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

Mechanisms and weapons in physical elder abuse injuries: Findings from legally adjudicated cases

INTRODUCTION

Elder abuse is common, but many characteristics have not been well-described, including injury mechanisms and weapons in physical abuse. Better understanding of these may improve identification of elder abuse among purportedly unintentional injuries. Our goal was to describe mechanisms of injury and weapons used and their relation to injury patterns.

METHODS

We partnered with District Attorney's offices in 3 counties and systematically examined medical, police, and legal records from 164 successfully prosecuted physical abuse cases of victims aged ≥60 from 2001 to 2014.

RESULTS

Victims sustained 680 injuries (mean 4.1, median 2.0, range 1-35). Most common mechanisms were: blunt assault with hand/fist (44.5%), push/shove, fall during altercation (27.4%), and blunt assault with object (15.2%). Perpetrators more commonly used body parts as weapons (72.6%) than objects (23.8%). Most commonly used body parts were: open hands (55.5% of victims sustaining injuries from body parts), closed fists (53.8%), and feet (16.0%). Most commonly used objects were: knives (35.9% of victims sustaining injuries from objects) and telephones (10.3%). The most frequent mechanism/injury location pair was maxillofacial/dental/neck injury by blunt assault with hand/fist (20.0% of all injuries). The most frequent mechanism/injury type pair was bruising by blunt assault with hand/fist (15.1% of all injuries). Blunt assault with hand/fist injury was positively associated with victim female sex (OR: 2.27, CI: [1.08 - 4.95]; p = 0.031), while blunt assault with object mechanisms was inversely associated with victim female sex (OR: 0.32, CI: [0.12 - 0.81]; p = 0.017).

CONCLUSION

Physical elder abuse victims are more commonly assaulted with an abuser's body part than an object, and the mechanisms and weapons used impact patterns of injury.

Types, characteristics and anatomic location of physical signs in elder abuse: a systematic review : Awareness and recognition of injury patterns

Aim

Identify types, characteristics and anatomic location of physical signs in elder abuse.

Findings

Physical signs in elder abuse are most common bruises and anatomically predominantly located on the head, face/maxillofacial area, neck, upper extremities and torso.

Message

Increase knowledge on physical signs in elder abuse so as to enhance timely detection and intervention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00550-z.

Purpose

Elder abuse is a worldwide problem with serious consequences for individuals and society. The recognition of elder abuse is complex due to a lack of awareness and knowledge. In this systematic review, types, characteristics and anatomic location of physical signs in elder abuse were identified.

Methods

Databases of MEDLINE, COCHRANE, EMBASE and CINAHL were searched. The publication dates ranged from March 2005 to July 2020. In addition to the electronic searches, the reference lists and citing of included articles were hand-searched to identify additional relevant studies. The quality of descriptive and mixed-methods studies was assessed.

Results

The most commonly described physical signs in elder abuse were bruises. The characteristics of physical signs can be categorized into size, shape and distribution. Physical signs were anatomically predominantly located on the head, face/maxillofacial area (including eyes, ears and dental area), neck, upper extremities and torso (especially posterior). Physical signs related to sexual elder abuse were mostly located in the genital and perianal area and often accompanied by a significant amount of injury to non-genital parts of the body, especially the area of the head, arms and medial aspect of the thigh.

Conclusions

Most common types, characteristics and anatomic location of physical signs in elder abuse were identified. To enhance (early) detection of physical signs in elder abuse, it is necessary to invest in (more) in-depth education and to include expertise from a forensic physician or forensic nurse in multidisciplinary team consultations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-021-00550-z.

Improving forensics: Characterizing injuries among community-dwelling physically abused older adults

BACKGROUND

Physical elder abuse affects a substantial number of older adults, leaving victims at increased risk for negative health outcomes. Improved detection of abuse-related injuries may increase victim access to professional support, but providers report difficulties distinguishing between accidental and abuse-related injuries, due in part to victims' pre-existing health conditions and medication use.

OBJECTIVES

To describe the spectrum and characteristics of injuries among physically abused older adults and identify injury characteristics associated with abuse.

DESIGN

Case-control study.

SETTING

Physically abused adult protective services clients were interviewed in their home; non-abused comparison group participants were interviewed in an outpatient geriatrics clinic.

PARTICIPANTS

Sample included 156 community-dwelling adults aged 65 and older, including 57 physically abused and 99 non-abused individuals. Self-reported abuse history was confirmed through independent case assessment by a LEAD (Longitudinal, Expert All-Data) panel of clinicians with family violence expertise.

MEASUREMENTS

Full-body assessments were conducted, documenting injury incidence, diagnosis, and location. We also collected sociodemographic characteristics, level of social support, functional ability, medical history, and medication use.

RESULTS

Physically abused older adults were more likely to be injured upon assessment (79.0% vs 63.6%; p < 0.05) and have a greater number of injuries ( x ¯ = 2.9 vs x ¯ = 2.0 , p < 0.05). Injuries seen more often among abused individuals included: upper extremity ecchymoses (42.1% vs 26.3%; p < 0.05), abrasions (31.6% vs 11.1%; p < 0.01), and areas of tenderness (8.8% vs 0.0%; p < 0.01); and head/neck/maxillofacial ecchymoses (15.8% vs 2.0%; p < 0.01) and tenderness (15.8% vs 0.0%; p < 0.001). Lower extremity abrasions (12.3%) were common but unrelated to abuse status.

CONCLUSION

While physical abuse does not always result in physical injury, victims more commonly display head/neck/maxillofacial ecchymoses or tenderness and upper extremity abrasions, ecchymoses, or tenderness. Detection of these injuries among older adults warrants further interview and examination.

Can diagnostic imaging help improve elder abuse detection?

Elder abuse is an underdetected, under-reported issue with severe consequences. Its detection presents unique challenges based on characteristics of this vulnerable population, including cognitive impairment, age-related deconditioning, and an increased number of co-morbidities, all of which predispose to increase vulnerability to injury. While radiologists play a critical role in detection of child abuse, this role is currently not paralleled in detection of elder abuse. We conducted a thorough review of the literature using MEDLINE to describe the current knowledge on injury patterns and injury findings seen in elder abuse, as well as barriers to and recommendations for an increased role of diagnostic imaging in elder abuse detection. Barriers limiting the role of radiologists include lack of training and paucity of rigorous systematic research delineating distinctive imaging findings for physical elder abuse. We outline the current ways in which imaging can help raise clinical suspicion for elder abuse, including inconsistencies between purported mechanism of injury and imaging findings, injury location, multiple injuries at differing stages of healing, and particular patterns of injury likely to be intentionally inflicted. We additionally outline the mechanism by which medical education and clinical workflow may be modified to increase the role for imaging and radiologist participation in detecting abuse in older adult patients, and identify potential future directions for further systematic research.

Developing the Geriatric Injury Documentation Tool (Geri-IDT) to Improve Documentation of Physical Findings in Injured Older Adults

BACKGROUND

Standardization in tools and documentation of child abuse and intimate partner violence have proven helpful in completely documenting injuries and suspected abuse among these populations. Similar tools do not yet exist for older adults and elder abuse.

OBJECTIVE

To (1) use insights from experts to develop a tool to assist clinicians in appropriately and completely documenting physical findings in injured older adults for potential future forensic investigation of abuse or neglect and (2) to assess the feasibility of incorporating this tool into clinical practice.

DESIGN

Two-phase, exploratory qualitative study. Phase 1: individual interviews with elder abuse experts from various specialties in medicine and criminal justice. Phase 2: focus groups with anticipated end users of the tool.

PARTICIPANTS

Phase 1 telephone-based key informant interviews were conducted with 11 elder abuse experts (2 detectives, 3 prosecutors, 1 forensic pathologist, 2 geriatricians, and 3 emergency medicine physicians). Phase 2 focus groups were conducted among emergency medicine (n = 10) and primary care (n = 8) providers.

APPROACH

Key informant interviews were conducted telephonically while the two focus groups were held in-person at an emergency medicine site in New York, NY, and a primary care site in Los Angeles, CA.

KEY RESULTS

Experts agreed that medical providers' documentation of geriatric injuries is usually inadequate for investigating alleged elder abuse/neglect. They highlighted elements needed for forensic investigation: initial appearance before treatment is initiated, complete head-to-toe evaluation, documentation of all injuries (even minor ones), and documentation of pertinent negatives. Several noted the value of photographs to supplement written documentation. End users identified practical challenges to utilizing a tool, including the burden of additional or parallel documentation in a busy clinical setting, and how to integrate it into existing electronic medical records.

CONCLUSION

A practical tool to improve medical documentation of geriatric injuries for potential forensic use would be valuable. Practical challenges to utilization must be overcome.