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 injuries (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.

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 photographs of bruises occurring in persons over the age of 65. They concluded 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 included 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 intentional 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 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.

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 Paget's disease, make the bones more brittle. Any type of cancer that invades bone weakens the osseous structure, making the patient more prone to fractures—these 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: vertebral 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, Paget's 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. Elders' 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; therefore, falls alone should not necessarily increase suspicion of abuse. Most persons who fall experience one to three falls per year. A person who falls 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 retrospective chart review that fractures of the head, spine, and trunk are more likely to be assault injuries than limb fractures, sprains or strains, or musculoskeletal 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 rotational component (Medical Tribune, 1995). Fractures in nonalcoholics at sites other than the hip, wrist, or vertebrae should raise suspicions of abuse.

Standards of Care for Elders

The only acceptable reason for restraining an elder is to prevent significant 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 replacement, 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). Restraints, 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 falling. Restraints can be a form of neglect when used in lieu of adequate caretaking because they render persons “easier” to care for. They can be a form of physical abuse, for example, when they leave scars or result in wrist wounds or decubiti.

Age-Related Changes and Standards of Care

Normal aging skin has relatively well-preserved blood flow. The elderly 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 doesn't 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 nutritional supplementation, and bedding. New therapies available for treatment including hydrocolloid dressings and hydrogel preparations, are superior to wet-to-dry dressings and the use of povidone iodine in wounds (Patterson and Bennett, 1995).

Clinical and Forensic Markers Indicating Abuse or Neglect

There are divergent views regarding which decubiti are due to illness and which are due to neglect or even abuse. The failure to adhere to the standard of care could be due to medical, institutional, or caregiver neglect. 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.

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, depression, dementia, and malabsorption syndromes, also may contribute to weight loss and undernutrition (Thomas, 1998). Numerous other disorders can lead to malnutrition, including strokes, Parkinson's disease, amyotrophic 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 institutional 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 nutritional 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 be an important predisposing factor for other illness or death and may be due to mismanagement of persons living in nursing homes (Hood, 2000).

Age-Related Changes

The elderly are much more prone to dehydration with minimal provocation 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 Geriatrics Society Review Syllabus, 1998). Hydration status is particularly difficult 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 personnel. 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 vital signs should be brought to the attention of a clinician or otherwise promptly evaluated. Where the explanation for dehydration in an institutional setting is a refusal of fluids, this should be historically and appropriately documented. As with malnutrition, inadequate staff support may lead to neglectful, inadequate hydration.

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 prescribing 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, approximately 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 neighbors' medication or overdose on alternative therapies. Others 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. Standards of care for specific disease states, such as a three-drug regimen for persons with heart failure or a two-drug regimen for Alzheimer's disease, have been established.

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 received 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 practitioners 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 practitioner 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 elders' drugs themselves, or overdose patients to keep them quiet and manageable. 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.

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.

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 incidences 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 alcohol dementia (Abrams et al., 1995c).

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 ability, and ultimately decision-making capacity. They can prevent persons from seeking help, advocating on their own behalf, or extricating themselves from abusive situations, and they make elders more prone to exploitation 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 otherwise well-developed social skills and, without formal testing, can escape notice by physicians and other professionals who care for them. The National Elder Abuse Incidence Study asked nonmedical volunteers to comment on depression and dementia based on their opinions. They found 59.5 percent incidence of dementia and 43.6 percent incidence of depression. 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 Department of Protective and Regulatory Services, self-neglect and medical neglect (failure to obtain or have obtained appropriate medical care) cases were more likely to be associated with other types of elder mistreatment than were cases of physical or sexual abuse (Dyer et al., 2000a). 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 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 Connecticut (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.

Age-Related Changes

There are no changes in one's hygiene that occur strictly with age. Occasionally, impaired eyesight may make it more difficult to keep one's 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.

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.

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 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 disease 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.

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 victims are often widows or widowers, often in the seventh or eighth decade of life, and living in the community.

Financial exploitation includes credit card and telemarketing fraud, predatory lending, and theft or extortion. Such activities are usually targeted at vulnerable older adults and may leave them unable to pay for medications, health care, food, and the other necessities of life. Evidence of signing over of deeds or changes in wills should raise suspicion of exploitation as should the transfer of personal belongings or material goods without consent (Fulmer and Birkenhauer, 1992). The level of suspicion for this type of abuse should be increased for persons with cognitive impairment, which predisposes the victim to be trusting of caregivers, relatives, and acquaintances (Tueth, 2000). It is believed that many cases of financial exploitation go unrecognized and occur in conjunction with other types of abuse and neglect.

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 evaluation 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), requires 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 (hospital, 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.

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 validity 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 difference between disease and abuse.

The Mount Sinai/Victim Services Agency Elder Abuse Project Questionnaire. 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 assessments. 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 form's 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 clinical settings.

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 consensus panel reviewed the initial subsample. Cronbach alpha tests demonstrated 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 initially 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 complex.

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 elder's capacity to participate fully in his or her own decision making. In addition, acute illness can reduce an older person's 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 diminished capacity decides against hospital transport, resulting in inadequate 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 elder's capacity to participate in his or her own care, a situation on which statutes do not provide clear guidance (Loue, 2001). Aravanis and colleagues (1993) along with Benton and Marshall (1991) recommend capacity 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 one's 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 individual 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 specific situation, judgment about abuse or neglect cannot always be rendered. 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 severity 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 evaluation. Developing and evaluating a standardized tool for performing a psychological autopsy, especially one directed toward determining the degree of dementia, cognitive impairment, and decision-making capacity before 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 necessary 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.)

Overview of Forensic Centers

Forensic centers have been developed to address and study numerous categories of illegal conduct usually associated with complex social problems as diverse as child abuse and neglect, sexual abuse, terrorism, food tampering, and computer crime. These centers are intended to bring together multidisciplinary groups of leading experts in their fields; to use state-of-the-art science, analytic tools, and techniques; to identify wrongdoing; to support law enforcement; to provide diagnostic resources; to conduct research and training; and to advance understanding in the specific field.

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 victimization 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, which others could use as a resource until more information is better distributed 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 dedicated to the diagnosis of and response to elder abuse and neglect, to research 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 proposed 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 potential 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 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 Medicine's 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 preliminary 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 multidisciplinary 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 available, 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.

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 propensity 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 research 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 disorders? Because dementia and alcoholism are treatable and depression and 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 develop precise anatomic diagnostic criteria, something that is yet to be determined for child sexual abuse (Kerns, 1998). Studies are needed comparing anogenital examination findings and psychological characteristics in sexually 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, malnutrition, 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).

Reporting

There is a wide divergence of views regarding whether reporting of elder abuse and neglect should be mandatory, whether mandatory-reporting 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 reporting 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 improved 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 recommendations could be made. The reader is directed to Elder Justice Roundtable Report (2000).