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Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America
tims are often widows or widowers, often in the seventh or eighth decade of life, and living in the community.
Financial exploitation includes credit card and telemarketing fraud, predatory lending, and theft or extortion. Such activities are usually targeted at vulnerable older adults and may leave them unable to pay for medications, health care, food, and the other necessities of life. Evidence of signing over of deeds or changes in wills should raise suspicion of exploitation as should the transfer of personal belongings or material goods without consent (Fulmer and Birkenhauer, 1992). The level of suspicion for this type of abuse should be increased for persons with cognitive impairment, which predisposes the victim to be trusting of caregivers, relatives, and acquaintances (Tueth, 2000). It is believed that many cases of financial exploitation go unrecognized and occur in conjunction with other types of abuse and neglect.
SPECIAL CONSIDERATIONS IN THE POSTMORTEM ANALYSIS
The mandate of the medical examiner or coroner is to determine the cause and manner of death. Determining the cause and manner of death involves not only a physical examination and/or autopsy in many cases but also extensive investigation, review of medical records, toxicology testing, and such special studies as radiology, cultures, or serology.
Many of the same potential markers for elder abuse and neglect set forth above in the context of evaluation of living persons also apply in a postmortem evaluation but are limited by inability to interview the patient and evaluate such things as mental status and capacity. External examination should include an objective evaluation of the state of nutrition, including evaluation of markers for hydration, utilization of vitreous electrolytes to confirm visual evaluation, and documentation of cleanliness. A body with crusted fecal material and secretions or dirt in creases, which is clad in very clean or new-appearing clothing should suggest an attempt to disguise poor hygiene and living conditions. Documentation of decubiti, if present, should include measurements of size, depth, and location. 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. Locations, extent, type, and multiplicity of injuries may suggest nonaccidental mechanisms or repetitive abuse. Explanations for multiple rib fractures such as, “She falls a lot,” are not adequate and may be inaccurate. Explanations of how injuries occurred must be elicited and