Elder Abuse Workshop: Elder Abuse Forensics - Reports from Current or Recently Completed Research Projects

Panel Presentations:

Laura Mosqueda — Bruising as a Forensic Marker of Elder Abuse

Goal: Working in partnership with APS, document the bruises of elders who have been physically abused.

Study Design: Study population to include 100 adults, ages 65 and older, alleging physical abuse within six weeks. Cognitive impairment is allowed when a caregiver/surrogate is available. One-time home visit assessment, including documentation of all physical markers of abuse, will be conducted. Data will be subject to LEAD Panel assessment to determine the presence (or absence) and severity of abuse.

Observations: An earlier study described bruises associated with abuse and those that were not. Findings showed that 90 percent of accidental bruises were on the extremities, none on neck, ears or genitals. Only 20 percent of persons with accidental bruises knew how they got them. It is important to make a distinction between accidental and inflicted bruising to ensure that caregivers are not unfairly accused of abuse, to get guidelines for suspicious bruising to improve reporting, and to give health care providers parameters for evaluating bruising in the elderly.

Conclusions: None yet. Preliminary data on 59 participants shows:

  • Bruises with accidental or unknown causes were more likely to be on the extremities, while inflicted bruises were more likely to be on the head and/or trunk.
  • The size of an inflicted bruise was greater than an accidental bruise, which could indicate that a larger bruise on head or trunk has clinical relevance.

Solomon Liao — A Multisite Study to Characterize Pressure Ulcers in Long-Term Care Under Best Practices

Goal: To determine whether pressure ulcers can occur with good care, characterize full-thickness pressure ulcers in terms of who will get them, and establish best care practices.

Study Design:

  • Select top-performing skilled nursing facilities (SNFs) with no citations for pressure ulcers for the past 12 months and conduct an on-site facility evaluation to confirm the quality of the institution.
  • Conduct a one-time assessment of pressure ulcers on residents, including measurements of ulcer characteristics, digital photos and medical record review.
  • Present all information except current wound characteristics to LEAD Panel, which will determine quality of care.

Observations: Challenges have included: 1) IRB (institutional review board) issues regarding a) protecting the facility and staff and b) mandatory reporting, and 2) difficulty in recruiting facilities because of low prevalence of ulcers and facility concern about oversight and discovery with a study funded by the DOJ.

Conclusions: None yet.

Erik Lindbloom — Mandatory Reporting of Nursing Home Deaths: Markers for Mistreatment, Effect on Care, Quality and Generalizability

Goals:

  • Further elucidate markers for elder mistreatment.
  • Identify whether or not the reporting law (all nursing home deaths must be reported in Pulaski County, Arkansas) has had an effect on the quality of nursing home care in Pulaski County.
  • Explore possible generalizability to other counties.

Study Design:

  • Review death investigation records for the 3,175 reported deaths, including discussions with family members in 18.8 percent of cases (596).
  • Note presence of pressure sores.
  • Document factors associated with cases referred for further investigation, which includes dissatisfied family members, presence of pressure ulcers and race.
  • Review MDS linkage data for predictors of referral to the attorney general.
  • Review autopsy case series, n=20.
  • Survey Arkansas coroners.

Observations: A previous project explored the details of death investigations suspicious for mistreatment. Since 1999, in Pulaski County, more than 3,000 nursing home deaths have been investigated and more than 100 cases referred to the Arkansas Attorney General's office on suspicion of abuse or neglect.

Conclusions:

  • Some factors were elucidated that were associated with a higher suspicion of mistreatment among investigators.
  • Discrepancies were found in autopsies, underscoring the importance of autopsies in death investigations.
  • No evidence was found for care improvement as a result of the reporting law, but the study was limited by the use of retrospective and self-reported data (MDS).
  • The coroner survey outlined formidable barriers to generalizing such investigations to other locations.

Laura Mosqueda — People with Dementia as Witnesses to Emotional Events

Goals: To determine whether there is a subset of persons with dementia who are reliable witnesses to emotional events and, if so, to determine what are the measurable characteristics.

Study Design:

  • Start-up (in progress) — Meet with industry experts to refine study design and instrumentation.
  • Phase 2: Recruit 100 dementia dyads (i.e., people with dementia and a reliable informant) and controls for a one-time home visit during which separate interviews will be conducted with each member of the dyad to assess variables such as confabulation, mental status, disease stage, awareness and attention. Outcomes assessment will be audio recorded, and reliable emotional memory will be assessed based on unanimous inter-rater agreement.
  • Phase 2: Recruit 10 participants from the population to represent the two polar groups: five older adults with reliable emotional memory and five without. These participants will undergo an MRI (magnetic resonance imaging) protocol to assess amygdalar volume and undergo salivary cortisol assays to test the hypotheses that an ADRD (Alzheimer's disease or a related dementia) patient with reliable emotional memory will have significantly greater amygdalar volume and normal patterns of daytime salivary cortisol levels.

Observations: Clinical experience shows that people with dementia can recall emotional events. A previous study showed that 47.3 percent of the demented older adults in the study had experienced one or more types of abuse. Judges know very little about cognitive changes in older adults, and there is little understanding of dementia.

Conclusions: None yet.

Nancy Knight — Whole-Body CT Imaging in Post-Mortem Detection of Elder Abuse and Neglect

Goals:

  • Phase 1: To determine whether a noninvasive protocol (examination by a forensic pathologist for evidence of external injuries and whole-body CT [computed tomography] scan evaluated by a radiologist for internal injuries) is a sensitive/accurate method for detection or exclusion of abuse and/or neglect in elder individuals.
  • Phase 2: To determine whether the optimized version of the CT protocol will obviate the need for complete autopsy in some percentage of suspected elder abuse cases.
  • Phase 3: To determine to what extent the CT will provide a time- and cost-efficient model for rapid investigation of suspected elder abuse and neglect.
  • To prepare a database of freely available images and descriptive technical reports that will facilitate replication of this scanning protocol.

Study Design:

  • Phase 1: N=30 decedents ages 65+ in whom residential care abuse/neglect is suspected. Compare sensitivity, specificity and accuracy of whole-body CT for indications of abuse/neglect with autopsy findings by CME (chief medical examiner).
  • Phase 2: N=50 decedents ages 65+ in whom residential care abuse/neglect is suspected. Assess relative duration and cost of noninvasive imaging protocol and autopsy, and number of autopsies avoided or facilitated by imaging.
  • Phase 3: Assess/report: 1) sensitivity, specificity and accuracy of CT, 2) quantitative and subjective results on effect of addition of this protocol to OCME's (Office of the Chief Medical Examiner) routine processing of elder deaths, 3) additional analysis of specific demographics (e.g., sex, type and location of injury), and 4) limitations and challenges of this forensic imaging approach.

Observations: Recent studies suggest a major role for high-resolution 3-dimensional CT and MRI in the forensic investigation of death. However, autopsy by CT imaging has some limitations, including the inability to evaluate all pathologies, unfamiliarity of many forensic pathologists with CT and MRI, lack of widespread access to scanners and no data demonstrating the potential for cost-effectiveness. An additional consideration is the minimally invasive ultrasound-guided autopsy (MIUGA), which offers service where consent for a full autopsy is refused and is an option for autopsy where hazardous infectious agents are suspected.

Conclusions: None yet from this study. Early experience with other studies suggests that autopsy by CT imaging showed promise as a sensitive tool for detection of major injuries and cause of death after accidental blunt trauma and drowning. In non-accidental traumatic death, CT can be a valuable adjunct to mandatory autopsy and may shorten autopsy time.

Discussant, Judy Salerno

Dr. Salerno stated that she was not commenting as a researcher in making this summary. Each presentation reminded her of a clinical case that was confounding. She recalled taking her own crying child to the hospital as a young mother and being grateful for the very thorough examination that found encephalitis from a pertussis vaccination. It showed her the importance of doing proper fact-finding to protect people.

It has been said that there is hard science and then there is really hard science. In this field it is necessary to think innovatively and creatively to get data. Bruising and pressure ulcers are clues to mistreatment but are not hard evidence. While it is clearly important to try to link presentation and clinical signs to elder mistreatment, as clinicians we must think about risk factors and prospectively identify patients at risk for mistreatment. For clinicians, the question is when to act and report — a decision that is not easy with sick patients. The picture becomes even more complicated with patients with dementia, particularly because there are different types and degrees of dementia. Some types involve memory loss, others cognitive impairment — and sometimes there is cognitive impairment without dementia. There are great stresses to caregiving and things become invisible because they happen behind closed doors. There has been little science in this area, but we must look at risk factors and think in terms of how the patient presents.

We are looking at the interface of health and a social system of care and are not doing a good job of straddling the divide. We need a more interdisciplinary approach. Today we are trying to understand how widespread elder mistreatment is, but we can be hopeful because the unknown is not unknowable. Clinical protocols may allow us to identify things that make us suspect elder mistreatment — and pressure ulcers may not be such an indicator.

The big issue is dependency, because people depend on family members to care for them. Perhaps we need to engage caregivers more in the dialogue — they will tell us. As a teacher, I also think about trainees. We have not taught our young health trainees to ask the right questions, sometimes even the most rudimentary ones.

We need a broader use of home evaluation. The home care workers are the boots on the ground — they have built the trust with the family and with that can come increased information. These relationships need to be developed — they are not one-shot deals.

The data don't seem to support more reporting from nursing homes to the medical examiner, but we have a long way to go in evaluating these data. We should think more about unannounced visits in institutional care settings. We need to see things as they really are.

Discussion of Forensics Issues and Priorities in Future Research

Detective Cherie Hill thanked the panel from a law enforcement perspective, noting that studies such as theirs affect the way she and other law enforcement officials do their jobs.

Dr. Hawes asked Dr. Lindbloom whether he considered staffing in his study. Dr. Lindbloom replied that the study looked at facility and individual levels, but did not identify any links other than those presented in his talk. He noted that because of the large amount of data, the study used a P value of .0001. Dr. Mosqueda asked Dr. Knight whether her forensic pathologists had training in geriatrics. Dr. Knight stated that a gerontologist is working with her group to address pertinent areas that would require more study in that area. She agreed that many medical examiners do not have a geriatric focus. Dr. Mosqueda asked whether Dr. Knight's team considers elder abuse when the cause of death does not indicate clear evidence of elder abuse. Dr. Knight replied that her team does document old fractures and other traumas that could indicate prior abuse.

Dr. Hawes recounted two incidents in which medical examiners were aware of events that should have raised a red flag, but they declined to act: one in which two deaths occurred from smothering due to mattress placement near bed bars, and the other that involved seven deaths in six months from falls with no injury other than head trauma. Both were very unusual occurrences, but neither generated official reports. She expressed a deep concern about the lack of investigation of these incidents and asked that participants consider the constraints of confidentiality versus the responsibility to report such unusual and disturbing incidents. A participant noted that in the case of ongoing studies funded by the NIH (National Institutes of Health), investigators are required to report adverse events on a regular basis. Dr. Hawes responded that there are confidentiality constraints that prohibit reporting and argued that the balance between these constraints and the welfare of the elderly participants who are part of the research study must be considered.

Dr. Carrie Mulford brought up misuse of medications as a form of abuse and asked whether this is being captured in any studies.

  • Dr. Lindbloom said that his studies looked at medication and toxicity screens.
  • Dr. Maggie Baker reported on a pilot study that touched on medications.
  • A participant noted that more chemical restraints were used in the long-term care setting if the patient was difficult.
  • Dr. Verhoek-Offendahl raised a concern that in the elder community when a caregiver is not giving medications, this kind of medical neglect does not seem to get the same attention as with child mistreatment.

Dr. Salerno asked Dr. Branch about the difference between intended and unintended harm in the elder mistreatment setting. Dr. Branch replied that caregivers' intentional acts with unintended consequences, such as leaving an elderly person home alone for too long a time, should be included as elder abuse. The participants discussed the line between clinical abuse, negligence and malpractice, noting that although legal issues such as civil versus criminal prosecution and levels of proof and intentionality inform this discussion, some areas do overlap. The issue of distinguishing between nursing facility staff that is not properly trained and staff that simply makes a mistake was raised. Ms. Erica Smith suggested that it was critical to have definitions of malpractice and lack of training, but that it is hard to capture the nuances to arrive at a standardized definition. A participant suggested that this is where intent (e.g., “I knew that if I didn't do X, Y would happen”) must be used broadly to tease out actions that are unintentional mistakes. Other participants agreed that it can sometimes be difficult to determine when a person has crossed the line into criminal negligence. Ms. Connolly suggested that this is an area that requires data collection across disciplines.

The participants discussed the comment made in an earlier presentation that caregivers, when asked, will tell that they are abusing. Dr. Acierno pointed out that this generally refers to anonymous reporting and that domestic violence literature indicated that proxies would admit to abuse when reporting is anonymous. Dr. Alex Crosby noted that sexual violence perpetrators are the exception to this, as they do not report abuse, even anonymously. Dr. Mosqueda stated that she routinely asks family caregivers questions such as “Do you ever get to the point that you hit?”, and they do admit to this.

Ms. Kathleen Quinn asked whether, in the context of trying to define elder abuse, which is harm to the older person, the issue was being clouded by mixing in the accountability of the perpetrator regarding whether his or her actions were intentional or resulted in unintended consequences. A participant suggested that the reporting of the abuse remains the same, but the distinctions about the perpetrator affect the type of intervention that is required. Ms. Quinn stated that this assumes that the person receiving the report is trained and has the tools to make such judgments, which may not be true in all cases.

Dr. Georgia Anetzberger asked whether putting emphasis on the evident signs of abuse, such as pressure sores and bruising, causes people to ignore or miss the more subtle signs of abuse. Dr. Mosqueda stated that this question was a great cautionary note and that clinicians and others must resist the temptation to latch on only to the obvious signs. However, she added that if everyone would even just be aware of the obvious things, we would be way ahead of where we are right now because so much of the obvious is missed.

Detective Hill recounted a case in which a grandson injured his elderly grandmother's wrist by roughly taking the TV remote control from her. Both the grandmother and family members lied about the cause of her injury to protect the grandson. Ultimately, the nature of the injury made it clear her story was false, and the grandson confessed. Detective Hill noted that this case demonstrated the importance of looking at the whole picture. Dr. Branch contended that this was not a case of elder abuse because it was not done by the caregiver, but rather was an example of abuse of an elder. Dr. Acierno suggested that this is a good example of why one should measure an event and decide what it was afterward. Ms. Jane Raymond asked Dr. Branch for more clarification about how he defined elder abuse in the context of whether it was perpetrated by the caregiver, wondering whether he looked at it as incident specific. Dr. Branch replied that he was assuming in this case that the grandson was not in a caregiving relationship, and thus the grandson's actions constituted assault, which was a crime against the elderly, not elder abuse. Dr. Branch noted that the line is not always easy to draw, recounting that caseworkers have mentioned how difficult cases of psychological abuse can be to define where, for example, a couple may have gone for years with one partner being psychologically abusive, and then when the abused partner becomes frail, at what point does this become elder psychological abuse?

Dr. Kerry Burnight noted that over the past eight years, as knowledge in this field has been accumulating, it has come in more of a piecemeal fashion as if adding pieces of a puzzle, rather than in a more systematic, building block way. She stated that she did not consider this a problem because the body of knowledge was indeed expanding.

Dr. Solomon Liao suggested that a valuable area of future research would be end-of-life care, because the elderly are such a vulnerable population. He cited as an example of an area where there is no research is the issue of non-administration of pain medications, thus allowing an elderly dying person to suffer needlessly.

Ms. Connolly adjourned the meeting at 5:00 p.m.

Date Created: August 11, 2008