validity and reliability and be sufficiently delineated so that it can be replicated.

The other situation in which causal reasoning could be called on is one in which a harm has been detected without a clear conduct that could have caused it. While this too could be considered a failure in the measurement of conduct, some research indicates that there are certain harms that older persons may suffer that can only have been by mistreatment (or have a such high probability of having been caused by mistreatment that they are presumed to be due to mistreatment until proven otherwise). An example of such a presumed case would be the presence of a clinical phenomenon that could only have occurred by the conduct of another person.

Identifying Physical Markers of Elder Mistreatment

Some physical findings in children, such as shaken baby syndrome, are considered to be hallmarks of abuse. Characteristic injuries in this syndrome include retinal hemorrhages, subdural hematomas, and rib or long bone fractures. Are there similar hallmarks that may comprise a syndrome of physical abuse or neglect in the elderly? Possible examples discussed by Dyer et al. (this volume) include lacerations of specific body parts, certain types of burns, dehydration in certain contexts, and possibly specific types of bone fractures. Further clinical, behavioral, and forensic research in this area is needed to determine what harms under what circumstances would constitute almost unequivocal evidence of having been caused by the conduct (acts or omissions) of another person.

There are to our knowledge no published studies of physical markers of elder mistreatment that help distinguish preventable, unavoidable signs from those that are intentional, inflicted, or avoidable. One study of skin tears in nursing home residents described the characteristics of the tears, but almost half (48 percent) of the tears had an unknown cause, and the possibility of mistreatment was not addressed (Malone et al., 1991). The only study on bruising that included elderly subjects did not address the influence of medications, functional status, illnesses, or living situation, nor did it address etiology (Langlois and Gresham, 1991).

Possible markers of neglect and abuse include bruises, pressure sores, fractures, burns, and abrasions. A key to interpretation of these markers is not merely their presence but their characteristics—such as anatomic location, extent, morphology, severity, and multiplicity—which may help differentiate between an intentional injury and an avoidable one. For example, a single bruise on the back of the forearm is probably common in cases of accidental bruising, but multiple bruises in various stages of healing on the neck, anterior upper arm, and abdomen raise a suspicion of physical abuse. Also, it is not known if hip fractures due to spontaneous falls have



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