Effectively Detect and Manage: ELDER ABUSE

Nurse Practitioner,  Aug 2004  by Brown, Kathleen,  Streubert, George E,  Burgess, Ann W

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Inspecting the genitalia of an elderly female is a clinical challenge. Many elderly women cannot be placed into the traditional position for pelvic examination. Contractures, arthritis, and many other medical conditions common in the elderly prohibit this position. External genitalia must be carefully inspected using a colposcope or a highintensity light source. Injury may occur at any genital location, but careful attention should be given to inspection of the posterior aspect of the entrance to the vagina and to the perineum. A small, narrow speculum (although not a pediatrie speculum because length is required to reach the cervix) should be utilized. Lubrication with sterile water is not desired, but may be necessary. Common genital injuries in elderly victims of sexual assault are lacerations, abrasions, and bruises.

* Orthopedic Injuries

Elderly victims are more prone to orthopedic injuries from minor trauma than the rest of the population. This is due to osteoporosis and decreased muscle mass. Fractures of the arms can occur, either while breaking a fall with the arms or by raising the arms to ward off blows from the attacker. Fractured lower extremities may also occur during an assault. Blows to the extremities, falls to the ground, and attempts by the attacker to restrain extremities can create fractures. Diagnosis of a fracture requires radiographs. Cervical spine injuries in the elderly are common. The possibility of cervical spine injuries post-assault should be considered during evaluation.

Following relatively minor trauma in the elderly, degenerative and arthritic changes make diagnosis difficult but necessary for appropriate treatment. Radiographs as well as CT, MRI, and/or bone scans may be required. Closed pelvic fracture must be considered in elderly victims of assault.

* Pain Perception and Memory Loss

Decreased pain perception is an issue when dealing with elderly victims of assault. Elderly victims of trauma often have more injury than they report. Assessment cannot be confined to what the victim reports to be uncomfortable or painful. The entire body must be evaluated for injury.

Loss of short-term memory makes giving an accurate account of the events during the assault difficult for some elderly victims. Victims may simply be unable to remember all the details. This possibility requires meticulous examination of the entire body for indications of injury and an interview with the person accompanying the elder to the examination.

* Documentation

Sexual assault cases are forensic cases: that is, documentation may be used in criminal and/or civil litigation proceedings. It is recommended that NPs conducting forensic examinations be specially trained as sexual assault nurse examiners. Such training generally suggests documentation of physical injuries and signs using the acronym "TEARS." 18 This acronym provides a consistent structure for gathering data. TEARS stands for:

Tears or lacerations and/or tenderness

Ecchymosis

Abrasions

Redness

Swelling