compared with the injuries observed. Tendency to multiple falls should be verified (or refuted) through medical records or objective observations if possible. Although abrasions and skin tears are common in the elderly, large skin tears or excessive scarring from more serious lacerations without an adequate explanation is suggestive of inflicted injuries or rough handling by caretakers.

Bruising also occurs frequently and may resolve more slowly in older than in younger persons. Color changes may occur slowly and may persist for weeks or longer. Loose, thin skin not only may bruise readily, but bruises can also spread through fascial planes to more distant areas, especially in such locations as the eyelids, neck, and scrotum. Medical conditions and medications (such as the blood thinners Coumadin and heparin) may greatly expand the extent of the bruise site. Patterned bruising or abrasions, when present, may be useful in determining the object(s) causing the injury. For example, a line of circular bruises on the inner aspects of the upper arms, especially if present bilaterally, may represent finger marks from forcibly lifting or pulling a person by the upper arms, such as moving a person onto or from a bed or a stretcher. Other patterns, such as the parallel lines caused by impact by a rounded or cylindrical object or an unusual pattern may be attributable to a specific object.

Internal examinations may obtain additional evidence relating to potential markers or findings of abuse and neglect. Internal organ examinations should include evaluation of the state of nutrition and hydration, and evidence of natural disease such as cardiovascular disease, chronic lung disease, infections, or malignancies. Stomach and bowel contents should be documented grossly and microscopically. Bones should be evaluated for osteoporosis and other changes, grossly, microscopically, and radiologically as indicated. The medical examiner or coroner should perform inspection of the external and internal genitalia to evaluate for sexual assault. Age-related and hormonal changes make the internal and external genitalia more susceptible to injury by penetration.

Child abuse protocols are by and large not applicable to adults; however, protocols for an adequate elder abuse examination could, like that for child abuse, include total-body x-rays. 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. For example, a



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