indicators of physical and sexual abuse judith race, csw coordinator of direct services elderly...

Indicators of Physical and Indicators of Physical and Sexual AbuseSexual Abuse

Judith Race, CSWJudith Race, CSWCoordinator of Direct ServicesCoordinator of Direct Services

Elderly Crime Victims Resource CenterElderly Crime Victims Resource CenterNYC Department for the AgingNYC Department for the Aging

Adolfo Firpo, MD, MPAAdolfo Firpo, MD, MPADirector, Elder Mistreatment Training ProjectDirector, Elder Mistreatment Training ProjectNYU Steinhardt School of Education, Division NYU Steinhardt School of Education, Division

of Nursingof Nursing

NYC Elder Abuse Training Project

What is elder abuse?What is elder abuse?

Intentional behavior that results Intentional behavior that results in the physical, sexual, in the physical, sexual, emotional or financial harm or emotional or financial harm or injury or neglect or injury or neglect or abandonment of an older person abandonment of an older person (60+) by a family member, (60+) by a family member, friend, fiduciary or caregiverfriend, fiduciary or caregiver


Types of Elder AbuseTypes of Elder Abuse

Emotional/PsychologicalEmotional/Psychological PhysicalPhysical SexualSexual FinancialFinancial NeglectNeglect

Active or intentionalActive or intentional Inactive or unintentionalInactive or unintentional


Physical Abuse of the ElderlyPhysical Abuse of the Elderly

Use of physical force that may result Use of physical force that may result inin Bodily injuryBodily injury Physical painPhysical pain ImpairmentImpairment DiseaseDisease


Results of Physical AbuseResults of Physical Abuse

WoundsWounds BruisingBruising BurnsBurns Syndromes: medicinal misuse; Syndromes: medicinal misuse;

shakingshaking FracturesFractures Decubitis ulcers (bedsores)Decubitis ulcers (bedsores) MalnutritionMalnutrition DehydrationDehydration


Difficulties in Detecting Difficulties in Detecting AbuseAbuse

Hard to distinguish betweenHard to distinguish between A disease process A disease process An injuryAn injury

Often assumed that death was the Often assumed that death was the result of old ageresult of old age Physical inspection not always donePhysical inspection not always done

Deaths are often not evaluated in detailDeaths are often not evaluated in detail Autopsies rarely performed (ageism)Autopsies rarely performed (ageism)


Forensic Markers of Forensic Markers of Physical AbusePhysical Abuse

Injuries Injuries Not properly cared forNot properly cared for Delay in seeking medical treatmentDelay in seeking medical treatment

FracturesFractures Unset broken bonesUnset broken bones

Note: some injuries and fractures may be the Note: some injuries and fractures may be the result of a medical condition (e.g., result of a medical condition (e.g., osteoporosis) and/or medication (e.g., osteoporosis) and/or medication (e.g., Coumadin)Coumadin)


Medical Causes of FracturesMedical Causes of Fractures

Age Age Osteoporosis and other bone diseasesOsteoporosis and other bone diseases

Poor nutritionPoor nutrition Vitamin D deficiencyVitamin D deficiency AlcoholismAlcoholism Age-related sex hormone deficienciesAge-related sex hormone deficiencies Cancer that invades bone Cancer that invades bone

(e.g., osteosarcoma)(e.g., osteosarcoma)


Sites of Fractures in the Sites of Fractures in the ElderlyElderly

Hip in Hip in >>75 years old75 years old Wrist in Wrist in <<75 years old75 years old

Common site of fracture with fallsCommon site of fracture with falls Many use their hands to help break a fallMany use their hands to help break a fall

Head (face, teeth, cheekbones)Head (face, teeth, cheekbones) TrunkTrunk SpineSpine


FallsFalls

Added difficulty in detecting abuseAdded difficulty in detecting abuse Broken bones can be the result of a fallBroken bones can be the result of a fall

Prevalence of fallsPrevalence of falls 30% of community-dwelling older persons 30% of community-dwelling older persons 50% of nursing home patients 50% of nursing home patients Most persons who fall experience one to three Most persons who fall experience one to three

falls a yearfalls a year Note: Detailed examination of the patient, Note: Detailed examination of the patient,

medical records, and/or collateral history medical records, and/or collateral history from caregivers is needed to determine abusefrom caregivers is needed to determine abuse


Facial FracturesFacial Fractures

TeethTeeth Fracture or partial dislocationFracture or partial dislocation

Bony structures around the eyes Bony structures around the eyes

(zygomatic arch)(zygomatic arch) Jaws (mandible and maxilla)Jaws (mandible and maxilla) Facial fractures should raise Facial fractures should raise

suspicions of abusesuspicions of abuse


BruisingBruising

In the older adultIn the older adult Occurs more frequentlyOccurs more frequently Resolves more slowly (may last for months)Resolves more slowly (may last for months) Progression is normalProgression is normal

Recent bruising (reddish blue, blue, purple)Recent bruising (reddish blue, blue, purple) Older bruising (bluish green, greenish yellow, Older bruising (bluish green, greenish yellow,

and brown)and brown)

Multiple bruises in different stages of Multiple bruises in different stages of healing may indicate abusehealing may indicate abuse


Bruises Healing StagesBruises Healing Stages

10 hrs 4-5 days 12 days


Sites of BruisingSites of Bruising

In abuse victims, most often seen In abuse victims, most often seen onon Knuckles and fingersKnuckles and fingers Face and neckFace and neck Chest wallChest wall AbdomenAbdomen ButtocksButtocks Palms and soles of feetPalms and soles of feet


Bruising Distribution and Bruising Distribution and PatternsPatterns

Face & Neck Medial Surfaces


Patterns of BruisingPatterns of Bruising

Pattern of bruising may suggest the Pattern of bruising may suggest the cause cause Bilateral Bilateral Parallel marks (tramline bruising)Parallel marks (tramline bruising) Inside of arms and thighsInside of arms and thighs ClustersClusters


Bruising Patterns Bruising Patterns

BilateralBilateral Different colors Different colors

ranging from ranging from purple (recent) to purple (recent) to yellow green yellow green (older)(older)

Shape and PatternShape and Pattern Facial distributionFacial distribution


Morphological SignsMorphological Signs

Bruises or burns shaped like an Bruises or burns shaped like an objectobject IronIron Curling ironCurling iron Belt marksBelt marks FingersFingers Cigarette burnsCigarette burns Rope burns (e.g., resulting from Rope burns (e.g., resulting from

restraints)restraints)


Prevalence of BurnsPrevalence of Burns

In healthy adults: rareIn healthy adults: rare In the frail elderly: rare in In the frail elderly: rare in

institutional settingsinstitutional settings 70% of all burns are the result of 70% of all burns are the result of

abuse/neglectabuse/neglect


Violent ShakingViolent Shaking

Similar to shaken baby syndromeSimilar to shaken baby syndrome

Possible results in the elderly:Possible results in the elderly: WhiplashWhiplash Detached retinasDetached retinas Contusions Contusions Brain atrophyBrain atrophy Brain hemorrhagesBrain hemorrhages


Other markersOther markers

Ruptured eardrumsRuptured eardrums Boxing the victim’s earsBoxing the victim’s ears

Changes in hairstyleChanges in hairstyle Cover up for Cover up for

Hair that may have been ripped outHair that may have been ripped out BruisesBruises


Decubitis Ulcers (bedsoresDecubitis Ulcers (bedsores))

The result of circulatory failure due to The result of circulatory failure due to pressure resulting in dead tissue (necrosis)pressure resulting in dead tissue (necrosis)

May indicate that a bed-ridden patient is not May indicate that a bed-ridden patient is not being properly cared for and/or moved by the being properly cared for and/or moved by the caregiver caregiver

Note: can also result from insufficient Note: can also result from insufficient circulation due to medical conditions (e.g. circulation due to medical conditions (e.g. diabetes)diabetes)

Suspect neglect if:Suspect neglect if: Deep decubiti, multiple sitesDeep decubiti, multiple sites Foul smelling dead tissueFoul smelling dead tissue


Decubitus UlcersDecubitus Ulcers

Bed sore Bed sore ImmobilityImmobility Skin over bony surfacesSkin over bony surfaces Vasculature compressionVasculature compression Vascular insufficiencyVascular insufficiency Tissue necrosisTissue necrosis InflammationInflammation InfectionInfection SepsisSepsis ShockShock


Prevalence of Decubitis Prevalence of Decubitis UlcersUlcers

In healthy adults: neverIn healthy adults: never In the frail elderly, risk factors include:In the frail elderly, risk factors include:

Medical illnessMedical illness Cognitive impairmentCognitive impairment IncontinenceIncontinence Poor nutritionPoor nutrition

In abuse victimsIn abuse victims More frequent illnesses means victims More frequent illnesses means victims

dependent on others for proper skin caredependent on others for proper skin care Neglect more likelyNeglect more likely


Skin Ulcers in Diabetic with Severe Vascular Insufficiency

General Condition•Edges•Centers•Smell•Surrounding Skin


MalnutritionMalnutrition

Poor health status due to the Poor health status due to the decreased intake of necessary decreased intake of necessary nutrientsnutrients Poor dietPoor diet MalabsorptionMalabsorption


Medical Causes of Medical Causes of MalnutritionMalnutrition

Natural aging factorsNatural aging factors Decline of smell and taste reducing Decline of smell and taste reducing

appetiteappetite Inappropriate medications, including Inappropriate medications, including

psychotropic drugspsychotropic drugs Medical conditionsMedical conditions

(cancer, COPD, dementia, stroke, (cancer, COPD, dementia, stroke, Parkinson’s Disease, disorders of the Parkinson’s Disease, disorders of the esophagus)esophagus)


Other Causes of MalnutritionOther Causes of Malnutrition

Neglect (poor caregiving)Neglect (poor caregiving) Self-neglectSelf-neglect Poor dentitionPoor dentition Poor oral hygienePoor oral hygiene

Loss of teethLoss of teeth DepressionDepression Loss of appetiteLoss of appetite


Causes of Appetite Loss Causes of Appetite Loss in the Elderlyin the Elderly

In the frail elderly:In the frail elderly: DepressionDepression Change in environmentChange in environment Change in medical conditionChange in medical condition Medication (over/under)Medication (over/under)

In the abuse victimIn the abuse victim Inappropriate or excessive medications Inappropriate or excessive medications

can affect swallowing and/or memorycan affect swallowing and/or memory Ignoring of cultural food preferencesIgnoring of cultural food preferences Force feeding or other appropriate feedingForce feeding or other appropriate feeding


DehydrationDehydration

Loss of more fluids than are taken inLoss of more fluids than are taken in Elderly more proneElderly more prone Often caused by medical illnessOften caused by medical illness Neglect present if:Neglect present if:

Inadequate fluids are offered or providedInadequate fluids are offered or provided Dehydration goes unrecognized for a long Dehydration goes unrecognized for a long

period of time by medical or nursing period of time by medical or nursing personnelpersonnel


Symptoms of DehydrationSymptoms of Dehydration

DizzinessDizziness

Dry mouth and noseDry mouth and nose

Decreased urine productionDecreased urine production


Possible Causes of DehydrationPossible Causes of Dehydration

Gastrointestinal illness (e.g., stomach flu)Gastrointestinal illness (e.g., stomach flu) Food poisoningFood poisoning Alcohol overloadAlcohol overload DietingDieting Ignoring of thirstIgnoring of thirst Diabetes Diabetes Neglect or withholding of fluidsNeglect or withholding of fluids Too much caffeineToo much caffeine


Misuses of MedicationsMisuses of Medications

Elders may misuse prescription Elders may misuse prescription drugs becausedrugs because They lack capacity They lack capacity They reject efforts by medical They reject efforts by medical

professionals professionals

to help themto help them


Misuses of MedicationMisuses of Medication

Medications can be used as a tool Medications can be used as a tool for abusefor abuse

ExamplesExamples Giving a person too much or too little of Giving a person too much or too little of

an indicated drugan indicated drug Withholding a necessary medication Withholding a necessary medication Administration of unnecessary or Administration of unnecessary or

inappropriate medicationinappropriate medication


Misuses of MedicationsMisuses of Medications

Over-medicationOver-medication To keep patients quiet and manageableTo keep patients quiet and manageable

Under-medication or withholding of Under-medication or withholding of medicationmedication Caregiver may use the drug him/herselfCaregiver may use the drug him/herself

Unnecessary or inappropriate Unnecessary or inappropriate medicationmedication

Over/under-medication can result in Over/under-medication can result in medical or cognitive impairmentmedical or cognitive impairment


Sexual Abuse of the ElderlySexual Abuse of the Elderly

Non-consensual sexual contact of Non-consensual sexual contact of any kindany kind

Sexual contact with any person Sexual contact with any person incapable of giving consentincapable of giving consent

Elderly are more vulnerable due to Elderly are more vulnerable due to Cognitive impairmentCognitive impairment Physical inability to protect oneselfPhysical inability to protect oneself


Sexual AbuseSexual Abuse

Includes but is not limited toIncludes but is not limited to Unwanted touchingUnwanted touching All types of sexual assault or battery such asAll types of sexual assault or battery such as

RapeRape SodomySodomy Coerced nudityCoerced nudity Sexually explicit photographySexually explicit photography

Difficult to detect in the elderlyDifficult to detect in the elderly Difficult for victim to discussDifficult for victim to discuss Older adults are vulnerable to sexual Older adults are vulnerable to sexual

abuseabuse


Physical Forensic Markers Physical Forensic Markers of Sexual Abuseof Sexual Abuse

Torn, stained, bloody underclothingTorn, stained, bloody underclothing Difficulty in walking, standing and/or Difficulty in walking, standing and/or

sittingsitting Changes in bowel movement or Changes in bowel movement or

bladder activitybladder activity Pain, itching, bruising, burning in Pain, itching, bruising, burning in

genital areagenital area Unexplained venereal diseaseUnexplained venereal disease


Physical Forensic Markers Physical Forensic Markers of Sexual Abuseof Sexual Abuse

BruisingBruising Palate (hard plate at roof of mouth)Palate (hard plate at roof of mouth) Uvula (appendage to palate) Uvula (appendage to palate) Genital area (75% of those who have Genital area (75% of those who have

been sexually abused)been sexually abused) Sexually transmitted diseaseSexually transmitted disease Signs of restraintSigns of restraint


Behavioral Forensic Markers Behavioral Forensic Markers of Sexual Abuseof Sexual Abuse

WithdrawalWithdrawal FearFear DepressionDepression AngerAnger InsomniaInsomnia Increased interest in sexual mattersIncreased interest in sexual matters Increased sexual or aggressive behaviorIncreased sexual or aggressive behavior


Prevalence of Sexual AbusePrevalence of Sexual Abuse

More frequent in the cognitively More frequent in the cognitively impaired and those needing help impaired and those needing help with ADLs and/or IADLswith ADLs and/or IADLs


Important Information to Important Information to ConsiderConsider

Medical historyMedical history Medical records from primary care Medical records from primary care

physicianphysician

Functional HistoryFunctional History Are there any physical limitations?Are there any physical limitations? What are the victim’s ADLs/IADLs?What are the victim’s ADLs/IADLs?


Important Information to Important Information to ConsiderConsider

Mental/Cognitive capacityMental/Cognitive capacity

Other issuesOther issues Recent illnessesRecent illnesses Victim’s attitudes, feelingsVictim’s attitudes, feelings Does the victim have regular check-ups?Does the victim have regular check-ups? Doctor and/or hospital hoppingDoctor and/or hospital hopping


Working with an Elderly Working with an Elderly Victim Victim

of Sexual Abuseof Sexual Abuse

Is the victim able to give consent?Is the victim able to give consent? Especially important in sexual assault Especially important in sexual assault

casescases

Could the suspect reasonably have Could the suspect reasonably have believed that the victim understood believed that the victim understood and was able to give legal consent?and was able to give legal consent?


Questions for the VictimQuestions for the Victim

Ask:Ask: ““Do you have other bruises, burns, or clusters Do you have other bruises, burns, or clusters

of bruises on your body?” (May have come of bruises on your body?” (May have come from repeated abuse)from repeated abuse)

““How often do you go to the doctor?”How often do you go to the doctor?” ““How many different doctors do you see?”How many different doctors do you see?” ““How often have you been to the emergency How often have you been to the emergency

room in the past year?”room in the past year?” ““How many different hospital emergency rooms How many different hospital emergency rooms

have you visited in the past year?”have you visited in the past year?” Are the answers consistent with what Are the answers consistent with what

you see?you see?


Important Steps Important Steps in Detecting Abusein Detecting Abuse

Explore the use of medicationsExplore the use of medications Side effectsSide effects InteractionsInteractions Medications can be used as a tool for abuseMedications can be used as a tool for abuse Exploring the use of multiple medicationsExploring the use of multiple medications

Determine cognitive functioning and Determine cognitive functioning and functional dependency of victim functional dependency of victim Refer to a psychiatrist for evaluation Refer to a psychiatrist for evaluation

(e.g., Folstein mini-mental, Geriatric (e.g., Folstein mini-mental, Geriatric

Depression Screen, PTSD symptom scale)Depression Screen, PTSD symptom scale)


Photo creditsPhoto credits Slide 15 left: http:Slide 15 left: http://www.elderabusecenter.org/default.cfm?//www.elderabusecenter.org/default.cfm?

p=basics.cfmp=basics.cfm 15 mid, right:15 mid, right:

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CTVNews/1076082613040_71491813/?hub=WFiveCTVNews/1076082613040_71491813/?hub=WFive 17, bottom:17, bottom:

http:http://www.elderabusecenter.org/default.cfm?p=basics.cf//www.elderabusecenter.org/default.cfm?p=basics.cf 24:24:

httphttp://www.moondragon.org/images/bedsoresslowgh.jpg://www.moondragon.org/images/bedsoresslowgh.jpg 26 left::26 left::

http://www.woundcarefelpline.com/whcimages/page123.jpghttp://www.woundcarefelpline.com/whcimages/page123.jpg 26 right:26 right:

http://ww.vein.cniPOP_Know/image/ulcers.jpghttp://ww.vein.cniPOP_Know/image/ulcers.jpg

indicators of physical and sexual abuse judith race, csw coordinator of direct services elderly...

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