Elder neglect and the pathophysiology of aging

On tackling abuse of older people: The forensic challenges in fatal cases investigation

The World Health Organization recently presented the priorities for tackling abuse of older people in a coordinated and strategic way. However, data on the forensic scenario is still lacking. In this context, the aim of the present work was to provide a comprehensive literature review of this inherently complex phenomenon in the post-mortem setting, in order to better characterize it from a forensic point of view. A comprehensive literature search was performed in three electronic databases following the PRISMA guidelines. Sociodemographic and medical data of victims and perpetrators, post-mortem data, types of abuse and risk factors were extracted from non-aggregated data. Forty-eight papers dealing with abuse in the post-mortem setting were included, with a predominance of case reports and case series. The review showed that neglect was the most common type of abuse and victims are predominantly older women who are abused in a domestic setting by trusted family member. To generate more and better data, expanded research in the forensic field requires standardized methods and the raise of professional awareness about abuse of older people.

Elder Mistreatment: Emergency Department Recognition and Management

Elder mistreatment is experienced by 5% to 15% of community-dwelling older adults each year. An emergency department (ED) encounter offers an important opportunity to identify elder mistreatment and initiate intervention. Strategies to improve detection of elder mistreatment include identifying high-risk patients; recognizing suggestive findings from the history, physical examination, imaging, and laboratory tests; and/or using screening tools. ED management of elder mistreatment includes addressing acute issues, maximizing the patient's safety, and reporting to the authorities when appropriate.

Sequelae of Eating Disorders at Imaging

Although eating disorders are common, they tend to be underdiagnosed and undertreated because social stigma tends to make patients less likely to seek medical attention and less compliant with medical treatment. Diagnosis is crucial because these disorders can affect any organ system and are associated with the highest mortality rate of any psychiatric disorder. Because of this, imaging findings, when recognized, can be vital to the diagnosis and management of eating disorders and their related complications. The authors familiarize the radiologist with the pathophysiology and sequelae of eating disorders and provide an overview of the related imaging findings. Some imaging findings associated with eating disorders are nonspecific, and others are subtle. The presence of these findings should alert the radiologist to correlate them with the patient's medical history and laboratory results and the clinical team's findings at the physical examination. The combination of these findings may suggest a diagnosis that might otherwise be missed. Topics addressed include (a) the pathophysiology of eating disorders, (b) the clinical presentation of patients with eating disorders and their medical complications and sequelae, (c) the imaging features associated with common and uncommon sequelae of eating disorders, (d) an overview of management and treatment of eating disorders, and (e) conditions that can mimic eating disorders (eg, substance abuse, medically induced eating disorders, and malnourishment in patients with cancer). Online supplemental material is available for this article. ^©RSNA, 2022.

Nonaccidental Injury in the Elderly: What Radiologists Need to Know

Elder abuse may result in serious physical injuries and long-term psychological consequences and can be life threatening. Over the past decade, attention to elder abuse has increased owing to its high prevalence, with one in six people aged 60 years and older experiencing some form of abuse worldwide. Despite this, the detection and reporting rates remain relatively low. While diagnostic imaging is considered critical in detection of child abuse, it is relatively underused in elder abuse. The authors discuss barriers to use of imaging for investigation and diagnosis of elder abuse, including lack of training, comorbidities present in this vulnerable population, and lack of communication among the intra- and interdisciplinary care providers. Moreover, imaging features that should raise clinical concern for elder abuse are reviewed, including certain types of fractures (eg, posterior rib), characteristic soft-tissue and organ injuries (eg, shoulder dislocation), and cases in which the reported mechanism of injury is inconsistent with the imaging findings. As most findings suggesting elder abuse are initially discovered at radiography and CT, the authors focus mainly on use of those modalities. This review also compares and contrasts elder abuse with child abuse. Empowered with knowledge of elderly victims' risk factors, classic perpetrator characteristics, and correlative imaging findings, radiologists should be able to identify potential abuse in elderly patients presenting for medical attention. Future recommendations for research studies and clinical workflow to increase radiologists' awareness of and participation in elder abuse detection are also presented. An invited commentary by Jubanyik and Gettel is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

Neglect of Older People: Touching on Forensic and Pathophysiological Aspects

BACKGROUND AND OBJECTIVES

Neglect of older people is common and may result in fatal and nonfatal outcomes. Normal changes of aging and disease-related symptoms may overlap with markers of neglect and lead to under-detection. This review aims to delineate medical, psychiatric, and pathophysiological indicators in the victim-identified in forensic case reports-to point out areas of overlap and raise awareness in Health Care Professionals.

RESEARCH DESIGN AND METHODS

Medical and forensic databases were searched with the search terms: neglect, elder, elderly, forensic, homicide for detailed case reports on elder neglect. Cases were reviewed as to victim age, sex, medical/psychiatric diagnosis, perpetrator, victim-to-perpetrator relationship, cause of death (if fatal), location of incident, autopsy findings (if fatal), and ancillary studies. A total of 168 publications were retrieved, of these 11 publications, containing a total of 25 cases, yielded sufficient detail on each case to be included in the qualitative analysis.

RESULTS

Neglect is associated with poor physical, psychological, and mental health. Neglect can be a direct cause of death or contribute to a fatal outcome by exacerbating existing conditions. Red flags of neglect included malnutrition, dehydration, poor hygiene, untreated decubitus ulcers, hypothermia, contractures, and an uncooperative caregiver. However, incontrovertible evidence of neglect is not always easy to obtain due to age and disease-related changes.

DISCUSSION AND IMPLICATIONS

The findings document the extent and seriousness of elder neglect and highlight the importance of detailed documentation as well as collaboration between clinicians, allied health professionals, law enforcement and medical forensic services to improve patient outcomes and reduce the risk of further incidents.

Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases

STUDY OBJECTIVE

Elder abuse is common and has serious health consequences but is underrecognized by health care providers. An important reason for this is difficulty in distinguishing between elder abuse and unintentional trauma. Our goal was to identify injury patterns associated with physical elder abuse in comparison with those of patients presenting to the emergency department (ED) with unintentional falls.

METHODS

We partnered with a large, urban district attorney's office and examined medical, police, and legal records from successfully prosecuted cases of physical abuse of victims aged 60 years or older from 2001 to 2014.

RESULTS

We prospectively enrolled patients who presented to a large, urban, academic ED after an unintentional fall. We matched 78 cases of elder abuse with visible injuries to 78 unintentional falls. Physical abuse victims were significantly more likely than unintentional fallers to have bruising (78% versus 54%) and injuries on the maxillofacial, dental, and neck area (67% versus 28%). Abuse victims were less likely to have fractures (8% versus 22%) or lower extremity injuries (9% versus 41%). Abuse victims were more likely to have maxillofacial, dental, or neck injuries combined with no upper and lower extremity injuries (50% versus 8%). Examining precise injury locations yielded additional differences, with physical elder abuse victims more likely to have injuries to the left cheek or zygoma (22% versus 3%) or on the neck (15% versus 0%) or ear (6% versus 0%).

CONCLUSION

Specific, clinically identifiable differences may exist between unintentional injuries and those from physical elder abuse. This includes specific injury patterns that infrequently occur unintentionally.

Elder abuse: a retrospective analysis of autopsy cases from the department of legal medicine in Genoa from 2006 to 2017

Elder abuse is a form of violence that is often misunderstood and still underestimated. This kind of abuse is classified in physical abuse, psychological abuse, financial abuse, sexual abuse, neglect and self-neglect. In this study, 784 cases of dead people over 65 years of age were retrospectively analyzed: in all cases, the cause of death was determined by the autopsy. Ten cases have been classified as victims of elder abuse: 7 females and 3 males aged between 67 and 91 (average age of 78.9 years). The types of abuse were as follows: neglect: 8 cases; physical abuse: 2 cases; psychological abuse: 2 cases; financial abuse: 2 cases; self neglect: 2 cases. In three cases, the victims had been subjected to two or more types of abuse. In 5 cases the victims had a neuro-psychic decay. In cases of neglect the cause of death was due to sepsis or dehydration. In a case of physical abuse, death was traumatic and related to physical violence. In cases of self neglect, death occurred due to cardiac causes. In cases of domestic abuse, the perpetrator was in most cases the elder's son and in one case the paid caregiver. In three cases, however, the abuses were committed against elderly guests in Nursing Homes. In three cases the perpetrator was affected by psychiatric disorders. Recognizing the elder abuse is often difficult and the understanding of the phenomenon in the case of death requires an integrated analysis of the autopsy data and the anamnesis of the victim.

Identifying and Initiating Intervention for Elder Abuse and Neglect in the Emergency Department

Elder abuse and neglect are common and may have serious medical and social consequences but are infrequently identified. An emergency department (ED) visit represents a unique but usually missed opportunity to identify potential abuse and initiate intervention. ED assessment should include observation of patient-caregiver interaction, comprehensive medical history, and head-to-toe physical examination. Formal screening protocols may also be useful. ED providers concerned about elder abuse or neglect should document their findings in detail. ED interventions for suspected or confirmed elder abuse or neglect include treatment of acute medical, traumatic, and psychological issues; ensuring patient safety; and reporting to the authorities.

Describing visible acute injuries: development of a comprehensive taxonomy for research and practice

BACKGROUND

Little literature exists classifying and comprehensively describing intentional and unintentional acute injuries, which would be valuable for research and practice. In preparation for a study of injury patterns in elder abuse, our goal was to develop a comprehensive taxonomy of relevant types and characteristics of visible acute injuries and evaluate it in geriatric patients.

METHODS

We conducted an exhaustive review of the medical and forensic literature focusing on injury types, descriptions, patterns and analyses. We then prepared iteratively, through consensus with a multidisciplinary, national panel of elder abuse experts, a comprehensive classification system to describe these injuries.

RESULTS

We designed a three-step process to fully describe and classify visible acute injuries: (1) determining the type of injury, (2) assigning values to each of the characteristics common to all geriatric injuries and (3) assigning values to additional characteristics relevant for specific injuries. We identified nine unique types of visible injury and seven characteristics critical to describe all these injuries, including body region(s) and precise anatomic location(s). For each injury type, we identified two to seven additional critical characteristics, such as size, shape and cleanliness. We pilot tested it on 323 injuries on 83 physical elder abuse victims and 45 unintentional fall victims from our ongoing research to ensure that it would allow for the complete and accurate description of the full spectrum of visible injuries encountered and made modifications and refinements based on this experience. We then used the classification system to evaluate 947 injuries on 80 physical elder abuse victims and 195 unintentional fall victims to assess its practical utility.

CONCLUSIONS

Our comprehensive injury taxonomy systematically integrates and expands on existing forensic and clinical research. This new classification system may help standardise description of acute injuries and patterns among clinicians and researchers.

Geriatric assault victims treated at U.S. trauma centers: Five-year analysis of the national trauma data bank

INTRODUCTION

While geriatric trauma patients have begun to receive increased attention, little research has investigated assault-related injuries among older adults. Our goal was to describe characteristics, treatment, and outcomes of geriatric assault victims and compare them both to geriatric victims of accidental injury and younger assault victims.

PATIENTS AND METHODS

We conducted a retrospective analysis of the 2008-2012 National Trauma Data Bank. We identified cases of assault-related injury admitted to trauma centers in patients aged ≥60 using the variable "intent of injury."

RESULTS

3564 victims of assault-related injury in patients aged ≥60 were identified and compared to 200,194 geriatric accident victims and 94,511 assault victims aged 18-59. Geriatric assault victims were more likely than geriatric accidental injury victims to be male (81% vs. 47%) and were younger than accidental injury victims (67±7 vs. 74±9 years). More geriatric assault victims tested positive for alcohol or drugs than geriatric accident victims (30% vs. 9%). Injuries for geriatric assault victims were more commonly on the face (30%) and head (27%) than for either comparison group. Traumatic brain injury (34%) and penetrating injury (32%) occurred commonly. The median injury severity score (ISS) for geriatric assault victims was 9, with 34% having severe trauma (ISS≥16). Median length of stay was 3 days, 39% required ICU care, and in-hospital mortality was 8%. Injury severity was greater in geriatric than younger adult assault victims, and, even when controlling for injury severity, in-hospital mortality, length of hospitalization, and need for ICU-level care were significantly higher in older adults.

CONCLUSIONS

Geriatric assault victims have characteristics and injury patterns that differ significantly from geriatric accidental injury victims. These victims also have more severe injuries, higher mortality, and poorer outcomes than younger victims. Additional research is necessary to improve identification of these victims and inform treatment strategies for this unique population.

The Forensic Lens: Bringing Elder Neglect Into Focus in the Emergency Department

We present 2 case studies of older patients who were brought to the emergency department (ED) in severely debilitated states. Both presented with severe malnutrition, contractures, and decubitus ulcers, and were nonverbal, with histories of dementia and end-stage disease. Their primary caregivers, adult children, were uncooperative with Adult Protective Services and disregarded treatment recommendations. Although both elders had signs suspicious for neglect, a comprehensive review revealed many layers of complexity. We use these cases to illustrate an approach to the assessment of possible elder neglect in ED settings and how to intervene to ensure patient safety. We begin with a discussion of the differences between willful, unintentional, and unsubstantiated neglect by a caregiver and then describe when to suspect neglect by evaluating the elder, interviewing the caregiver and first responders, assessing the caregiver's ability to meet the elder's needs, and, if possible, obtaining medical history and information about the home care environment. These cases illustrate the importance of careful documentation in cases of suspected neglect to assist investigative agencies, reduce the risk of further harm, and improve patient outcomes.

Screening and detection of elder abuse: Research opportunities and lessons learned from emergency geriatric care, intimate partner violence, and child abuse

This article provides an overview of elder abuse screening and detection methods for community-dwelling and institutionalized older adults, including general issues and challenges for the field. Then, discussions of applications in emergency geriatric care, intimate partner violence (IPV), and child abuse are presented to inform research opportunities in elder abuse screening. The article provides descriptions of emerging screening and detection methods and technologies from the emergency geriatric care and IPV fields. We also discuss the variety of potential barriers to effective screening and detection from the viewpoint of the older adult, caregivers, providers, and the health care system, and we highlight the potential harms and unintended negative consequences of increased screening and mandatory reporting. We argue that research should continue on the development of valid screening methods and tools, but that studies of perceived barriers and potential harms of elder abuse screening among key stakeholders should also be conducted.

Emergency Department Presentations for Injuries in Older Adults Independently Known to be Victims of Elder Abuse

BACKGROUND

Elder abuse is under-recognized by emergency department (ED) providers, largely due to challenges distinguishing between abuse and accidental trauma.

OBJECTIVE

To describe patterns and circumstances surrounding elder abuse-related and potentially abuse-related injuries in ED patients independently known to be physical elder abuse victims.

METHODS

ED utilization of community-dwelling victims of physical elder abuse in New Haven, CT from 1981-1994 was analyzed previously. Cases were identified using Elderly Protective Services data matched to ED records. Sixty-six ED visits were judged to have high probability of being related to elder abuse and 244 were of indeterminate probability. We re-examined these visits to assess whether they occurred due to injury. We identified and analyzed in detail 31 injury-associated ED visits from 26 patients with high probability of being related to elder abuse and 108 visits from 57 patients with intermediate probability and accidental injury.

RESULTS

Abuse-related injuries were most common on upper extremities (45% of visits) and lower extremities (32%), with injuries on head or neck noted in 13 visits (42%). Bruising was observed in 39% of visits, most commonly on upper extremities. Forty-two percent of purportedly accidental injuries had suspicious characteristics, with the most common suspicious circumstance being injury occurring more than 1 day prior to presentation, and the most common suspicious injury pattern being maxillofacial injuries.

CONCLUSION

Victims of physical elder abuse commonly have injuries on the upper extremities, head, and neck. Suspicious circumstances and injury patterns may be identified and are commonly present when victims of physical elder abuse present with purportedly accidental injuries.

The medico-legal observation of an aggressive urogenital fibromatosis with isolated development not related to any traumatic event

Desmoid tumor is a fibroproliferative neoplasm with an intermediate malignancy and it can be localized in every bodily district: some locations are considered exceptional, like the urogenital localization. The Author point out a rare case of giant idiopathic scrotal fibromatosis that was found during an autopsy. A widower, that lived alone in poor hygienic conditions, was found dead in his house. The Judicial Authority ordered the autopsy, that was performed two days later at the Medico-Legal Section of Milan University. External examinations revealed only the considerable dimension of the scrotum (cm 24 × 41). The cause of death was fixed in a cardiac tamponade due to a natural heart laceration localized in correspondence of a transmural infarction. The toxicological exam resulted negative, while the histopathological and immunohistochemical analysis qualify the scrotal mass as a desmoids tumor. Due to the absence of predisposing conditions and of fibroproliferative infiltration in bladder and retroperitoneal space, the neoplasm was configured as an idiopathic desmoid tumor. The presented case gives the reason for the discussion concerning medico-legal aspects that are typical of rare neoplasms.

Decubitus ulcers and ligature marks as evidence in a homicide case

When abuse, maltreatment and neglect are suspected, a proper physical examination is essential. This is even more important at autopsy, when there is no possibility to gain information from the alleged victim and where the forensic pathologist has to link the evidenced signs or sequalae of abuse with the possible manner and cause of death. This case report presents the results and conclusions of the medico-legal autopsy of a 30-year-old woman found dead in her fiancé's home. The conditions and material evidence found on scene aroused doubts on the cause and manner of death. Dermatological signs found on the corpse (abrasions, contusions and decubitus ulcers) suggested a history of domestic abuse and neglect that was further confirmed by a detailed macroscopic and microscopic examination of the body. An insight into the woman's medical history further implied the possibility of long-term domestic violence. The forensic pathologist reported bronchopneumonia as the main cause of death, provoked by the combined effect of malnourishment, deliberated immobilization and neglected decubitus ulcers. This case is uncommon as it presents the homicide of a young woman caused by a prolonged abusive behaviour associated with complete neglect of her aggravating health conditions and provoked injuries.

Verbal mistreatment of the elderly

Elder mistreatment is expected to rise with the aging of the American population. To date, the association between specific forms of mistreatment and decreased quality of life is poorly understood. The aim of the present study was to explore the association between verbal mistreatment among elderly individuals and depression and quality of life. A sample of 142 older adults (40% male) aged 65 or over was enrolled from a large medical practice and academic dental practice, mean (SD) age = 74.88 (6.98) years. Thirty-eight percent of the sample reported verbal mistreatment. Controlling for sociodemographic characteristics and depression, verbal mistreatment was a significant predictor of social functioning (r = -.28, p < .001), mental health (r = -.25, p < .001), and role limitations OR = 3.02, 95% CI [1.34-6.77]. The present findings highlight the prevalence of verbal mistreatment of elderly individuals.

Medical and laboratory indicators of elder abuse and neglect

Elder abuse and neglect are highly prevalent but woefully underdetected and underreported. The presentation is rarely clear and requires the piecing together of clues that create a mosaic of the full picture. More research needed to better characterize findings that, when identified, can contribute to certainty in cases of suspected abuse. Medical and laboratory data can be helpful in the successful determination of abuse and neglect.

Understanding the medical markers of elder abuse and neglect: physical examination findings

A specific foundation of knowledge is important for evaluating potential abuse from physical findings in the older adult. The standard physical examination is a foundation for detecting many types of abuse. An understanding of traumatic injuries, including patterns of injury, is important for health care providers, and inclusion of elder abuse in the differential diagnosis of patient care is essential. One must possess the skills needed to piece the history, including functional capabilities, and physical findings together. Armed with this skill set, health care providers will develop the confidence needed to identify and intervene in cases of elder abuse.

Investigation of Deaths of Chronically Disabled Persons and Institutionalized Persons

The investigation of deaths involving chronically disabled and/or institutionalized persons represents an important challenge to the medicolegal death investigation community. For the purposes of this review, the chronically disabled and/or institutionalized are considered to include three non-mutually exclusive subcategories: the disabled elderly, the severely disabled, and psychiatric patients. Because deaths within certain of these populations tend to be common and expected, a very important goal when such deaths occur is the appropriate referral of cases to the medical examiner/coroner. Although each subcategory has distinct issues of importance regarding death investigation, there is also a reasonable amount of overlap between the three groups. This review provides an overview of the three subcategories, the reasons such persons may be at risk for premature, unexpected, or unnatural death, the many important issues of concern when investigating deaths within these vulnerable populations, and important preventative strategies within each group.

Investigation of Elder Deaths

The maltreatment of elders aged 60 years and older is a worldwide problem with an increasing frequency. Individuals are living longer, resulting in a larger elder segment of populations. Furthermore, as medicolegal investigative and epidemiologic research progresses, more cases are recognized and reported. Elders are a vulnerable population not only because of advanced age and acquired diseases and frailty, but also because of a lack of education in the realm of overall elder healthcare and pathophysiology. Therefore, when investigating an elder death, the challenge is even greater as the medicolegal death investigator and forensic pathologist/medical examiner attempt to separate normal or expected findings from maltreatment. A methodical approach starting with the initial death and scene investigation, followed by a complete elder autopsy and concluding with an organized elder death review, will allow proper classification of cause and manner of death as well of prevention of future cases of elder maltreatment.

Physical mistreatment in persons with Alzheimer's disease

Physical mistreatment has been estimated to affect 2 million older persons each year and dramatically affects health outcomes. While researchers have attempted to examine risk factors for specific forms of abuse, many have been able to focus on only victim or perpetrator characteristics, or a limited number of psychosocial variables at any one time. Additionally, data on risk factors for subgroups such as persons with Alzheimer's disease who may have heightened and/or unique risk profiles has also been limited. This paper examines risk for physical violence in caregiver/patient dyads who participated in the Aggression and Violence in Community-Based Alzheimer's Families Grant. Data were collected via in-person interview and mailed survey and included demographics as well as measures of violence, physical and emotional health, and health behaviors. Logistic regression analysis indicated that caregivers providing care to elders with high levels of functional impairment or dementia symptoms, or who had alcohol problems, were more likely to use violence as a conflict resolution strategy, as were caregivers who were providing care to elders who used violence against them. By contrast, caregivers with high self-esteem were less likely to use violence as a conflict resolution strategy. Significant interaction effects were also noted.

The Underweight Elder: Maltreatment, Self-Neglect, or Normal Aging?

An elder is an individual 65 years of age and older. In general, increased age is associated with numerous physical and cognitive changes. When an elder is underweight, the underlying cause can be due to a natural change of aging, an underlying disorder, secondary to medical treatment, elder neglect, or self-neglect. In order to accurately classify the cause of the weight loss, forensic pathologists and investigators must examine all aspects of the elder: the pathophysiology of aging, the autopsy and physical findings, past and recent medical history, and the scene and social environment.

Elder abuse: dermatologic clues and critical solutions

Elder abuse affects approximately 2% to 10% of older Americans. Unfortunately, it is often unrecognized and certainly underreported. Dermatologists have a unique role in the detection and reporting of elder abuse. An analysis of risk factors, clinical signs, reporting requirements, and prevention of elder abuse brings this issue into focus.

Elder abuse

Five types of elder abuse (physical, psychological, sexual, neglect and financial) are recognized. They are not new, occur worldwide and are associated with persistent morbidity and mortality. The forensic clinician has responsibilities to: (i) the patient, with competent history taking and examination, (ii) interpret findings and recognize patterns of harm and (iii) promulgate this issue in wider professional and public forums. Research into elder abuse is relatively recent; standardized terminology remains unsettled, and small-scale, local studies are hard to generalize. Cross-sectional, population-based studies of elder abuse should be possible, and standardized endpoints will require forensic science contributions.

Fatal Staphylococcus aureus bacteremia in the Felty syndrome: a maltreatment-suspected case

Familial neglect was suspected when an older deceased female was found to have large decubitus ulcers and weight loss. Postmortem examinations including histopathology and bacterial culture revealed systemic Staphylococcus aureus infection as the cause of death. The victim might have exhibited Felty syndrome, which is characterized by complications of splenomegaly and neutropenia in the underlying rheumatoid arthritis. As a result of neutropenia, the affected individual was susceptible to skin ulcer formation and sepsis. The manifestation of pressure ulcers as abuse biomarkers should also be explored from interaction with intrinsic disease factors.

Predictors of health decline in older adults with pneumonia: findings from the Community Acquired Pneumonia Impact Study

BACKGROUND

The purpose of this study was to identify predictors of health decline among older adults with clinically diagnosed community acquired pneumonia (CAP). It was hypothesized that older adults with CAP who had lower levels of social support would be more likely to report a decline in health.

METHODS

A telephone survey was used to collect detailed information from older adults about their experiences with CAP. A broader determinants of health framework was used to guide data collection. This was a community wide study with participants being recruited from all radiology clinics in one Ontario community.

RESULTS

The most important predictors of a health decline included: two symptoms (no energy; diaphoresis), two lifestyle variables (being very active; allowing people to smoke in their home), one quality of life variable (little difficulty in doing usual daily activities) and one social support variable (having siblings).

CONCLUSIONS

A multiplicity of factors was found to be associated with a decline in health among older adults with clinically diagnosed CAP. These findings may be useful to physicians, family caregivers and others for screening older adults and providing interventions to help ensure positive health outcomes.