary findings of cases in Virginia.
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