Elder abuse: a review

Accidental Injury or "Shaken Elderly Syndrome"? Insights from a Case Report

Subdural haemorrhage (SDH) as result of a traumatic brain injury (TBI) is a common cause of death in cases of fatal physical abuse. Since intracranial bleeding is a common finding in elderly due to age-related intracranial changes or increasing prevalence of anticoagulant medication, differential diagnosis between inflicted and non-inflicted head injury is challenging. A case of an elderly woman's death caused by TBI is reported. Autopsy showed multiple polychromatic bruises and a frontoparietal hematoma with bilateral subacute SDH. History excluded paraphysiological or pathological non-traumatic conditions that could justify SDH, while iatrogenic factors only played a contributory role. Since polychromatic bruises distributed on the face, the upper extremities and the chest were consistent with forceful grasping/gripping or repeated blows and SDH can form in absence of impact or by mild/minor blows, SDH was considered the result of repeated physical abuses. Differential diagnosis between traumatic and non-traumatic SDH is still challenging for forensic pathologists. As largely accepted in the pediatric population and occasionally described also in adults, however, violent shaking should be also considered as a possible mechanism of SDH-especially in elderly who do not have any sign of impact to the head.

Validation Study: The Iranian Version of Caregiver Abuse Screen (CASE) among Family Caregivers of Elderly with Dementia

Since abuse screening is difficult among the elderly with dementia, detection of elder abuse is a serious issue; meanwhile, the number of available tools to assess elder abuse by caregivers is limited. The aim was to evaluate validity and reliability of the Iranian version Caregiver Abuse Screen (CASE) tool. After the translating process of the tool to the Farsi language for 236 dementia participants ≥60 years old and their informal caregivers' from outpatient' clinics, in a cross-sectional method then the validity, reliability and factorial structure of the CASE was evaluated. The translated Iranian version CASE reveals a good psychometric property (α = 0.868) with strong internal consistency and reliability. Some variables (depression, burden, dementia intensity, and ADLs) were associated with abuse in dementia elderly. The two-factor structure was obtained in exploratory factor analysis labeled interpersonal abuse and neglect. Generally, the Iranian version of CASE approved with sufficient validity and reliability as a suitable instrument to find the risk of elder abuse among dementia caregivers.

Prevalence and factors associated with caregiver abuse of elderly dependents: The hidden face of family violence

This cross-sectional study was carried out in Manguinhos, Rio de Janeiro, Brazil and aimed to identify the prevalence and factors associated with familial violence perpetrated by caregivers against elderly dependents. A sample of 135 pairs was evaluated using instruments to assess both caregivers (social support, alcoholism, burden, violence) and elders (depression, cognition, functional capacity). Statistical tests compared the percentages of reported violence according to the characteristics of caregiver and elders. A logistic regression model investigated the association between violence and caregiver/ elder characteristics. More than 30% of caregivers gave responses consistent with risk of elder abuse. Among them, high burden level and comorbid alcohol abuse increased the risk of violence by 11 and 3.8 times, respectively. Elderly men were 2.9 times more likely to be mistreated than elderly women, and depressed ones were 6.9 times more likely to report mistreatment than those without depression. Conclusion: We detected a high prevalence of caregiver violence against elderly dependents, with substantially greater risk among caregivers with high levels of burden, alcohol-related problems, and those caring for depressed elders. Family support strategies are needed to reduce domestic violence and protect elderly victims.

Elder abuse: perception and knowledge of the phenomenon by healthcare workers from two Italian hospitals

With ageing population the number of elderly vulnerable to abuse is expected to grow. Hospital personnel play a crucial role in identifying mistreatment. The aim of this study was to establish the level of awareness and perception of elder abuse by healthcare workers, and to understand if they are able to recognize and properly report elder abuse, as well as to identify the physical signs of abuse and neglect. A 41-question survey was administered to healthcare professionals, working in the Internal Medicine and Geriatric Wards of two different University Hospitals of Southern Italy, representative of the Italian health public system. The data collection resulted in 98 questionnaires. For the majority, neglect represents a type of abuse, whereas 40% of physicians and 37% of nurses considered this concept false. All the professionals recognized the elder abuse as a violation of the human rights, but 46.94% were not sure about the existence of standard procedures for abuse reporting/treatment. The most of the nurses and the care assistants declared they never had suspected or witnessed abuse, while few physicians stated to have suspected/witnessed abuse 1-3 times in their career. In both the suspected and witnessed cases, the healthcare personnel did not made any action, neither reported them to public authorities nor adult protective service agencies. The level of awareness and perception of elder abuse by healthcare professionals are still poor especially regarding the reporting procedures. There is still strong need for education and specific training programs on elder abuse.

"I prefer dying fast than dying slowly", how institutional abuse worsens the mental health of stranded Syrian, Afghan and Congolese migrants on Lesbos island following the implementation of EU-Turkey deal

Background

In 2015 and early 2016, close to 1 million migrants transited through Greece, on their way to Western Europe. In early 2016, the closure of the "Balkan-route" and the EU/Turkey-deal led to a drastic reduction in the flow of migrants arriving to the Greek islands. The islands became open detention centers, where people would spend months or years under the constant fear of being returned to Turkey.Syrians were generally granted refugee status in Greece and those arrived before the 20th of March 2016 had the option of being relocated to other European countries. Afghans had some chances of being granted asylum in Greece, whilst most migrants from the Democratic Republic of Congo were refused asylum.In a clinic run by Médecins sans Frontières on Lesbos Island, psychologists observed a deterioration of the migrant's mental health (MH) since March 2016. In order to understand the MH needs for this stranded population it was essential to explore how, and by what factors, their mental health (MH) has been affected on Lesbos Island due to the EU/Turkey-deal.

Methods

This was a qualitative study in which eight service providers' interviews and 12 focus group discussions with male and female Syrian, Afghan and Congolese migrants in two refugee camps on Lesbos Island. Thematic-content analysis was manually applied and triangulation of findings was undertaken to enhance the interpretation of data.

Results

Three main themes were generated: 1) Institutional abuse, 2) Continuous traumatic stress (CTS) and 3) MH service provision. Institutional abuse was expressed by inhumane living conditions, lack of information in order to make future decisions, humiliation and depersonalization. This led to CTS that was expressed through being in a state of permanent emergency under lack of protective measures. Delays in appointments, lack of psychiatric care and differences in MH perceptions amongst migrants highlighted the provision of MH services.

Conclusion

The EU/Turkey-deal reduced migrant flows at a very high price. Decongestion of the camps and the elimination of institutional abuse is urgently needed to reduce CTS and improve migrants' MH.

Signs of physical abuse and neglect in the mature patient

Neglect and physical abuse of elderly are worrisome health problems, which are expected to grow even further, considering the aging of the population. By 2060, the number of people aged above 65 years is expected to double, whereas birth rates are low. This trend will cause a significant imbalance between different age groups and put more senior adults at risk for abuse. Risk factors, associated with abuse and neglect, are well established and can be categorized in sociodemographic-, victim-, or perpetrator-related risk factors. The effects of these risk factors depend mainly on the setting, which can be community-dwelling or institutionalized older adults. In community-based settings, 90% of perpetrators are family members. In each setting, suspicious physical injuries should be recognized and addressed promptly. This can be very challenging in elderly, among others, due to the age-related skin changes, which can mimic abuse; however, there are some cutaneous clues that should always raise suspicion of abuse, such as patterned shape or distribution, different healing stages of wounds, parallel injuries, signs of blunt trauma, and irregular patches of alopecia. General awareness is needed, and the advice of dermatologists, who are best trained to differentiate between those lesions, should be systematically sought, to reduce false-positive and false-negative interpretations.

The elder physical abuse reflected in judicial authorities in Eskisehir

AIM

Elder abuse is a health and human rights problem that may occur among every race and ethnic group all around the world. This study aims at describing all cases of physical abuse of elderly which have been reported to, and investigated by Eskisehir - a western city of Turkey.

METHODS

Physical abuse incidents above 65 years of age which were evaluated by the Eskisehir Council of Forensic Medicine for expert witness opinion during 5year period between 01.01.2010 and 12.31.2014 are examined in this descriptive, cross-sectional study.

RESULTS

253 cases are found and evaluated in the scope of the study. It is determined that all aggressors are the acquaintance of the victim, and for 114 cases (45.1%) the aggressor is the victim's son. It is found that only investigation procedures of cases are completed, but no protection and rehabilitation program has been issued.

CONCLUSION

In conclusion, it is determined that elder victims are abused by family members and relatives who are mostly the care givers. It is seen that emergency physicians play a great role in the detection of abuse.

Reciprocal Abuse: Elder Neglect and Abuse by Primary Caregivers and Caregiver Burden and Abuse in Turkey

The aim of the study was to determine the relationship between the neglect and abuse that older people were exposed to by their primary caregivers and the experiences of caregivers' burden and abuse by their charges. This descriptive, cross-sectional and correlational study was conducted with 186 individuals over the age of 65 and 136 caregivers. The data were collected using questionnaires to determine neglect and abuse experienced by both older people and caregivers, and the Zarit Burden Scale. Abuse rate of the older people and their caregivers is both high and similar. This study is to make psychiatric nursing professionals aware of the problem of elder abuse and neglect. For researchers, educators, practitioners, and policymakers in the fields of aging, health, and mental health this study provides important data about elder abuse and neglect.

Elder Abuse and Neglect Versus Parricide

Violence in families and elder abuse can take many forms, which his sometimes difficult to recognize. In Russia, elder abuse is rarely discussed in professional literature and mass media. A border between elder abuse and parricide can be indistinct. Borderline cases can include involvement of older people in binge drinking, denial of help, and manipulation towards suicide. Three example cases are discussed in this report. A concluding point is that for prevention of parricide, it should be kept devoid of its reputation as an extraordinary crime, committed mainly by mentally ill individuals. The perpetrators can be mentally healthy or have a personality disorder. Parricide can have trivial appearance, not always recognized as such by victims and social environment.

A literature review of findings in physical elder abuse

PURPOSE

To review the medical literature for reports on the types of physical injuries in elder abuse with the aim of eliciting patterns that will aid its detection.

MATERIALS AND METHODS

The databases of PubMed, CINAHL, EMBASE, and TRIP were searched from 1975 to March 2012 for articles that contained the following phrases: "physical elder abuse," "older adult abuse," "elder mistreatment," "geriatric abuse," "geriatric trauma," and "nonaccidental geriatric injury." Distribution and description of injuries in physical elder abuse from case-control studies, cross-sectional studies, case series, and case reports as seen at autopsy, in hospital emergency departments, or in medicolegal reports were tabulated and summarized.

RESULTS

A review of 9 articles from a total of 574 articles screened yielded 839 injuries. The anatomic distribution in these was as follows: upper extremity, 43.98%; maxillofacial, dental, and neck, 22.88%; skull and brain, 12.28%; lower extremity, 10.61%; and torso, 10.25%.

CONCLUSION

Two-thirds of injuries that occur in elder abuse are to the upper extremity and maxillofacial region. The social context in which the injuries takes place remains crucial to accurate identification of abuse. This includes a culture of violence in the family; a demented, debilitated, or depressed and socially isolated victim; and a perpetrator profile of mental illness, alcohol or drug abuse, or emotional and/or financial dependence on the victim.

Perfil dos idosos em situação de violência atendidos em serviço de emergência em Recife-PE

OBJETIVO: Determinar o perfil da violência sofrida pelo idoso atendido em serviço de emergência do Hospital da Restauração (HR), em Recife-PE. METODOLOGIA: Estudo epidemiológico, descritivo, quantitativo de corte transversal. Foram analisados todos os prontuários médicos referentes aos atendimentos em cirurgia geral, ortopedia e clínica médica realizados na emergência de adultos do HR entre 1º de janeiro e 31 de dezembro de 2007, disponibilizados pelo Serviço de Arquivo Médico, totalizando 72.232 prontuários. RESULTADOS: Do total de prontuários analisados, foram registrados 79 casos de violência contra o idoso. Destes, 63,3% do sexo masculino. A faixa etária predominante foi compreendida entre 60-70 anos (72,2%). Em 81,1% dos prontuários, não houve registro sobre vínculo empregatício ou situação previdenciária do agredido. Em relação ao local de residência da vítima, a maioria (46,8%) residia em Recife-PE. Quanto ao levantamento de dados sobre o agressor, quando este foi citado (3,7%), todos pertenciam ao sexo masculino, sendo notificada a relação com a vítima em um único caso (filho). O tipo de violência mais frequente foi a física (97,5%). Quanto à natureza da lesão, a mais comum foi a contusão (27,8%). Os sítios de lesão mais acometidos foram a face (35,4%), crânio (31,6%) e extremidades (22,8%). Em relação ao instrumento, os contundentes foram os mais utilizados (29,1%), seguido dos perfuro-cortantes (19%). O mês de janeiro prevaleceu com o maior número de atendimentos (21,6%) e os casos de violência ocorreram principalmente na sexta-feira (16,1%), quarta-feira (17,7%), sábado (17,7%) e domingo (17,7%). CONCLUSÃO: O idoso vítima de violência foi principalmente homem, com faixa etária de 60-70 anos. O tipo de violência mais frequente foi a física, especialmente contusão em face ou crânio, ocorrendo mais no fim de semana.

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.

Self-neglect of the elderly. An overview

Self-neglect is characterized by the inability to perform essential self-care tasks threatening a person's health and safety. The exact prevalence of self-neglect in a community-based aged population is not known. Cognitive impairment is the most important predisposing factor of self-neglect. There are also a number of other predisposing factors such as psychiatric diseases, pre-morbid personality, alcohol abuse, poor physical ability, lack of social support and a low socioeconomic situation. Self-neglect has a number of serious consequences. It is an independent risk factor for early mortality among the aged. It commonly causes malnutrition, frailty and the deterioration of physical ability, therefore, increasing the risk of falls and fractures. Untreated medical conditions result in emergency visits and acute hospitalization. The neglect of housekeeping and financial affairs seriously affects the domestic environment. Diagnosis and treatment of self-neglect should be based on the medical and psychosocial assessment of a patient. Patients require multidisciplinary support at home or in hospital, and sometimes long-term care is inevitable. There is no sufficient scientific evidence to support the benefits of early intervention in self-neglect. Controlled studies are needed, especially to show whether early diagnosis followed by increased social support and tailored health care services have an effect on the outcome.

Fatores associados à violência doméstica contra a pessoa idosa

OBJETIVO: determinar os fatores associados à violência doméstica do tipo física em idosos submetidos a exame de corpo de delito, entre 2004 e 2007, no Instituto de Medicina Legal do Recife. METODOLOGIA: as informações do estudo de corte transversal procederam de 511 laudos de exames de corpo de delito traumatológicos realizados em idosos (60 anos ou mais). Na análise da associação entre as variáveis, utilizou-se o teste Qui-quadrado com IC de 95%. RESULTADOS: os fatores associados à violência doméstica, em relação à consequência da violência, foi a parte do corpo acometida (tronco/membros); quanto à vítima, foram sexo (feminino), estado civil/situação conjugal (sem companheiro) e ocupação (aposentado, pensionista ou do lar). Em relação ao agressor, houve associação com o sexo (feminino), quantidade (um) e parentesco/relação estabelecida com a vítima (familiar). CONCLUSÃO: os fatores associados à violência estudada, vinculados a aspectos sociais, econômicos e culturais, evidenciam a complexidade do fenômeno e seu enfrentamento.

Prevalence of older adults' abuse and neglect in Portugal: an overview

Purpose

The purpose of this paper is to identify, describe and compare the studies of the prevalence of abuse and neglect of older adults developed in Portugal.

Design/methodology/approach

A retrospective bibliographic search of seven descriptors in English and Portuguese, of academic and professional papers and university institutional repositories was performed.

Findings

Of the nine studies selected, seven consisted of grey literature – research developed within the course of academic post‐graduate studies. The studies were conducted on a small scale, more often than not, through a non‐probabilistic convenience sampling method. From the nine studies, two instruments prevailed: the Questions to Elicit Elder Abuse aimed at older adults and the Caregiver Abuse Screen aimed at caregivers. Community‐dwelling older adults self‐reported a higher prevalence of abuse (between 66.7 and 86.7 per cent) than care professionals working with older adults suffering from dementia (between 26.7 and 47.4 per cent). Emotional abuse and neglect were the first and second most prevalent forms of abuse, followed by financial abuse, whereas physical abuse was the least prevalent type of abuse encountered. A poorer perception of health, not making/receiving visits and residing in an urban area were the more consistent variables associated with abuse of older adults.

Originality/value

Overall, this paper provides a first consideration to the prevalence rates of older adult abuse and neglect from research studies in Portugal. The revised design studies and screening methods employed can help researchers improve future study design and move from the description to a more theoretically oriented research. Furthermore, it can help practitioners learn screening methods and discover the findings associated with abuse.

Physical abuse of older people reported at the Institute of Forensic Medicine in Recife, Pernambuco State, Brazil

This cross-sectional study aimed to determine the profile of physical abuse against older people who underwent forensic examination at the Institute of Forensic Medicine in Recife, Pernambuco State, Brazil. The cases, with data from 1,027 forensic reports, were described according to characteristics of the incident, victim, and aggressor. Most cases of violence were produced by mechanical energy, either with blunt objects or by empty-handed attack; the most common day of the week was Sunday, most frequently in the evening, and in the victim's home; typical cases involved mild injuries on more than one part of the victim's body. The majority of the victims were men, 60 to 69 years of age, brown (mixed-race), married or living with a partner, and retirees/pensioners. The majority of the aggressors were men, known to the victim, and attacking alone. The social transcendence of violence against older people clearly calls for investment in programs to deal with the problem in order to ensure better quality of life for the elderly.

A violência doméstica contra idosos nas áreas de abrangência do Programa Saúde da Família de Niterói (RJ, Brasil)

Este artigo investiga a magnitude e as características da violência contra idosos no domicílio por pessoas de confiança no bairro da Ilha da Conceição, em Niterói (RJ), adscritos ao Programa Saúde da Família. Através de um inquérito domiciliar, foram entrevistados 343 indivíduos com 60 anos ou mais, selecionados por amostragem aleatória simples. Para identificação de violência usou-se a Escala Tática de Conflitos. As informações sobre identificação, características demográficas e socioeconômicas foram obtidas pela Pesquisa Nacional por Amostra de Domicílio. Avaliou-se a saúde mental pelo Miniexame do Estado Mental. Para avaliação da capacidade funcional, usou-se o Health Assessment Questionnaire. Quanto à suspeita de uso de álcool pelos homens, utilizou-se o instrumento CAGE; para a idosa ou cuidadora, o instrumento TWEAK. 43% relataram pelo menos um episódio de violência psicológica. A violência física foi relatada por 9,6% dos entrevistados; 6,1% referiram ocorrência de violência física grave nesse período. A prevalência das diversas modalidades de violência foi maior entre os mais novos, com maior escolaridade, entre os que apresentam uma das patologias que caracterizam o idoso como tendo uma vulnerabilidade (depressão e/ou incontinência urinária/fecal e/ou diabetes e/ou reumatismo) e entre os que moram com maior número de indivíduos.

Violência contra a pessoa idosa: análise de aspectos da atenção de saúde mental em cinco capitais brasileiras

Trata-se de investigação sobre aspectos da atenção à saúde mental ofertada à pessoa idosa vítima de violência nos municípios de Curitiba, Rio de Janeiro, Brasília, Recife e Manaus. Foi utilizada a abordagem de triangulação de métodos a partir da análise de dados secundários, informações de questionários e entrevistas individuais e em grupo, definindo-se como público-alvo profissionais e gestores da atenção à saúde mental. Investigou-se a consonância das práticas desenvolvidas nos serviços em relação às políticas que regem a atenção à saúde mental e as dirigidas às pessoas idosas vítimas de violência. Entre os resultados destacam-se: a disparidade dos registros de atendimento de idosos entre as unidades hospitalares (22,3%) e extra-hospitalares (0,4%); a ausência de informações sobre o atendimento de idosos vítimas de violência; e a incipiente percepção dos profissionais quanto à violência como objeto de intervenção da saúde. Conclui-se pela necessidade de maiores investimentos públicos: na melhoria da qualidade da informação; na adequação da estrutura física dos serviços; na capacitação/habilitação dos profissionais para atenderem às especificidades de saúde do idoso. No aspecto da violência, observou-se a necessidade da adoção de ações de prevenção e atenção dos transtornos mais frequentes em idosos.

Coping successfully with aging

Aging is associated with physical decline, often accompanied by pathology and disability that can cause unhappiness and dissatisfaction. Despite this, many elders report a high level of satisfaction. This article discusses the anxiety associated with aging that some people experience, highlights research findings and models of aging, and pays particular attention to how elders compensate and cope with loss. Long-term care practitioners can help residents deflect negative stereotypes and improve their own attitudes about aging.

Perfil dos idosos que sofreram trauma em Londrina - Paraná

O objetivo foi caracterizar os idosos que sofreram trauma e foram internados nos três hospitais terciários, da cidade de Londrina - Paraná. Pesquisa quantitativa através de um estudo observacional, transversal, com 121 idosos de 60 a 74 anos e seus cuidadores, realizada durante um período de seis meses, por meio de entrevistas e visita domiciliar. Os resultados evidenciaram que a maioria dos idosos era do sexo masculino, com média de idade de 67,7 anos. Os traumas sofridos foram: 62,0% quedas, 25,6% acidentes de transporte e 10,4% outras causas. Como conseqüência ao trauma houveram de uma a três lesões, e 11 idosos (9,1%), foram a óbito. A queda foi a principal causa de trauma, a qual pode ser evitada observando os fatores intrínsecos e os extrínsecos que a predispõem, com o intuito de estabelecer estratégias de prevenção desse tipo de trauma.

Elder abuse, ageism, human rights and citizenship: implications for nursing discourse

Elder abuse is a significant social issue in society. Although this area has generated an increasing research base, there is scant literature on elder abuse viewed through the lens of ageism and its sway on human rights and citizenship. These three perspectives on the topic allow for a meaningful and equitable benchmark from which elder abuse may be considered. Ageism influences the way human rights and citizenship are articulated for older people and is conceptualised as stereotypical views of older people leading to prejudiced attitudes, actions and societal marginalisation. Such attitudes function to both disadvantage and devalue older people providing a covert basis for societal tolerance of elder abuse. This paper reviews pertinent literature in the area of elder abuse, human rights, citizenship and ageism, and argues that although society aspires to certain ideals in terms of equality and valuing the human individual, these aspirations may often be questionable in terms of older people and abuse.

Prevalência de maus-tratos na terceira idade: revisão sistemática

OBJETIVO: Identificar estudos sobre prevalência de abuso na terceira idade e analisar a qualidade dos estudos. MÉTODOS: Revisão sistemática estudos de base populacional em bases de dados eletrônicos (PubMed, LILACS, Embase, ISI, PsycInfo), referente aos anos de 1988 a 2005. Foram incluídos os estudos de base populacional e excluídos os estudos sem definição metodológica delineada e estudos realizados em clientela de serviços especializados. RESULTADOS: Foram encontrados 440 artigos, mas apenas 11 artigos foram selecionados. A maioria dos artigos foi de corte transversal, apenas dois apresentaram desenho longitudinal. Os estudos foram conduzidos em diversas regiões do mundo, sobretudo dos Estados Unidos e da Europa. Observou-se variação nas definições de abuso. Os estudos de prevalência encontraram coeficientes de abuso físico entre 1,2% (Holanda) e 18% (Finlândia). CONCLUSÕES: Existe substancial variação de prevalência entre os países, parecendo haver uma variável cultural importante. Como o número de idosos é crescente no mundo, são necessários mais estudos de base populacional representativos dessa faixa etária para melhor compreensão do fenômeno.

Elder abuse and neglect

Elder abuse and neglect is a critical health care issue that must be brought to the attention of health care providers and older adults' family members. Adults older than 65 who live at home or in long-term care facilities may be at risk for abuse. Nurses should be aware of the causes, screening questions, symptoms of abuse, and resources in the community. Armed with information and a better understanding about the issue, nurses can minimize the devastating effects of abuse on older adults and their families.

The relationship between intimate partner violence and other forms of family and societal violence

Intimate partner violence was previously considered a private matter sometimes requiring law enforcement intervention. It is increasingly accepted as not only a medical issue for the victim, but a public and safety issue. Some of these other related issues, including unplanned pregnancy, same-sex relationships, overlap with elder, child, and animal abuse, and effects on workplace and school violence are explored. Screening, medical manifestations, documentation, reporting intervention, and referral are also discussed.

Elder Maltreatment: A Review

Context.—Elder maltreatment is not a new entity but is one that is recently recognized as a widespread and growing social problem. Unfortunately, few physicians are trained to recognize the different forms of elder maltreatment including physical abuse, sexual abuse, and neglect. The elder, age 65 years or older, is also a unique individual with respect to pathophysiology. The natural changes of aging must be considered when assessing any physical or laboratory findings.

Objective.—The practicing pathologist and resident/fellow in training must be familiar with the 6 forms of elder abuse, in particular the 3 forms that are seen in general and forensic pathology: physical abuse, sexual abuse, and neglect. Naturally occurring conditions must also be recognized so that these are not erroneously interpreted as trauma or neglect. Furthermore, the victims and perpetrators, scenarios and risk factors, common anatomic and clinical findings, the pathophysiology of aging, and possible imitators of abuse must be understood.

Data Sources.—This review explores the current medical and psychological understanding of elder maltreatment. Current scientific literature including peer-reviewed journal publications and texts is cited.

Conclusions.—As a prevalent form of domestic violence, we can only expect to see more cases of elder maltreatment as the number and percentage of elders in our population increase. The correct interpretation of physical and laboratory findings is needed to adequately classify these cases, certify the cause and manner of death, and prevent future incidents.

Burn Injuries Inflicted on Children or the Elderly: A Framework for Clinical and Forensic Assessment

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the difference between battery and assault in U.S. law and the concepts of the phrase "child abuse" and "elder abuse." 2. Understand that state statutes vary and can define abuse narrowly or with great specificity, and that either definition has inherent problems for physicians treating victims of abuse and neglect. 3. Know where to find the state-specific legal criteria for child or elder abuse and neglect, along with the corresponding standards for mandatory reporting and physician accountability. 4. Understand the relevant law regarding physician-patient privilege and the repercussions of incorrect but good faith reporting and of failing to report suspected abuse or neglect of children or the elderly. 5. Understand that there are no pathognomic signs for inflicted burn injury. 6. Clinically assess burned pediatric or elderly patients within a framework that will minimize the risk of missing or inappropriately suspecting injuries that stem from abuse or neglect.

SUMMARY

This article deals with burns inflicted on children and the elderly, two particularly vulnerable societal groups. Though inflicted burning is a relatively rare method of inflicting physical abuse, failure to diagnose it has far-reaching ramifications. These injuries pose both medical and forensic problems for physicians, along with unique ethical dilemmas. This article is a collaboration between surgeons and lawyers providing a holistic, workable approach to the management of inflicted burn injury. The authors first describe the legal considerations that must be appreciated by U.S. physicians, then they suggest a rational and balanced clinical approach to the assessment of burn injuries that may have been inflicted intentionally or negligently on children and the elderly.

Elder abuse

Elder abuse and neglect is a prevalent, underrecognized problem among today's senior citizens. Fortunately, awareness is increasing, and services are being provided to elders on a more ready basis. Still, the emergency care provider must act as a patient advocate and assume responsibility for the detection, treatment, and safe disposition of unfortunate victims.

Elder Abuse at End of Life

CONTEXT

Advances in health care and changing demographics have led to an aging population whose care at the end of life has become complex. Patients at the end of life, by the nature of their clinical and social circumstances, are at high risk for elder abuse. Underreporting of elder abuse is a growing concern. The clinical presentation of abuse may overlap with the natural dying process, further compounding the problem.

EVIDENCE ACQUISITION

Articles were obtained through a PubMed search using the terms "elder abuse" and "elder mistreatment" and from the University of California, Irvine's Elder Abuse Forensic Center library. Additional references were followed through these first set of articles and also from colleagues expert in this field.

EVIDENCE SYNTHESIS

Multidisciplinary teams have been shown to be the most effective intervention for the assessment and prevention of abuse. Most abuse occurs at home by family members; the hospice team may be the only outside professionals coming into the home. Caregiver stress and victim dependency increase the risk for abuse. Although physical abuse is the most commonly envisioned, neglect is the most common form of abuse. Financial abuse is often the underlying motivation for other forms of abuse.

CONCLUSIONS

Health professionals have an ethical and legal responsibility to both report and work to prevent suspected abuse. The interdisciplinary team can make a significant impact on elder abuse, a major detriment on quality of life.

Elder abuse and neglect: an overview

The dramatic growth of the American elderly population has great implications for our health care system. The "demographic imperative" that has fueled the awareness of the needs of older adults has a major impact on issues related to social welfare, justice, and economics. There are 45 million people over the age of 60 and 3 million over the age of 85. Those over age 85 represent the fastest growing segment of the elderly population. With this trend comes a segment of the population that is at risk for abuse, neglect, or self-neglect. We are challenged to be aware of the many faces of elder mistreatment and to understand it in the broader context of domestic violence. All health care professionals working with older adults need to become familiar with the recognition, treatment, and prevention of elder abuse and neglect.

Dementia and Elder Abuse

Dementia and elder abuse are relatively common and under-diagnosed geriatric syndromes. A unique relationship is observed when the two entities coexist. Special issues can confound the care of the dementia patient suspected of being abused. Impaired language or motor abilities to communicate abusive situations to a third party, lack of decisional capacity to address the abusive situation, disinhibited behavior that contributes to a cycle of violence, and coincident depression of the abused elder complicate the diagnosis and management of elder abuse. Education of the caregiver and attention to caregiver stress, including depression, may prevent onset and perpetuation of abuse.

Medical Implications of Elder Abuse and Neglect

Recognition of elder abuse and neglect among health care professionals has been a relatively recent phenomenon. Each year, millions of elderly persons suffer as the result of abuse and neglect. Their quality of life is severely jeopardized in the form of worsened functional status and progressive dependency, poorly rated self-health, feelings of helplessness, and from the vicious cycle of social isolation, stress and further psychologic decline. Other medical implications of abuse and neglect include higher health systems use in the form of frequent ER visits, higher hospitalization, and higher nursing home placement; most importantly, it is an independent predictor for higher mortality. Physicians are well situated in detecting and reporting suspected cases and taking care of the frail elders who are victims of abuse and neglect, but there are barriers on the individual level, and there is a broader need for system change. Through education, training, and reinforcement, there are strategies to get health care professionals more involved and provide effective management protocols and guidelines for us to advocate for our patients in the current epidemic of elder abuse and neglect.

Intentional burn injury: an evidence-based, clinical and forensic review

Burn injury can be inflicted intentionally either by one person to another whenever one has the ability to physically control the other, or it can be self-inflicted. There is scant evidential basis for much that is written about and practiced in the evaluation and care of patients that have sustained intentional burn injuries. Yet this is an area in which medical personnel must necessarily be trained in both the therapeutic and forensic aspects of a complex problem. Failure to appreciate the complexity of medical and forensic interactions may have far reaching effects. A missed diagnosis can result in inappropriate medical care, on-going abuse and future fatality. Inept management can result on the one hand, in blame levelled inappropriately placing incomparable strain on family units and innocent parties, and on the other, allow abusers to continue unchecked. This is the first review on the subject in which lawyers and doctors collaborate to produce a holistic approach to this subject. In it we describe the legal considerations that medical staff must appreciate when approaching patients who may have suffered intentional burns. We analyse the various scenarios in which intentional burning can be found and challenge the clinical dogma with much of the management of paediatric inflicted burns has become imbued. We suggest a rational and balanced approach to all intentional burn injuries-especially when children are involved. In the light of current case law in which dogmatic medical evidence has been implicated in wrongful convictions for child abuse in the UK, it is imperative that medical professionals gather evidence carefully and completely and apply it with logic and impartiality. This paper will aid clinicians who may not be experienced in dealing with burn injuries, but find themselves in the position of seeing a burn acutely, to avoid common mistakes.

Domestic elder abuse and the law

OBJECTIVES

The authors evaluated the impact of state adult protective service legislation on rates of investigated and substantiated domestic elder abuse.

METHODS

Data were collected on all domestic elder abuse reports, investigations, and substantiations for each US state and the District of Columbia for 1999. State statutes and regulations pertaining to adult protective services were reviewed.

RESULTS

There were 190 005 domestic elder abuse reports from 17 states, a rate of 8.6 per 1000 elders; 242 430 domestic elder abuse investigations from 47 states, a rate of 5.9; and 102 879 substantiations from 35 states, a rate of 2.7. Significantly higher investigation rates were found for states requiring mandatory reporting and tracking of numbers of reports.

CONCLUSIONS

Domestic elder abuse documentation among states shows substantial differences related to specific aspects of state laws.