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12 The Clinical and Medical Forensics of Elder Abuse and Neglect Carmel Bitondo Dyer, Marie-Therese Connolly, and Patricia McFeeley* T he medical forensic aspects of elder abuse and neglect are largely unexplored and undocumented. 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 domes- tic violence 10 to 15 years ago (Elder Justice Roundtable Report, 2000). Within the relevant victimized populations there are similarities and differ- ences among the factors contributing to their vulnerability and victimiza- tion. Similarities include feared retaliation, perceived stigmatization at having been victimized, desire not to leave home, desire to protect the *Carmel Bitondo Dyer, M.D., is an assistant professor of medicine at Baylor College of Medicine, Houston, Texas, and the Director of the Harris County Hospital District Geriatrics Program; Marie-Therese Connolly, J.D., is a senior trial counsel in the Civil Division, Depart- ment of Justice; Patricia McFeeley, M.D., is an associate professor in the Office of the Medi- cal Investigator at the University of New Mexico. The views expressed in Marie-Therese Connollyâs contributions to this paper are her own and do not necessarily reflect those of the Department of Justice. The authors would like to acknowledge Samuel Riley and Rosa Torres for their technical assistance, and Jill Callahan for her editorial assistance. They are also grateful for review of the manuscript by Drs. Kenneth L. Minaker and Constantine G. Lyketsos and members of the National Academy of Sciences Panel on Risk and Prevalence of Elder Abuse and Neglect. 339
340 ELDER MISTREATMENT wrongdoer, other emotional harm, and as in some cases involving persons with diminished capacity, difficulties in communicating what transpired. Perhaps the starkest difference is that whereas children and younger victims of domestic violence are generally healthy and not expected to die, older people often have numerous underlying medical problems, and func- tional dependencies and are assumed to be more vulnerable to stressors causing death. Thus, when a younger person dies of unexplained causes, the cause of death is almost always carefully analyzed. The death of an older person, however, is rarely as carefully scrutinized, if at all, regardless of risk factors or indications of possible abuse or neglect. In addition, old age often brings medical conditions and physiological attributes that may mimic or mask the markers of elder abuse and neglect, further complicating the analysis and detection. Despite these many complexities, a recent studyâone of the few in the areaâmost clearly underscores the importance of increasing our under- standing of these phenomena. That study (Lachs et al., 1998) demonstrates that elder abuse and neglect significantly shorten older victimsâ lives, even controlling for all other factors. Incidents of mistreatment that many would perceive as minor can have a debilitating impact on the older victim. A single episode of victimization can âtip overâ an otherwise productive, self- sufficient older personâs life. In other words, because older victims usually have fewer support systems and reservesâphysical, psychological, and eco- nomicâthe impact of abuse and neglect is magnified, and a single incident of mistreatment is more likely to trigger a downward spiral leading to loss of independence, serious complicating illness, and even death. Unfortunately, there is a paucity of primary data relating to forensic markers of elder abuse and neglect, or even regarding the phenomena them- selves. 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. Some of the mark- ers discussed are actual observations (such as bruises or fractures), whereas others are descriptions or conclusions based on underlying observations (for example, sexual abuse is a conclusion that might result from the obser- vation of a vaginal tear or abdominal bruise, and a conclusion of neglect might result from the observation of poor hygiene and burns). Some of the markers are also potential risk factors (for example, self-neglect, cognitive and mental health problems, and financial abuse). But the current evidence regarding risk factors does not tell us the amount of risk conferred or by what mechanism. Where evidence-based data or other studies were found relating to the
CLINICAL AND MEDICAL FORENSICS 341 forensic markers discussed in this paper, they are referenced. But the majority of information on this topic currently is derived from working hypotheses based on the experience of clinicians and pathologists. Discus- sion of each factor includes (a) a definition of the phenomenon, (b) a discussion of how it is affected by age-related changes, and (c) what we currently know of clinical and forensic markers indicating abuse and ne- glect. The term forensic is defined as pertaining to the law or employed in legal proceedings. Thus, medical forensic markers of elder abuse and ne- glect are factors that are relevant to medical and legal determinations of whether elder abuse or neglect has occurred. Consistent evidence-based medical definitions are urgently needed to assist health care and social service professionals in detecting, treating, responding to, referring, and better understanding this grave and increasingly important public health problem. Coherent legal definitions are needed for legal and public safety professionals to determine when the law may have been broken, what types of criminal, civil, or administrative cases may be pursued, and for lawmak- ers to determine what new laws should be proposed or enacted. Defining appropriate forensic markers will lead to more effective prevention strate- gies 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. Potential legal interventions include the following: federal, state, and local law enforcement entities (including prosecutors, investigators, and police) may pursue criminal and civil cases relating to allegations of elder abuse and neglect. The government generally pursues such cases in its police power capacityâto punish, deter, remediate, and/or redress wrongdoing. Government also may use the law in its parens patrie capacityâpursuing guardian and commitment cases, primarily intended to protect those who cannot care for themselves. Almost all cases brought by government enti- ties in this field rely on medical forensic evidence. Some government enti- ties (such as the Departments of Justice and Health and Human Services) have resources to fund projects relevant to medical forensic issues. Private plaintiffs may file civil suits against health care providers depending on available medical forensic evidence. Federal and state legislative bodies can enact laws that provide for funding, create new entities, establish civil and criminal causes of action, and provide for other measures to address the problem. Federal and state regulatory bodies determine and/or enforce reimbursement, licensure, and administrative enforcement rules. Each legal aspect of this issue would benefit from being informed by more and better research. Elder abuse and neglect are often not detected or diagnosed, precluding any intervention, including prosecution. Thus research aimed at improving
342 ELDER MISTREATMENT detection is crucial to law enforcement. Furthermore, even when there is detection or diagnosis, cases will not be prosecuted unless the suspected abuse or neglect is reported (which often is not the case even where there are mandatory reporting laws). Criminal and civil elder abuse and neglect prosecutions are pursued for many reasons, including to stop, redress, pun- ish, and deter the wrongdoing, and to recoup government monies provided for care that was not rendered. 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. DETECTING ABUSE AND NEGLECT IN ELDERS The American Medical Association (1996) has defined physical abuse as an act of violence that may result in pain, injury, impairment, or disease. Neglect is the failure to provide the goods or services necessary for func- tioning or to avoid harm. A caregiver may be a family member, a friend, or an employee of the elder or of a nursing or other type of facility, or it may be the entity responsible for providing care. Definitions and intent stan- dards may vary depending on discipline, entity, location, or jurisdiction, as well as the relationship of the victim and the perpetrator. Furthermore, intent in a legal proceeding is the province of the fact finder (judge or jury) and therefore opened to argument by both the plaintiff/prosecutor and the defendant. Thus, the above-provided descriptions are intended as a general guide and a way to frame the discussion, but not as specific legal defini- tions. Actual abuse or neglect is rarely directly observed by medical, legal, or protective service professionals. In the absence of eyewitness testimony, law enforcement must rely on other circumstantial evidence to prove the existence of abuse or neglect. In most instances the experience of other direct observers is sought or the circumstances are deduced through inves- tigation or physical examination. The state of current knowledge, how- ever, does not always allow health care and social science professionals to link physical signs with a diagnosis of abuse or neglect. Further research will help identify and define useful forensic markers to help practitioners detect and treat elder abuse and neglect victims. How, when, why, and by whom injuries have been inflicted on elderly victims are all important questions to be answered before actors in the legal system take any affirmative action to protect the victim and deter future wrongdoing. Thus, a fractured bone may heal and a bruise may resolve regardless of whether a practitioner can identify the cause. And yet, the
CLINICAL AND MEDICAL FORENSICS 343 cause of the break or the bruise is the starting point for any legal action. Thus, even where there are clear bad outcomes (harm to an older person), absent a causal link and evidence to support a hypothesis of illegal abuse or neglect, the law will provide no remedy or accountability. The most extreme cases of abuse and neglect are not diagnostic dilem- mas. In some casesâgunshot wounds, knife wounds, or rope burns, for instanceâit is clear that the older person has been abused. In other cases multiple large decubiti or starvation may indicate severe neglect. Bite marks, too, are established evidence of abuse (Rawson et al., 1984; American Board of Forensic Odontology, 1986). But most cases fall into a gray area where abuse and neglect are not so nearly clear-cut, often because of subtle physiologic and psychological changes that occur in old age. 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). Although abuse often is considered to require an overt act, whereas neglect is considered to require an omission, it sometimes is difficult to distinguish between the two. There are cases in which neglect is so profound and widespread, and the caretaker is knowledgeable of what was needed but not provided, that many would consider it abuse. For example, if a case includes apparently preventable decubiti, neglect may be indicated. The line between abuse and neglect becomes murkier, however, when a person presents with multiple serious decubiti, and the caregiver was aware of the decubiti and of what care was needed but still failed to render adequate care. The ambiguity between abuse and neglect is similarly demonstrated in scenarios where caregivers, particularly those who know better, either withhold necessary medication or fail to perform needed care (for example, fail to change a bandage and cause the loss of part of a limb and/or sepsis, or cause illness and death by not giving needed insulin). The absence of clear and consistent legal definitions of neglect limit our ability to address the phenomenon. Liability for neglect is dependent on the ability to assign blame, and blame is easier to assign with acts of commis- sion than acts of omission (Phillips, 1988). Definitional (and legal) distinc- tions also are necessary in determining when self-neglect evolves into caregiver neglect. This is a combined medical-legal inquiry: Is the person physically or mentally incapacitated? At what point does the legal respon- sibility for the care of that person shift from self to another? What are the legal responsibilities of a caregiver under law such that failure to render such care in a home or community setting subjects the caregiver to civil or criminal liability? What types of documentation must exist to justify a failure by caregivers to intervene in the face of self-neglect (e.g., refusal to eat) in an institutional setting? The answers to these questions, to the
344 ELDER MISTREATMENT extent that such answers exist, vary from state to state, and sometimes from community to community, complicating the analysis and any research of the issue. Resolution of these difficult distinctions is beyond the scope of this paper. It is worth noting, however, that whether elder abuse and neglect has occurred is a conclusion drawn from a constellation of factorsâsome are medical (the individualâs medical condition), and some are legal (the jurisdictionâs definition of caregiver neglect). Developing consistent defini- tions and laws relating to elder abuse and neglect is critical to (a) develop- ing useful forensic markers, (b) effective detection and diagnosis by health care professionals, (c) law enforcementâs determination of a violation of law and of what cases to prosecute, and (d) researchersâ and policy makersâ determination of the scope of the problem and of what new laws (including causes of action and remedies) and other measures are needed to adequately address it. To the extent that the term forensic is defined as âpertaining to the law,â medical forensic markers also are relevant to guardianship, involun- tary commitment, power of attorney, and other types of parens patrie cases. Because this panel is examining abuse and neglect, however, those applica- tions of forensic markers are not specifically discussed in this paper. Abuse and neglect may occur in community or institutional/residential settings. For most of the markers described, there is no literature describing the relevance of various settings to the medical forensic analysis. This, too, is a topic in need of study. POTENTIAL MARKERS OF ABUSE AND NEGLECT Fourteen potential markers of elder abuse and neglect are discussed below, including for each a brief definition, a description of age-related changes, and a review of what is known about each as a medical forensic marker of elder abuse and neglect. Most of the forensic markers discussed in this section apply both to living persons and to postmortem evaluations. Factors pertaining peculiarly in the postmortem context are discussed in the next section. Abrasions and Lacerations Abrasions are superficial injuries involving the outer layer of skin; lacerations are characterized by full-thickness splitting of the skin. Abra- sions are caused by movement of the skin over a rough surface; lacerations are the result of blunt force (Crane, 2000). Skin tears are a very common type of laceration seen in the elderly and are defined as a splitting of the
CLINICAL AND MEDICAL FORENSICS 345 epidermis (superficial layer of the skin) from the underlying connective tissue resulting in a flap of skin (Malone et al., 1991). Age-Related Changes Skin thickness and elasticity decrease with age. Tensile strength also declines, increasing the susceptibility to shearing-force trauma (Griffiths, 1998). Abrasions can occur in older persons with minor trauma. Common lacerations in elderly persons are the skin tears that occur most frequently on the forearms and occasionally on the legs. Persons usually have no more than one or two skin tears at a time, and skin tears often heal completely without scarring. A primary data study revealed that the annual incidence of skin tears in a large nursing home was a little less than one per year per resident. The majority of tears were approximately 0.75 inches in length, though nearly 6 percent were 1.6 inches or longer. Eighty-five percent of the lacerations occurred on the arms. A known cause was identified in less than half the cases (47 percent), and most known causes were attributed to falls or bumping into something; wheelchairs accounted for 30 percent of the inju- ries (Malone et al., 1991). In cases in which the cause was unknown (53 percent), the skin tears may have occurred accidentally and may not have been noticed or may have been forgotten by the elder, or they could have been due to rough handling or worse by staff members and others. 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. Skin tears in sites other than the arms and legs or multiple tears or abrasions should raise suspicion. Lacerations often heal with scarring (Knight, 1997), as opposed to skin tears, which heal without scarring. Abrasions or lacerations are most commonly seen in cases involving physical abuse, although they can occur in cases of caregiver neglect. Bruises A bruise is the result of blunt force with concomitant rupture of small blood vessels under the skin. Blood escapes to the surrounding tissues propelled by the muscular contractions of the heart. Bruises are most
346 ELDER MISTREATMENT commonly seen in physical abuse but can be a result of caregiver neglect. Bruises can surface hours to days after an initial insult, depending on the depth of the wounds. Blood can track through fascial planes and result in bruises distant from the site of injury. The eyelids, neck, and scrotum are very susceptible to bruising. Age-Related Changes Bruises often occur more frequently and resolve much more slowly in older persons than in younger persons and can last for months instead of the usual one to two weeks (Knight, 1997; Crane, 2000). Langlois and Gresham (1991) prospectively studied bruising by collecting over 200 pho- tographs of bruises occurring in persons over the age of 65. They con- cluded no bruises less than 18 hours old demonstrated yellow coloration (p < 0.001). The opposite was, however, not true; some bruises did not develop a yellow color until much later. This primary data study is in- cluded in the Appendix to Chapter 1. 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. Parallel marks, called tramline bruising, indicate injury from a stick (Knight, 1997; Crane, 2000). The site of the injury may also indicate abuse. The most common locations for nonaccidental injury are the face and neck, the chest wall, the abdomen, and the buttocks (Crane, 2000). Intentional injury was determined in a retrospective review of random charts in New Zealand to be 13 times more likely to involve the head than other areas of the body. In this study internal injuries were two times as common in the assault victims (Fanslow et al., 1998). Bruising on the palms and soles may serve as forensic markers since the tissue at those sites is made of tough fibrous tissue and is not usually injured accidentally (Knight, 1997). The color of the bruise is usually unhelpful for dating because two bruises in the same person may heal at different rates. Reddish blue, blue, or purplish bruises are more likely to be recent while bluish green, greenish yellow, and brown bruises are more likely to be in some stage of healing (Crane, 2000). Multiple bruises in various stages of healing may indicate physical abuse (Knight, 1997). Bruises are common sequelae of falls, the most common cause of injury in older persons. Abusive or neglectful caregivers often attribute inten- tional bruises to a fall. Falls, however, cannot always be prevented and have multiple causes, such as poor vision and transient ischemic attacks. The causes of any given fall in an elder should be evaluated and the results
CLINICAL AND MEDICAL FORENSICS 347 of the fall, such as the type of bruising or fracture, may be forensic markers worthy of study and provide useful information about whether abuse or neglect was involved. Fractures Fractures are broken bones and include a frank severing of the bone or a compression of intact bone. Age-Related Changes The bones of older persons are thinner and less dense, making them more susceptible to fractures as the result of bone disease or injury. Poor nutrition, vitamin D deficiency, alcoholism, and age-related sex hormone deficiencies also contribute to an increased propensity to fractures (Francis, 1998). Other bone diseases such as osteoporosis and all its causes, such as chronic steroid use, osteomalacia, and Pagetâs disease, make the bones more brittle. Any type of cancer that invades bone weakens the osseous structure, making the patient more prone to fracturesâthese are called pathological fractures. The most common sites of fracture are the hip in those over the age of 75 and the distal wrist in persons younger than 75 (Francis, 1998). The wrist is a common site of fracture with falls in older individuals because many use their hands to help break the fall. Older women in particular are susceptible to vertebral fractures. Alcoholics are prone to multiple falls with resulting fractures of the arms, legs, and ribs. Two types of bone fractures are known to occur spontaneously: verte- bral fractures in osteoporotic older women, and hip fractures. There are two series that report cases of hip fracture in which abuse was suspected but subsequently attributed to medical causes (osteomalacia or soft bones, prolonged bed rest, Pagetâs disease) (Kane and Goodwin, 1991; Connolly et al., 1995). Prolonged bed rest, chronic limb paralysis, or non-weight- bearing status put elderly persons at increased risk for spontaneous fracture (Kane and Goodwin, 1991). 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. Eldersâ bones, however, heal at much slower rates, making the child abuse data on fracture resolution invalid for older adults. Also, 30 percent of community- dwelling older persons and 50 percent of nursing home patients fall; there- fore, falls alone should not necessarily increase suspicion of abuse. Most persons who fall experience one to three falls per year. A person who falls
348 ELDER MISTREATMENT once has joined a grouping prone to frequent falls. A detailed examination of the patient, records, and/or collateral history from caregivers is needed to determine if fractures in frail elders constitute physical abuse. Dentists and oral surgeons often see physically abused patients with fractured, subluxed, or avulsed teeth or fractures of the zygomatic arch (the bony structures around the eyes) or the mandible and maxilla (jaw bones) (Fenton et al., 2000). Fanslow and colleagues (1998) showed in a retro- spective chart review that fractures of the head, spine, and trunk are more likely to be assault injuries than limb fractures, sprains or strains, or muscu- loskeletal injuries in adults. A spiral fracture of a large bone with no history of gross injury is diagnostic of abuse, as are fractures with a rota- tional component (Medical Tribune, 1995). Fractures in nonalcoholics at sites other than the hip, wrist, or vertebrae should raise suspicions of abuse. Restraints Restraints are means of controlling the behavior of older persons, espe- cially in hospitals and nursing facilities. There are two forms of restraints, mechanical and chemical. The following discussion refers to mechanical restrains, such as Posey vests, and wrist and ankle restraints made of leather, plastic, or cloth. Standards of Care for Elders The only acceptable reason for restraining an elder is to prevent signifi- cant harm (Knight, 1997). Appropriate restraints help stop the agitated patient from pulling out a tube that is a conduit for life-saving treatments such as an endotracheal intubation for mechanical ventilation, oxygen re- placement, or intravenous fluids and medications. 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. The restraints must not be so tight as to completely restrict movement. Proper bedding must be used to prevent decubiti (bedsores). In many studies, physical restraint is very strongly associated with increased injury and death (Miles, 1996; Mohr and Mohr, 2000). Re- straints, in fact, often do not control behavior and instead may result in a worsening of behavioral problems. Despite this evidence, many health professionals still believe that restraints will help prevent injury due to
CLINICAL AND MEDICAL FORENSICS 349 falling. Restraints can be a form of neglect when used in lieu of adequate caretaking because they render persons âeasierâ to care for. They can be a form of physical abuse, for example, when they leave scars or result in wrist wounds or decubiti. Decubiti The breakdown of skin integrity resulting in an ulcer is known as a decubitus, or bedsore. Decubiti are the result of circulatory failure due to pressure; shearing forces cause thrombosis of the microcirculation (clotting or blockage of blood in small blood vessels), resulting in tissue necrosis (Barton and Barton, 1981). Most decubiti occur over the sacrum; the hip and the heels are also common locations. Although decubiti may be di- vided into four stages, in general they are either deep or superficial. Age-Related Changes and Standards of Care Normal aging skin has relatively well-preserved blood flow. The eld- erly are more susceptible to decubiti because of disease states and not on the basis of age alone (Bennett and Bliss, 1998). Decubiti most often occur in medically ill or cognitively impaired individuals. Intrinsic causes such as acute illness, neurological disease, peripheral vascular disease, incontinence, and poor nutritional status place individuals at higher risk (Bennett and Bliss, 1998). Although poor nutrition is a risk factor, improving nutritional status doesnât always reverse or prevent the process (Henderson et al., 1992; Finucane et al., 1999). The healing may take weeks to months, depending on the underlying comorbidities and the extent of the decubiti. Risk factors for decubiti were found not to be predictive where appropriate care was provided; however, when the standard of care was not met, risk factors were found to be predictive (Berlowitz et al., 2001). The standard of care for decubitus ulcers is to prevent them from occurring, particularly in high-risk patients. Prophylactic measures include turning patients regularly, range-of-motion exercises, appropriate nutri- tional supplementation, and bedding. New therapies available for treat- ment including hydrocolloid dressings and hydrogel preparations, are supe- rior 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. The failure to adhere to the standard of care could be due to medical, institutional, or caregiver neglect.
350 ELDER MISTREATMENT Deep decubiti in multiple sites also may indicate neglect (Schor et al., 1995). Failure to provide proper care to high-risk persons may indicate neglect; if a foul-smelling or necrotic ulcer is not brought to the attention of a physician and not appropriately cared for, neglect is almost always present. Preventable decubiti are usually considered to be due to caregiver neglect, although the number, severity, and lethal result may cause some to ascribe the findings to abuse. Malnutrition Malnutrition is defined as poor health status due to the decreased intake of necessary nutrients. Age-Related Changes Old age results in a decline of both smell and taste, which decreases appetite. Many patients with cancer lose weight regardless of efforts to maintain nutritional status. Poor health, including poor dentition, depres- sion, dementia, and malabsorption syndromes, also may contribute to weight loss and undernutrition (Thomas, 1998). Numerous other disorders can lead to malnutrition, including strokes, Parkinsonâs disease, amyo- trophic lateral sclerosis, and disorders of the esophagus. Clinical and Forensic Markers Indicating Abuse or Neglect Malnutrition often is a marker of caregiver neglect, especially in institu- tional settings. More than 40 percent loss of body weight can result in death (Knight, 1997). Inappropriate prescribing of such medications as anticholinergic drugs (nerve blocking drugs, which cause excessive dry mouth and confusion), psychotropic drugs, and other medications that impair mentation or appetite may constitute neglect. Caregivers may fail to maintain oral hygiene, which can lead to the loss of teeth and poor nutri- tional intake. Nursing home residents may decline to eat when institutions do not recognize cultural food preferences. However, the most frequent cause of malnutrition due to neglect in an institutional setting appears to be an inadequate number of staff to assist those who need help with eating (Harrington et al., 2000). Similarly, such improper feeding techniques as forceful assistance or other inappropriate feeding may lead to choking, aspiration, pneumonia, or death. It may also lead to food revulsion, refusal to eat, and depression, catalyzing a downward spiral. Appropriate documentation is required where the explanation for malnutrition is refusal to eat. Malnutrition may
CLINICAL AND MEDICAL FORENSICS 351 be an important predisposing factor for other illness or death and may be due to mismanagement of persons living in nursing homes (Hood, 2000). Dehydration Dehydration, inadequate level of water in the body, is caused by de- creased fluid intake or excessive water loss seen commonly in persons living in very warm climates or in athletes such as marathon runners. Age-Related Changes The elderly are much more prone to dehydration with minimal provo- cation than are younger people. Dehydration is a common reason for emergency department visits by older persons (Lowenstein et al., 1986). Older persons have decreased body water reserves and thirst drive; their thirst drive may remain depressed even after 12 to 24 hours of water deprivation. The central nervous system regulation of water is altered; although antidiuretic hormone (ADH) is secreted properly in response to volume depletion, the older kidney responds less well to changes in ADH and continues to excrete water in the face of dehydration (American Geriat- rics Society Review Syllabus, 1998). Hydration status is particularly diffi- cult to monitor in older persons who can experience very rapid changes in their fluid status without much in the way of symptomatology. 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. Confusion and somnolence are common signs of volume depletion or dehydration, but they are nonspecific indicators and occur in many other disease states in the elderly. Sometimes the mental changes attributable to dehydration are subtle, especially in very demented persons. Neglect may be present if inadequate fluids are offered or provided or if dehydration goes unrecognized for a long period of time by medical or nursing person- nel. Neglect also may be present in cases in which caregivers, home or facility, fail to seek help when problems are apparent. Obvious changes in the weight or mental states of persons residing in nursing homes and other care facilities should be assessed carefully. Weight changes or changes in
352 ELDER MISTREATMENT vital signs should be brought to the attention of a clinician or otherwise promptly evaluated. Where the explanation for dehydration in an institu- tional setting is a refusal of fluids, this should be historically and appropri- ately documented. As with malnutrition, inadequate staff support may lead to neglectful, inadequate hydration. Medication Use Proper medication use is among the most important strategies for main- taining good health and preventing adverse side effects in the older indi- vidual Age-Related Changes Older patients use three times the number of medications that younger patients use (Monane et al., 1997). They do not respond as predictably to most medications as younger patients, and they have an increased risk of adverse side effects. A number of physiologic changes complicate the pre- scribing of effective yet safe drug regimens in older persons. Older persons have decreased hepatic metabolism (clearance of drugs through the liver) and decreased plasma protein binding, which increase drug levels. Older persons have decreased gastrointestinal absorption, and their bodies, due to age-related changes in body water, fat, and lean muscle, distribute drugs differently (Zubenko and Sunderland, 2000). In general, there is more fat and less water, leading to longer time of action of fat-soluble drugs and higher abrupt drug concentrations for water-soluble medications. Drug regimens in older people are complicated by the fact that often they include multiple medications, which may interact. In addition, ap- proximately one-half to one-third of patients do not take their medications properly (Monane et al., 1997). Patient noncompliance occurs for a variety of reasons. Some elders may not understand the instructions given. Some take their neighborsâ medication or overdose on alternative therapies. Oth- ers may not have the resources (funds, transportation) to obtain needed medication. The most common form of noncompliance is failure to take or to renew needed prescriptions. Polypharmacy in the elderly, as described by Monane and colleagues (1997), is the use of any unnecessary medication regardless of the total number of pills consumed. Conversely, needed medications, such as cancer chemotherapy, are withheld from older people for fear of side effects. Stan- dards of care for specific disease states, such as a three-drug regimen for persons with heart failure or a two-drug regimen for Alzheimerâs disease, have been established.
CLINICAL AND MEDICAL FORENSICS 353 Clinical and Forensic Markers Indicating Abuse or Neglect Misuse of medication, for example, giving a patient too much or too little of an indicated drug, withholding a necessary medication altogether, or administering unnecessary or inappropriate medication, may constitute either neglect or abuse, depending on whether the misuse or withholding was intentional or an excusable error. The forensic markers for abuse or neglect as the result of misuse or withholding of medication may present in many different ways. In general, older persons should receive medications in doses smaller than those re- ceived by younger patients; and thus, in general, a prescription for an older person of a standard dose of medication may be an indicator of abuse. The signs and symptoms of medication side effects should be monitored, and the failure to do so may constitute neglect. 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 practitio- ners requires proof of age-reliant continuing education and certification during the licensing procedures. Failure to obtain appropriate training for the population one is caring for is a potential cause of professional neglect. The reasons for adverse side effects are complex and varied. They may be due to improper dosing, noncompliance, drug-drug interactions, the different presentation of disease states in the elderly (especially demented patients), or the particular constellation of disorders in a given patient. Failure to follow the standards of care indicates abuse or neglect. The determination of neglect due to medication misuse is best made by a prac- titioner other than the prescribing doctor. Elders may misuse prescription drugs because they lack the capacity to handle this task or they reject efforts by medical professionals to help them. Abusive or neglectful caregivers may withhold necessary drugs, use the eldersâ drugs themselves, or overdose patients to keep them quiet and man- ageable. Insufficient staffing in facilities may result in increased medication errors and insufficient time to administer medication properly or at all. Depletion of institutional resources may result in failure to keep reliable and unexpired stores of necessary medications on the premises, including, for example, insulin for insulin-dependent diabetics. Burns A burn results from tissue injury following exposure to heat above 50Â° C (Knight, 1997). Burns are categorized by the body surface affected and the depth of tissue destruction.
354 ELDER MISTREATMENT Age-Related Changes Data from the National Fire Protection Association show that persons over the age of 65 have twice the national average death rate due to burns. This risk triples at age 75 and quadruples at age 85. At the U.S. Army Institute of Surgical Research, at the renowned burn unit of Fort Sam Houston in Texas, persons over the age of 60 represent 8 percent to 12 percent of all admissions (Bird et al., 1998). 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). Burns in older people also may result from abuse or neglect. Bowden and colleagues (1988), from the University of Michigan Burn Center, examined the relationship of adult abuse and neglect to burns. Seventy percent of the cases were deemed due to neglect and abuse. In a later study, Bird and colleagues (1998), at the Fort Sam Houston Burn Unit, found that 40 percent of burn cases occurring in persons over 60 were due to abuse or neglect, with 36 percent of the cases due to neglect. (See Appendix to Chapter 1). These two studies were conducted retrospectively with relatively small numbers of patients. Nonetheless, their data are intriguing and suggest that burns in elders might be a forensic marker for self-neglect and caregiver neglect as well as abuse. White (2000), in a paper about forensic nurses, also recommends that burns be considered a marker for elder neglect. Cognitive and Mental Health Problems Cognitive and mental health disorders are some of the most pervasive and clinically challenging problems of old age. The Texas Elder Abuse and Mistreatment (TEAM) Institute has treated over 300 abused or neglected elders; the most common cognitive and mental disorders noted are depres- sion, dementia, psychosis, and alcohol abuse (Dyer and Goins, 2000). Pre- liminary data from an ongoing cross-sectional research study of neglect clients not referred to a medical team revealed similar results (Dyer et al., unpublished data). Dementia is a progressive impairment of memory and other areas of cognition which results in an eventually reduced ability to care for oneself. Patients suffering from dementia frequently experience anxiety and depres- sion early in the disease and delusions and hallucinations in the later stages.
CLINICAL AND MEDICAL FORENSICS 355 Depression is characterized by sadness, decreased appetite, insomnia, and loss of interest in hobbies. Psychosis is an altered mental state characterized by delusions and hallucinations. Alcohol abuse exists if the intake of alcohol impairs social functioning. Substances other than alcohol may be abused, but in elderly populations, alcohol abuse is most common. 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 othersâin effect, a forensic marker. Self-neglect may be a risk factor in that it makes victims more vulnerable to and less able to ward off mistreatment by others who might prey on them. Similarly, as capacity for self-care decreases, depen- dence on others increases, and if potential caregivers are either unable or unwilling to provide assistance, then the risk for being abused and ne- glected by caregivers increases. Conversely, someone who has been victim- ized by abuse or neglect may become depressed and in turn lose the desire or capacity for self-care. Thus, self-neglect also may be a forensic marker that abuse or neglect has been committed by another person. Age-Related Changes Dementia. Dementia is present in 15 percent of persons over the age of 65 and 50 percent of persons over the age of 80 (Abrams et al., 1995a). Dementia is by definition a loss of function that often results in increased reliance on others for care. Many with the dementia syndrome refuse needed care, and/or their children are uneasy with becoming caregivers. Depression. Depression affects from 15 to 50 percent of older persons. Institutionalized elders and those with medical illness have the highest inci- dences of depression, which can be as high as 70 percent following a stroke. Elderly persons with depression are more prone to psychosis than are younger persons with depression (Abrams et al., 1995b). Psychosis. Four to five percent of older adults experience psychosis (Abrams et al., 1995b). It is most commonly associated with depression, but elders can experience acute and chronic episodes of paranoid ideation (formation of paranoid ideas). Alcohol Abuse. Alcohol abuse is present in up to 5 percent of older persons and is more common in men than in women. Older adults can become inebriated at lower levels of alcohol intake than younger adults and are more susceptible to its ill effects, including malnutrition, gastritis, and alco- hol dementia (Abrams et al., 1995c).
356 ELDER MISTREATMENT Clinical and Forensic Markers Indicating Abuse or Neglect Cognitive and mental health disorders affect a large number of aging persons and can lead to impairment of thinking, memory, functional abil- ity, and ultimately decision-making capacity. They can prevent persons from seeking help, advocating on their own behalf, or extricating them- selves from abusive situations, and they make elders more prone to exploi- tation by others. Dementia itself and its management can be a stimulus for abusive action when the family feels or is unprepared or unsupported in the care of an affected dependent. Ability to serve as a witness or provide testimony is diminished. Ultimately, the mental states of demented elders can progress to a point at which they are unable to meet even their most basic needs. Most statistics on this topic are derived from adult protective services (APS) databases. The definition of mental disorders varies from state to state, as do the training requirements of APS workers, many of whom are not health care professionals. Some elders with impairments have other- wise well-developed social skills and, without formal testing, can escape notice by physicians and other professionals who care for them. The Na- tional Elder Abuse Incidence Study asked nonmedical volunteers to com- ment on depression and dementia based on their opinions. They found 59.5 percent incidence of dementia and 43.6 percent incidence of depres- sion. Because the reporters were not health professionals nor did they have any mental health training, the data are estimates and not representative of actual diagnoses (National Center on Elder Abuse, 1998). Self-neglect usually but not always is associated with either dementia or some type of mental health problem. Individually, and particularly in combination, these conditions may constitute risk factors for, as well as signs of, abuse and neglect. In a preliminary analysis by the Texas Depart- ment 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). Self-neglect may very well represent a part of the continuum where older persons who are initially declining either functionally, mentally, or both try to care for themselves. If they can no longer meet their needs themselves, then they need help from others. Progressive functional decline may result in physical decline and in some instances institutionalization. Dementia. Dementia is related to elder abuse and neglect (Benton and Marshall, 1991; Aravanis et al., 1993; Coyne et al., 1993; Lachs and Pillemer, 1995). Two primary data studies demonstrated that dementia
CLINICAL AND MEDICAL FORENSICS 357 was an independent risk factor for abuse and neglect (Lachs et al., 1998; Dyer et al., 2000a). In the study by Dyer and colleagues (2000a), dementia was noted in 51 percent of neglected or abused patients and only 30 percent of patients referred to geriatric clinic for other reasons. Depression. Depression is a significant finding in abused or neglected patients (Benton and Marshall, 1991; Aravanis et al., 1993; Lachs and Pillemer, 1995; Dyer et al., 2000a). Dyer and colleagues found an even greater prevalence of depression than dementia in patients referred for mistreatment: 62 percent of neglected or abused patients had depression compared with 12 percent of patients referred for other reasons. Lachs and coworkers found the same clinical phenomenon using data from Connecti- cut (personal communication, 2001). Psychosis. 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. Alcohol abuse can lead to a failure to fulfill major role obligations, to alcohol use in situations that are physically hazardous, and to social or interpersonal problems (American Psychiatric Association, 1994). This pattern of behaviors puts persons at risk of perpetrating or being the victim of abuse and neglect, especially neglect (Goodyear-Smith, 1989; Fanslow et al., 1998; Marshall et al., 2000). Abuse of substances other than alcohol may have similar consequences. Hygiene Medical practitioners consider hygiene, defined as the ability to main- tain cleanliness, an important component of good health and disease pre- vention. Age-Related Changes There are no changes in oneâs hygiene that occur strictly with age. Occasionally, impaired eyesight may make it more difficult to keep oneâs home or clothes clean; however, if cognitive ability remains normal, elders are able to perform the activities of daily living and maintain appropriate hygiene. Demented or psychotic individuals, on the other hand, often lack the ability to care for themselves, and depressed individuals may become less inclined to care for themselves and display poor personal hygiene.
358 ELDER MISTREATMENT Clinical and Forensic Markers Indicating Abuse or Neglect Many have suggested that a decline in hygiene is a marker of neglect (Aravanis et al., 1993; Lachs and Pillemer, 1995; Butler, 1999; Marshall et al., 2000). Individuals may present with dirty clothes that reek of animal excrement; multiple insect bites due to mosquitoes, scabies, or fleas; or other signs of poor hygiene. For some persons, poor personal care is a matter of lifestyle or choice, and should not be blamed on age. Thus, this finding requires investigation of previous habits and any recent decline as well as screening for dementing or psychotic illness. Sexual Abuse Sexual abuse is characterized by sexual contact or exposure without the personâs consent, including those cases in which persons are not able to consent (American Medical Association, 1996). Mickish (1993) catego- rized sexual abuse as the least perceived, acknowledged, detected, and re- ported type of elder abuse. Although the least frequently reported type of elder mistreatment (Tatara, 1993; Pavlik et al., 2001), it is nonetheless heinous. Several studies have demonstrated that the overwhelming major- ity of victims have cognitive impairment (75 percent to 77 percent) and/or have functional limitations (67 percent to 92 percent) (Ramsey-Klawsnik, 1991; Holt, 1993; Teaster et al., 2000). In the study by Teaster and colleagues (2000), which includes APS reports from 1996 to 1999, the most common form of sexual abuse was sexualized kissing and fondling but ranged from unwelcome sexual interest to rape. Age-Related 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). Decreased estrogen levels result in changes in the shape of the vagina, increased vaginal dryness, and thinning of the vaginal walls. These changes may cause pain and bleeding during sexual intercourse. Such age-related changes as altered acidity of the vaginal secretions and decreased estrogen levels make older women more prone to spontaneous vaginal and bladder infections (Butler and Lewis, 1998). Note, however, that there is never a situation in which sexual abuse is considered normal, regardless of the age or functional status of the individual.
CLINICAL AND MEDICAL FORENSICS 359 Clinical and Forensic Markers Indicating Abuse or Neglect Victims of sexual abuse may present oral venereal lesions. Bruising of the uvula (Marshall et al., 2000) and bruising of the palate and the junction of the hard palate may indicate forced oral copulation (Fenton et al., 2000). Bleeding and bruising of the anogenital area as well as difficulty in sitting and walking may indicate sexual abuse in elderly women (Fulmer et al., 1984). A retrospective descriptive study of reported cases of sexual assault from New Zealand looked at women and children, including some elderly women ranging in age from 60 to 83 years. One-third of women were assaulted in their homes, and one-third were intoxicated at the time of the assault. Fifty percent were restrained, and 75 percent had evidence of trauma. The most common site of bruising, inflammation, tenderness, abrasions, or trauma was the anogenital area (41 percent of cases). The remainder of the cases involved other parts of the body, with no particular site injured more frequently than another (Goodyear-Smith, 1989). Other types of bruising, for example, on the abdomen, might be suggestive of sexual abuse (Burgess, 2000). New diagnoses of sexually transmitted dis- ease in nursing home residents or other elders may indicate abuse. Urinary tract infections in nursing home residents may indicate sexual abuse if several cases occur in a cluster. Behavioral signs indicating potential sexual abuse may include withdrawal, fear, depression, anger, insomnia, increased interest in sexual matters, or increased sexual or aggressive behavior. Financial Fraud and Exploitation Financial exploitation is the inappropriate use of an elderly personâs resources for personal gain (American Medical Association, 1996). Finan- cial fraud and abuse make up 12.3 percent of reports to protective service agencies (National Center on Elder Abuse, 1996). Age-Related 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) have studied the types of financial exploitation and the associated variables. They have determined that risk factors vary with the type of financial abuse; however, in general the vic-
360 ELDER MISTREATMENT 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 tar- geted 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 exploita- tion as should the transfer of personal belongings or material goods with- out 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. Postmortem Evaluation 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 examina- tion should include an objective evaluation of the state of nutrition, includ- ing 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 de- scription 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, âShe falls a lot,â are not adequate and may be inaccurate. Explanations of how injuries occurred must be elicited and
CLINICAL AND MEDICAL FORENSICS 361 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 with- out 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, espe- cially in such locations as the eyelids, neck, and scrotum. Medical condi- tions 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 po- tential markers or findings of abuse and neglect. Internal organ examina- tions 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 radiologi- cally as indicated. The medical examiner or coroner should perform in- spection 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; how- ever, protocols for an adequate elder abuse examination could, like that for child abuse, include total-body x-rays. A complete neuropathology exami- nation, 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
362 ELDER MISTREATMENT postmortem blood gas evaluation (measuring pH, oxygen, and carbon di- oxide levels) provides scant if any information, whereas the same test in a living person may be quite valuable in determining the care needed and the extent of underlying disease. On the other hand, some postmortem exami- nation procedures yield more information than physical examination and laboratory testing of a living patient. Antemortem computerized tomogra- phy and magnetic resonance imaging scans have significant limitations in detecting and evaluating such lesions as small central nervous system paren- chymal or surface hemorrhages or pulmonary nodules. However, utiliza- tion of radiologic expertise to help document the number and location of fractures at autopsy can be quite valuable. Although these determinations in an elderly person with osteoporosis are complex, careful documentation of such findings along with estimates of age or time of occurrence are useful. As in evaluations of other types of domestic violence, maxillofacial (jaw and face) injuries should prompt suspicion of abuse, and estimates of age or time of occurrence are useful. 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). However, little is known and there are few studies, if any, that document the type and location of fractures relative to mechanism and degree of force required in the elderly. Such studies and published information would also be of great use to forensic pathologists testifying in court in criminal and civil cases. Even if the cause of death may be obvious (for example, pneumonia), the manner of death (i.e. natural, accident, suicide, homicide, or undeter- mined) may vary depending on the contributions of other factors to the pneumonia. For example, if the pneumonia is secondary to rib fractures, the death could be accidental if the fractures were sustained in an accidental fall. However, if the rib fractures were numerous and serious enough that the patient should have received medical attention but no referrals or at- tempts to get treatment were made, the subsequent death could be consid- ered the result of neglect and potentially considered a homicide. If the fractures were sustained in a beating, the manner would clearly be homicide. Forensic Psychiatry Some cases may necessitate a postmortem psychological or psychiatric evaluation. Although the performance of a psychological or psychiatric autopsy has been described in some instances of suspected suicides, the utilization of these somewhat specialized investigative tools has not been specifically described in investigation of elder deaths. The demonstrated
CLINICAL AND MEDICAL FORENSICS 363 associations of dementia, depression, and self-neglect to elder abuse and neglect, however, make such autopsies potentially critical tools. Whether used in their fully developed form by a forensic psychiatrist or incorporated into a series of extensive death investigation interviews by someone else, understanding the degree of cognitive impairment or decision-making ca- pacity, even retrospectively, may be critical in investigating and classifying a death. The limitations would be that the most important informants might be those who were perpetuating the abuse or neglect, making them the least likely to give honest, objective responses. Similarly, indications of financial exploitation may provide valuable corroborating evidence during a death investigation. OTHER FORENSICS CONSIDERATIONS Three additional tools could be tremendously useful in developing and/ or identifying forensic markers of elder abuse and neglect: (1) consistent, validated screening tools, (2) forensic centers, and (3) multidisciplinary teams. Screening Tools There is general consensus that elder abuse and neglect are significantly underreported and underidentified, and that validated, uniform tools should be developed and tested to enhance detection. As set forth below, many different types of tools currently exist. But absent validation, uniform standards, and implementation, such tools will not gain general use, pro- vide an accurate picture of the phenomena, or supply a useful base of data to be used in research. It is essential to screen for elder mistreatment, particularly in older persons who are either unable, due to cognitive impairment, or unwilling, due to fear, to report it. Another confounder is that details about alleged abuse or neglect are derived through proxy interviews and in some circum- stances the proxy might be the perpetrator. Jones and colleagues (1988) reported that 72 percent of elder abuse victims did not complain of the abuse at the time of presentation to an emergency center. The American Medical Association recommends screening of geriatric patients regardless of whether they complain of abuse, if physical signs are present (1996). The U.S. Department of Health and Human Services recommends that hospitals have protocols for screening patients for abuse or neglect. In a 1997 survey of emergency department physicians by Jones and colleagues, 31 percent worked in a department that had protocols, 33 percent worked in departments without protocols, and 36 percent were unsure. The Joint Commission on Accreditation of Health Care Organizationâs 1992 stan-
364 ELDER MISTREATMENT dards require screening protocols for elder abuse as well as domestic vio- lence and child abuse (Aravanis et al., 1993). Others recommend that screening for elder mistreatment be a part of the routine health assessment for all older persons (Fulmer and Birkenhauer, 1992; Mouton and Espino, 1999). A number of factors have limited the development of screening tools for elder mistreatment. The low level of knowledge regarding the phenom- ena makes it difficult to develop a comprehensive and accurate tool. There is no gold standard test for elder abuse or neglect. Legal definitions, clinical experience, and standards relating to elder abuse and neglect vary from state to state and even from entity to entity. As a result, many cases of elder abuse and neglect go undetected and unreported, and some benign cases are reported to involve abuse or neglect (Loue, 2001). Moreover, the process of substantiating the validity and reliability of such tools is time-consum- ing, rigorous, and expensive (Wolf, 2000). 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. Some of the existing tools will be briefly described. A few, with special relevance to forensic analysis, will be described in greater detail. Comprehensive Geriatric Assessment. Several authors have suggested that the Comprehensive Geriatric Assessment (CGA) is an ideal tool for evalua- tion of abused or neglected individuals (Aravanis et al., 1993; Lachs and Pillemer, 1995; Dyer and Goins, 2000). CGA, an integrated approach to the screening of conditions in a variety of domains (Siu et al., 1994), re- quires obtaining a comprehensive history and physical examination, and the use of validated instruments to quantify measures of psychosocial health and functional ability. CGA has been shown to be an effective procedure in at least eight randomized trials in Sweden and the United States (Alessi et al., 1997). CGA can be performed efficiently in a variety of settings (hospi- tal, outpatient clinic, nursing home, and private home). A multidisciplinary team usually conducts the CGA because of the depth and breadth of the evaluation. The team members always include geriatricians, geriatric nurse practitioners, and gerontologic social workers and often include therapists, pharmacists, chaplains, and a variety of other specialists.
CLINICAL AND MEDICAL FORENSICS 365 AMA Assessment Protocol for Physicians. This assessment protocol does not incorporate any type of screening procedure. APS Protocols. Eighteen state APS programs have screening protocols for use by APS specialists, but only four agencies performed any tests of valid- ity or reliability on their tool (Wolf, 2000). Risk Factor Checklists. Such checklists have been developed in a variety of settings (Canadian Task Force on Periodic Health Examination, 1994). These questionnaires are mostly based on descriptive studies and not on empirical data. They often do not assess for neglect or address the differ- ence between disease and abuse. The Mount Sinai/Victim Services Agency Elder Abuse Project Question- naire. This tool (1998) developed in New York, is made up of nine closed- ended direct questions. It is short and easy to administer. Responses, however, rely on the subjective evaluation of the possible victim, who may not be forthcoming with or have the cognitive capacity to provide the personal information it requests. Positive responses should trigger further evaluation of potential abuse or neglect. This type of tool may be the best for quick screening in busy emergency centers or clinics. Elder Assessment Instrument (EAI). This instrument first was developed in 1981 and now includes a checklist assessing five domains, a summary, a disposition, and a narrative if the examiner is so inclined (Fulmer and Wetle, 1986). The EAI has a content validity index of 0.83 (Fulmer et al., 1984) and a reliability index of 0.83 (Fulmer and Wetle, 1986). This instrument is comprehensive and precise and can be used for serial assess- ments. Fulmer and colleagues (2000) demonstrated that the sensitivity and specificity were 71 percent and 93 percent, respectively, when compared with a panel of experts. The EIA has been used successfully by emergency department nurses and appears to be ideal for research. The time required to complete the formâs detailed inquiries make it less likely to be used by physicians in busy, acute medical settings (such as emergency departments) and more likely to be used in settings such as geriatric outpatient clinics. Brief Abuse Screen for the Elderly (BASE). This tool contains five brief questions that take only a minute to complete (Reis and Nahmiash, 1998). It is coupled with training and designed to screen elders who are either caregivers or care receivers. Reis and Nahmiash (1998) report a 86 percent to 90 percent agreement by trained practitioners and a correlation between abusive and nonabusive caregivers. The BASE may be useful in busy clini- cal settings.
366 ELDER MISTREATMENT Indicators of Abuse Screen (IOA). This tool began as a 48-item checklist and has been reduced to a 29-item list (Reis and Nahmiash, 1998). It is a subjective measure that requires an experienced and trained administrator and two to three hours to complete. A multidisciplinary committee consen- sus panel reviewed the initial subsample. Cronbach alpha tests demon- strated an internal consistency of 0.92 and 0.91 on two separate samples (Reis and Nahmiash, 1998). According to Wolf (2000), the IOA identified 78 percent to 84 percent of senior abuse cases seen by a health and social service agency. It appears to have great potential as a research tool but is too lengthy to be used by most medical, social service, APS, or ombudsman personnel. Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST). This test ini- tially pooled and distilled over 1000 items into a 15-item tool to measure physical abuse, vulnerability, and potential abusive situations (Wolf, 2000). The tool was further trimmed to six items based on discriminant analysis (Neale et al., 1991). Based on an additional study (Scofield et al., 1999), the researchers suggested six questions suitable for a brief screening tool. Special Issues Relating to Screening Tools Several specific factors make development of appropriate tools to screen for markers of elder abuse and neglect simultaneously vital and very com- plex. Dementia, Depression, Psychosis, and Substance Abuse. Several authors recommend screening for dementia, depression, psychosis, and substance abuse in older people to assess the risk of abuse and neglect. The TEAM Institute Battery includes the Mini-Mental State Examination, the Geriatric Depression Scale, the Clock Drawing Test, the Brief Psychiatric Rating Scale, and the CAGE questionnaire for their ease of administration during house calls and in busy clinics and for the interrater reliability (Dyer and Goins, 2000; Marshall et al., 2000). Failure to rule out reversible causes of these cognitive and mental health disorders also may indicate neglect. Assessment of Decision-Making Capacity. The factors listed above, alone or in combination, may diminish the elderâs capacity to participate fully in his or her own decision making. In addition, acute illness can reduce an older personâs ability to make rational and informed decisions. 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 dimin- ished capacity decides against hospital transport, resulting in inadequate
CLINICAL AND MEDICAL FORENSICS 367 medical care, worsening suffering, exacerbation of an illness or injury, or even death (Persse, unpublished data). In our society, patients have the legal right to be presumed competent, and evidence to the contrary must be presented before that right can be curtailed or removed. A competent individual has the right to be a fully informed participant in all aspects of decision making and, of course, has the right to refuse treatment. It is important to honor the choices of elders with capacity without abandoning those who lack capacity and whose expressed choices may lead to harm or even death. The determination of neglect versus poor choices hinges on an elderâs capacity to participate in his or her own care, a situation on which statutes do not provide clear guidance (Loue, 2001). Aravanis and col- leagues (1993) along with Benton and Marshall (1991) recommend capac- ity assessment for mistreated elders. There are no easily administered standard tools that assess capacity. The gold standard is psychiatric interview, which is a process that takes hours and requires a specialist, rendering it impractical. A shorter, but still accurate and sufficiently sensitive, screening tool is needed to assist in assessing capacity and identifying those at highest risk. Assessment Tools for Different Living Situations. Screening tools that presume normal or near-normal cognition are not useful in environments where many or most individuals do not have normal cognition. 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. Three care options exist: (a) provide care for oneself in oneâs home, (b) obtain care from a caregiver in the community, and (c) move to an institution or alternative setting such as a nursing home where basic daily needs can be met (Loue, 2001). Studies are needed to evaluate whether the assessment should differ based on whether the indi- vidual lives in a nursing home, at home, or in a community setting (assisted living home, group home, etc.). Assessment of the environment is one of the key indicators for abuse by APS specialists (Toronjo et al., unpublished data). In a study of abused or neglected children, Watson-Perczel and colleagues (1988) found homes with large amounts of garbage, dirty clothes, spoiled food, and feces. They used the Checklist for Living Environments to Assess Neglect (CLEAN) home assessment tool to measure home conditions and to monitor subsequent clean-up efforts. Perhaps such an evaluation could be modified for cases of elder neglect. Screening tools are not acid tests for mistreatment. As Fulmer and colleagues point out in a 1984 publication, without knowledge of the spe- cific situation, judgment about abuse or neglect cannot always be rendered.
368 ELDER MISTREATMENT In any screening tool the context and the social situation of each individual case must be explored. Postmortem Screening Tools. Injuries leading to morbidity or mortality in the older population should be investigated to determine whether the sever- ity of the injury is compatible with the reported mechanism of injury. Screening tools that have been and are being developed for evaluating injuries in living populations are useful in some cases of suspected fatal abuse or neglect but are not always applicable in the postmortem evalua- tion. Developing and evaluating a standardized tool for performing a psychological autopsy, especially one directed toward determining the de- gree of dementia, cognitive impairment, and decision-making capacity be- fore death, are worthwhile goals. In sum, although many instruments and protocols exist, they are a disparate group, and do not, taken together, achieve the uniformity neces- sary to support an effective and coherent response from the medical, social service, public safety, and legal communities. These communities must work together to encourage and support research into, and development of, uniform, validated screening tools. (See recommendations below.) 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 prob- lems as diverse as child abuse and neglect, sexual abuse, terrorism, food tampering, and computer crime. These centers are intended to bring to- gether multidisciplinary groups of leading experts in their fields; to use state-of-the-art science, analytic tools, and techniques; to identify wrongdo- ing; to support law enforcement; to provide diagnostic resources; to con- duct research and training; and to advance understanding in the specific field. As such, forensic centers can be and have been a very useful tool in bringing a specialized multidisciplinary approach (and dedicated funding) to addressing, understanding, and redressing various vexing issues. The authors uncovered no forensic center in this country dedicated to elder abuse and neglect. As the discussion above demonstrates, elder victimiza- tion involves complex phenomena. A forensic center, where expertise, attention, and new funding could be focused, could advance understanding, treatment, and research as well as detection, intervention, and prosecution of elder abuse and neglect. It could also provide concentrated expertise,
CLINICAL AND MEDICAL FORENSICS 369 which others could use as a resource until more information is better dis- tributed among the relevant practitioners. Potential Models for Elder Abuse and Neglect Forensic Centers National Forensic Center. 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 dedi- cated to the diagnosis of and response to elder abuse and neglect, to re- search and training in its related fields, and to its prosecution. The center would conduct postmortem evaluations, consultations with living patients (using videoconferencing, if necessary), and interviews to answer questions relating to elder abuse or neglect. Medical records, samples, and other relevant data could be sent to the center for evaluation. Regional Forensic Center. A regional center would be similar to the pro- posed national center, except it would be organized on a regional basis. Local Forensic Center. The local forensic center model would be much more localized. It could consist of a mobile unit or team, including a physician, an APS specialist, and possibly a forensic or law enforcement specialist, that could be dispatched to the home or facility where the poten- tial victim was located to do an on-site evaluation. Data could be collected and analyzed from several sites as part of a pilot project as well. Multidisciplinary Teams Multidisciplinary Screening Teams While not an instrument per se, multidisciplinary team assessment and treatment has been suggested by many as the ideal approach to elder abuse and neglect (Fulmer, 1989; Dyer and Goins, 2000). Mount Sinai Hospital has had a multidisciplinary elder abuse team for over 10 years (Fulmer et al., 2000). Baylor College of Medicineâs team has been in place for over 6 years. Other sites, including the University of California at Irvine and the Robert Wood Johnson Medical School of New Jersey, also have well- developed teams. Interdisciplinary comprehensive geriatric assessment (CGA) teams are available in most regions throughout the United States and employ a well-validated, well-accepted approach to frail elders. It only makes sense that these gerontological experts care for neglected elders, who are the frailest of the frail. Although there is no published outcome study of CGA and elder abuse, Dyer and colleagues (unpublished data) have pre-
370 ELDER MISTREATMENT liminary data that showed that CGA reduced the prevalence of elder abuse and neglect at six months and greatly increased the assessment of self- related health by the victim. Multidisciplinary Forensics Teams A handful of locations around the country have created multidisciplin- ary teams to review and respond to suspected cases of elder abuse and neglect. These teams are not only capable of providing a better coordinated intervention and response than unaffiliated professionals working outside a team structure, but they also are developing experience and expertise in supplying a more sophisticated forensic analysis than was previously avail- able, thereby increasing the likelihood that legal action is pursued and successful in appropriate cases. Multidisciplinary forensic teams may be employed to useful end in a variety of other contexts, for example as elder fatality or serious injury review teams. Because there are so few such teams and because the data are so scarce, multidisciplinary efforts dedicated to addressing elder abuse and neglect should be studied, encouraged, and supported. RECOMMENDATIONS FOR RESEARCH As a supplement to primary research in this area, it is critical to ensure that a validated evaluative component is built into all promising practices, innovative programs, and other efforts, so that results can be measured and others have ready access to outcome data. Given the nascent state of the field, the areas for potential research are plentiful. Only a sampling of potential areas of study are discussed here. 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 im- possible. Unless we develop benchmarks giving practitioners the tools to recognize elder abuse and neglect, we cannot measure or address the prob- lem. Such research should result in data that provide guidance to health, social service, and public safety professionals on the location, pattern, color, marking, severity, natural history, and other characteristics of injuries asso- ciated with elder abuse and neglect. Some of these factors (for example, medication misuse and cognitive and mental health problems) should be evaluated both as forensic markers and in terms of whether and to what extent they constitute risk factors for being a victim or a perpetrator of
CLINICAL AND MEDICAL FORENSICS 371 elder abuse and neglect. Mortality rates associated with each marker also should be evaluated. This research, among other things, should determine in a scientific manner the difference between age and unavoidable disease-related changes versus abuse and neglect. Very few studies of any of the 14 factors listed below have been done; more are needed. For example, descriptive studies of skin tears are needed that compare those with known causes to those with unknown causes. Burnight (2000) has suggested a national database of witnessed injuries. Many forms of trauma could be studied, beginning with witnessed falls, which occur commonly in hospitals and nursing homes. Research protocols should be designed to provide information applicable to minority populations and to both genders. The study by Langlois and Gresham (1991) was limited to whites; a study of bruising is needed for people of color. A few suggestions (there are many more) for research needed relating to the markers discussed in this paper include the following: Fractures The significance of type and location of fractures is not well understood relative to mechanism and degree of injury. Objective documentation of the degree and ensuing impact of osteoporosis is needed. Research into osteoporosis to determine its objective documentation postmortem and how it affects fracturing, mechanisms (i.e., degree of force required) would be useful to the forensic analysis. Burns The findings on burns and elder abuse or neglect are intriguing and could be further studied at U.S. burn centers. The high incidence of burns in cases of self-neglect raises the question: When does a history or propen- sity of an elder to set fires give rise to a duty by a caregiver to intervene? 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. Cognitive and Mental Disorders The existing data on cognitive and mental disorders raise many re- search questions. What is the impact of cognitive and mental disorders in cases of abuse or neglect? What is the prevalence of dementia, depression, and psychosis in abused or neglected individuals or perpetrators? Are mortality and morbidity higher in persons with cognitive or mental disor- ders? Because dementia and alcoholism are treatable and depression and
372 ELDER MISTREATMENT psychosis are curable, interventions derived from trials may decrease or even reverse some cases of elder abuse and neglect. Elder Sexual Abuse To improve recognition of elder sexual abuse, researchers need to de- velop precise anatomic diagnostic criteria, something that is yet to be deter- mined for child sexual abuse (Kerns, 1998). Studies are needed comparing anogenital examination findings and psychological characteristics in sexu- ally abused elders with findings in examinations of those who participate in consensual sexual relations. Studies in each of the additional categories below should be conducted to determine what physical and behavioral signs should catalyze further examination, inquiry, and possible reporting by caregivers. The categories include: abrasions and lacerations, bruises, restraints, decubiti, malnutri- tion, dehydration, medication use, self-neglect, and financial fraud and exploitation. Additional studies should be conducted to determine what other markers should be added to the list (for example, contractures). 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. Some caregivers may neglect patients because of a lack of knowledge, resources, training, assistance, and available time due to competing responsibilities. Others may neglect inten- tionally or sadistically. In the institutional context, a corporate decision maker may order cutbacks that result in neglect. Research is needed to develop appropriate standards of care for caregivers that are meaningful and achievable regardless of socioeconomic status. Most of the adverse events that happen to frail elders are not the result of abuse or neglect. Tracking of data on adverse and unexpected events is important in determining standards for such incidents and is already per- formed by state and federal agencies. Intermingled with data on, for ex- ample, falls, may be data on bruises and fractures that occurred because of abuse or neglect unbeknownst to investigators. Gurwitz and colleagues (1994) have collected data on adverse and unexpected events in long-term care settings. A study in which investigators collect a single stream of data, screen data for abuse and neglect, and compare positive cases to negative cases may give results that are more accurate.
CLINICAL AND MEDICAL FORENSICS 373 Assessment Tools The lack of statutory or well-studied screening instruments can result in highly subjective standards by mandated reporters, leaving prosecutors with very little hard evidence on which to base their cases (Loue, 2001). Health care providers and social services agencies may not reach the people who need them most if cases of abuse and neglect cannot be adequately identi- fied. Research is vital to creating validated, uniform screening tools. The lack of a gold standard requires using alternative methods for validating tools, such as a lead standard. One lead standard might be an expert consensus panel. Consideration should be given to developing (a) a form with a short format for busy environments, such as emergency centers, with questions applicable to all elders; (b) a form applicable to community- dwelling elders; and (c) a form suited to residents of institutions. These various forms are required because we do not know what risk different settings confer. A second form with a long format, also validated and uniform, should be developed with a structure similar to that of a, b, and c above. The long form would be intended to be used by those who historically take a lengthy interview, such as protective service specialists or ombudsmen. The long form could serve as a research tool in conjunction with the short form if the individual appears to be at high risk for abuse or neglect. Screening for all elders, coupled with targeted comprehensive assessment in high-risk popu- lations, 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. Just as in the evaluation of potential abuse and neglect in living per- sons, there is a need for development of screening or evaluation tools that are specifically useful in the postmortem setting. For example, research could compare the number, location, and type of fractures incurred in documented accidental situations versus those encountered in the setting of inflicted injury. It is intriguing to think that there might be biological markers of elder abuse or neglect. While the need for epidemiological research on screening and assessment tools is clear, it does not preclude searching for other objective laboratory measures. Mortality Data for Abused and Neglected Elders Although a 100 percent autopsy rate, including proper investigation, review of medical records, consultation with specialists, including geriatri-
374 ELDER MISTREATMENT cians, odontologists, radiologists, and other specialists would be ideal to obtain baseline information, it is not practical financially and would over- whelm most medical examiner/coroner systems. Consideration should be given to a pilot study using statistically selected cases for investigation and autopsy to determine the prevalence of abuse and neglect and their contri- bution to death in an autopsied elderly population. Medical examiners and coroners should exchange information with geriatricians and others, including being active members of multidisciplinary teams to review deaths, review reporting mechanisms, and identify system issues that work for and against adequate reporting and intervention. De- velopment of additional scientific literature on all markers would be useful to support a medical examinerâs diagnoses and conclusions when chal- lenged in court. It would be useful to study what number or percent of cases of elder abuse and neglect contributing to death are not investigated or autopsied. This research likely will require predicate research into the markers to enhance detection in the first instance. Research Regarding Certification of Elder Deaths To ensure better certification of eldersâ deaths, researchers should docu- ment aspects of aging that are natural and compare them with features of injury due to accidental mechanisms and to malevolence. Training in rec- ognizing 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. Policy makers should consider expanding elder death manda- tory-reporting laws beyond institutional cases. Development of standard- ized protocols for examination of deaths in elders, particularly when there is a suspicion of abuse or neglect, is fundamental and could benefit from the expertise of all health care professionals concerned about fatal abuse and neglect of the elderly. Legal Issues for Study Research is needed to determine what types of criminal, civil, and administrative cases best protect elders in all settings. To date, there has been no research on the efficacy of current laws and existing remedies or how to develop more effective ones. Reporting There is a wide divergence of views regarding whether reporting of elder abuse and neglect should be mandatory, whether mandatory-report-
CLINICAL AND MEDICAL FORENSICS 375 ing laws should be aggressively enforced, and regarding the efficacy, in general, of mandatory reporting. In addition, some states have specific reporting requirements, such as the Arkansas law requiring immediate re- porting of deaths of nursing home residents. Research protocols should be developed that inform this debate and to track the impact and efficacy of reporting laws. Developing Experts in Forensic Geriatrics Development of a group of forensic pediatricians has reportedly im- proved detection, diagnosis, reporting, and prosecution of child abuse and neglect. Pilot programs to train a group of forensic geriatricians, and to identify what types of programs are most effective, should be developed and tested. Screening Tools, Forensic Centers, and Multidisciplinary or Interdisciplinary Teams As discussed earlier in this paper, each of these potential tools should be the subject of study to determine how best to construct screening tools, forensic centers, and multidisciplinary/interdisciplinary teams (including fatality and serious-injury review teams), likely including several pilot or demonstration projects in several sites. 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 recommen- dations could be made. The reader is directed to Elder Justice Roundtable Report (2000). CONCLUSION Evidence-based forensic markers of elder abuse and neglect have at- tracted little research interest and therefore remain largely unidentified. No data exist regarding the number of documented forensic markers or pros- ecuted cases. A comprehensive research agenda should be developed that will provide the information needed to help derive accurate clinical and forensic markers for elder abuse and neglect in both living and deceased persons, in home and residential settings alike. The significantly increased mortality rate for elder victims of abuse and neglect underscores the pressing need for a national research agenda and extensive study by the relevant disciplines to address this growing issue.
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