Effectively Detect and Manage: ELDER ABUSE

Brown, Kathleen

Nurse practitioners are often in a position to initiate proper intervention and investigation when elder abuse is detected. Unfortunately, unless there are obvious signs of injury, elder abuse may be difficult to uncover.

Studies indicate that injured elderly persons differ from the injured younger population in terms of cause of injury, response to injury, and outcome.1"1 Nurse practitioners (NPs) are often in contact with older people and are in a position to not only detect abuse, but also initiate proper intervention and investigation. Unfortunately, unless there are obvious signs of injury, elder abuse may be difficult to detect.

* Causes of Injury

Falls are the most common cause of injury for the elderly, followed by motor vehicle accidents, pedestrian accidents, and stab and gunshot wounds.1'5'6 Unintentional injury is the eighth leading cause of death in all Americans over the age of 65 years.1 In contrast, motor vehicle accidents are the number one cause of injury for the younger population, followed by stab and gunshot wounds, falls, and pedestrian accidents.

Elderly people can also be injured intentionally as victims of assault and sexual abuse. Although not as well published as child assault and abuse, elder assault and abuse occurs in alarming numbers. There are no estimates of the incidence or prevalence of elder sexual abuse, in the general community, but the National Citizens' Coalition for Nursing Home Reform (NCCNHR) counted 1,749 cases of such abuse between 1996 and 1999 in the institutionalized elderly.7 For the fiscal year 2000, of the 15,010 total cases of abuse, gross neglect, and exploitation complaints in nursing homes reported to the NCCNHR, 662 were for sexual abuse. Of the 3,684 cases of abuse, gross neglect, and exploitation complaints in board and care facilities in fiscal year 2000, 201 were for sexual abuse. The Centers for Disease Control and Prevention reports that in 1999,32,219 people over the age of 65 died of unintentional injury. An unknown percentage of these cases were believed to be related to abuse or assault.

* Response to Injury

Because age affects the body's ability to respond to injury and disruptions in physiologic balance, the elderly recover at a slower rate from minor injury than younger people. Elderly persons may have preexisting diseases, but several studies suggest that chronic disease does not influence survival from trauma. The trauma itself creates morbidity and mortality.

* Outcome

Elderly people demonstrate decreased survival rates when compared to younger people with the same or similar injuries.3 A disparity is also noted for minor injury. The elderly are twice as likely as younger people to suffer serious injury in the commission of a crime and they require more hospitalization after a crime than any other age group.8

The nurse practitioner (NP) who conducts a forensic examination of an elderly victim must obtain consent from the victim and/or the victim's caregiver, provide emotional support during the exam, and follow the protocol for an evidentiary examination (photographing injuries and collecting evidence). The victim should be questioned alone, without the caregiver present, followed by questioning with the caregiver present. The reason for this is the possibility that the caregiver is also the abuser.

* Detection of Injury

Skin and Mucous Membrane

As one ages, skin becomes thin, loose, and transparent, and its vascularity decreases. The skin of the elderly is also atrophie, making it more fragile. The lighter the skin, the more it tends to look pale and opaque with age. An older sexual assault victim has more skin and mucous membrane injury than a younger victim due to the fragility of the skin and mucous membranes.

The fragility of the vessels in and under the skin also creates bruising in the elderly. Elderly people bruise under a force or pressure that would not create bruising in younger people.

In younger persons, the color of a bruise changes with time. A purplish red discoloration appears first, often accompanied by swelling. The bruise changes to dark purple within days, followed by a greenish yellow color as the bruise heals. The process of dating an accidental bruise in an elderly victim is currently under investigation. Until that research process is complete, an accurate description of observed bruising should include location, shape, and color of the bruise without any reference to the time or date when the bruise or bruises may have occurred.

It is also important that NPs document each observed injury using the appropriate terminology. An abrasion is a wound caused by rubbing or scraping the skin or mucous membranes. A bruise is caused by a blunt force injury that results in superficial discoloration of the skin due to hemorrhage into the tissue from ruptured blood vessels beneath the skin's surface, without broken skin. A bruise is also called a contusion. Ecchymosis is a hemorrhagic spot or blotch, larger than petechia, in the skin or mucous membranes forming a nonelevated, rounded, or irregular blue or purplish purpuric patch.9

Assessment for Bruises

The entire body of an elderly assault victim must be examined for signs of bruising. Fingertip bruising from restraint is frequently noted on the neck, the arms, and/or the legs. Bruising from punching may be seen on the face, the breasts, the chest, the abdomen, and the extremities. A bruise caused by a punch resembles the shape of a fist with a somewhat clear area in the center. This clear area is called the area of central clearing and is created when the blow forces the blood from the capillaries out and away from the targeted area.

Assessment for Abrasions

The elderly assault victim's body must be examined for abrasions and skin transferred from one area to another. If the elderly victim is pulled or dragged across a surface, the skin will abrade. This can be seen when an elder victim is dragged across pavement or grass; but it can also be seen on those who have been dragged across a sheet or a carpet because of the fragile skin of elder victims. If a pillow or similar object is held over the elderly victim's face, injury to the skin on the face is likely to occur.

Assessment for Lacerations

A cut in the skin can occur if a knife or similar weapon is used in the crime. Lacerations from blunt force trauma are much more common in sexual assault and may occur from the skin splitting due to the force applied. If the elderly victim is punched, pulled, or restrained, the fragile skin will often tear, creating a laceration.

Methodical and meticulous examination of the skin and genitalia of the elderly sexual assault victim is necessary, using an excellent light source. all injuries must be noted, whether or not they require medical intervention. Each injury must be described in writing and drawn on a body map. In addition, photographs of everv injury must be obtained to ensure proper documentation of each injury.

Response to Trauma

The skin of the elderly has a slower healing rate due to changes in circulation caused by aging. There is an increased risk of infection in an older victim's slower-healing wounds. Instructions should be given to the victim and/or the victim's caretaker on how to keep injuries clean and infection-free.

Early bruising is difficult to detect in any victim. A follow-up visit 24 hours after the assault may be necessary to obtain an accurate forensic documentation.

* Head Injury

Traumatic brain injury extracts a high morbidity and mortality in any age group. In the elderly, mortality following severe brain trauma is 90%.10-12

If the elderly victim experiences trauma to the head during the assault, she is more likely to experience a subdurai hematoma than a younger victim. The elderly have increased fragility in the veins in the head, increased cerebral atrophy, and increased stretching of the bridging veins in the head, making them more susceptible to this type of injury.

In studies focusing on geriatric trauma, a lack of history of head trauma in elderly victims with confirmed subdural hematoma was 35% to 50%.B Because even minor head trauma can lead to mortality in the elderly, every elder victim of assault should be evaluated for head injury, whether or not there are symptoms.

It is clear that any elderly victim of sexual assault who complains of headache, and/or has a change in mental status or a disturbance in gait, should be evaluated for head injury. If the victim does not display any of these symptoms, the history of the attack must be carefully solicited and decisions made regarding possible head trauma. Elder victims often have hearing deficiencies, sight deficiencies, altered equilibrium, and delayed reaction time, making assessment for central nervous system injury difficult.

If the assault involved force to the head and/or neck, a CT scan should be obtained. Lower thresholds are needed for the elderly given their fragility. CT scans may show hyperdense areas for the first 5 to 10 days, followed by isodense areas on days 7 to 20, with hypodense as the final phase. Anemia can be a confounding factor in the elderly, slowing recovery. In older victims, traumatic hemorrhage tends to be multiple rather than large and expansive. It is also necessary to remember the limitations of MRI scans with respect to detecting all subdural injury.

Sexual assault usually occurs in a reclinined position (i.e., as in "down" on a bed). If the victim is forced down and into a reclining position, head injury can occur. If the assault occurred in the victim's home or on the street and the victim was forced to the ground or floor, head injury must be considered. A victim can be forced from a standing or sitting position to the ground or floor as part of a blitz attack. Head injury can also occur via blows to the head. In addition, the victim head might also be violently shaken or slammed into the bed, floor, or ground, creating injury.

* Neck Injury

Neck injury can occur when the neck is compressed (as in strangulation). The assailant may try to silence the screams of the victim. NPs should find out how the assailant controlled the victim and whether or not the neck was held. Markings on the neck should be photographed. Careful and complete physical assessment coupled with knowledge of the crime is necessary for a decision on neck injury evaluation.

* Chest Wall Injury

The elderly victim is more susceptible to fracture than younger victims. The thoracic cage, which can be brittle, may be susceptible to fracture during an assault. Rib fractures, pulmonary contusions, and cardiac contusions can be detected via radiographs. If the facts of the case indicate the possibility of rib fractures, a radiograph should be obtained. Fractured ribs can create hemothorax or pnemothorax, both of which can be detected via chest x-ray and CT, and suspected when arterial blood gases are abnormal. Chest trauma creates more morbidity and mortality in the elderly than in younger populations.

Rib fractures occur when force is applied to the chest. Force can be applied when the offender overcomes the victim to gain control. If the victim is forced to the floor or ground and falls on the chest, fracture can occur. Ribs can also fracture if the perpetrator lies on top of the victim during the assault or holds the victim in the chest area as a means of restraint. Blows from hands, arms, or legs can fracture ribs as well.

* Abdominal Injury

An estimated 35% of all geriatric patients who are multiple trauma victims suffer from abdominal injury.3

If abdominal injury is suspected, a CT scan should be obtained. Doppler studies may be recommended and an ultrasound can be performed at the bedside. Abdominal injury in the elderly creates mortality five times more often than it does in younger populations.3

Abdominal injury occurs most commonly from blows to the abdomen. Abdominal injury can occur when the perpetrator is on top of the victim and grabbing, restraining, or moving her with force during the assault.

* Extremities

The arms and legs of the elderly are more vulnerable to bruising than younger people. Injury on the inner thighs, especially fingertip bruising from forcing the legs open or scratches on the inner thighs, is a common finding in sexual assault victims. Bruising on the outside of the thigh may be seen if the legs were forced open and pushed against something firm, such as a bedrail or a wall. If the elderly victim's extremities are restrained, bruising of the extremities and tearing of the skin is likely to occur.

* Genital Injuries

Penetration of the vulva, mouth, and anus are the primary sites of genital injury during a sexual assault. Bruises, abrasions, and lacerations need to be assessed. One of the critical problems with observing genital injury in the elderly is an understanding of the mechanism of injury. The most common explanation of genital bruising (and bleeding) in institutionalized elderly is either a "botched catheterization" or "rough perineal care". Bruising to the abdominal area is often attributed to tight restraints. It should be noted that if investigators do not believe an elderly victim's declarations of sexual assault, they may be tempted to attribute any genital injuries to these more commonplace causes.

The few existing studies on elderly rape victims are equivocal regarding injury. Genital trauma, evident even without a colposcope, is more evident in postmenopausal sexually assaulted women than it is in their younger counterparts.14'15 However, as with those 65 and younger, rape may occur without obvious injury.16,17

The medical and forensic records of 129 women ages 50 years or older and 129 women from a comparison group (ages 14 through 49) were reviewed. The records spanned a timeframe between 1986 and 1991. Trauma generally occurred in 67% of the older group and 71% of the younger group. Genital trauma was more common in older victims than in younger victims (66% vs. 49%). Forensic findings were similar in both groups; however, in the older group, motile spermatozoa were seen only in those examined within 6 hours after the assault.13

The high rate of genital injury in this study is related to decreased levels of estrogen in the victims, which leads to less lubrication of the genital mucous membrane as well as thinning genital tissue. The mucous membrane in an elderly woman's genitals is susceptible to trauma because it is atrophie and fragile. The genital mucosa of elderly females is pale, thin, and dry. With the decline of estrogenic stimulus, the labia and clitoris become smaller. The vagina also narrows and becomes shorter, creating the increased probability of vaginal injury.

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

* Hospital Admission

Sexual assault victims are typically evaluated and released, provided the evaluation rules out medical necessity for admission. Considering the fragility of elderly victims of assault, this policy may require revision. Perhaps elder victims of assault should be admitted to a hospital facility to increase the possibility of a more thorough medical evaluation of injury. The probability of detecting injury might increase with longer observation time and additional testing. Admission would also allow the victim to be interviewed in stages, eliminating the pressure for total recollection during one encounter.

Studies of geriatric trauma note that elderly victims have better outcomes if they are admitted to a trauma center following the crime.3 Criteria for admission to a trauma center should be lowered for geriatric victims. If the geriatric victim of assault has an injury requiring medical intervention, requirements for admission to a trauma center should be carefully considered. Admission to such a facility ensures a comprehensive evaluation and early initiation of treatment.

Mortality rates in the injured geriatric population are significantly higher than for younger adults. Even with correction for severity of injury, the elderly are still five to six times more likely to die of similar injuries than their younger people. Careful evaluation over time is required to ensure the health and safety of these older victims.

* Discussion

In assessing elderly victims for assault, physical as well as sexual injury should be considered. In sexual abuse cases involving elders, victims maybe unable to communicate clearly and bruises may be attributed to the aging process. Another problem is that investigators may not be trained in how to properly examine and question an elderly victim.

In addition, investigators may not believe that a rape occurred simply because the victim is elderly. To counter this attitude, NPs are advised to examine and record all of the information they receive as they would in any other type of forensic case. The only people designated to determine whether or not a sexual assault occurred are the judge and jury who try the case.

In summary, when elderly people are victimized, they may suffer greater physical injuries than people of other age groups. Furthermore, the aging process brings decreased ability to heal after injury. Older victims may never fully recover from the trauma of victimization.

CE Test

Effectively Detect and Manage Elder Abuse

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REFERENCES

1. Centers for Disease Control and Prevention. The effects of unintentional injury. Activity Report 2001 CDC's Unintentional Injury Prevention Program. Available at http://www.cdc.gov/ncipc/pub-res/unintentional_activity/ 02_effects.htm. Accessed june 28, 2004.

2. Bobb J: Trauma in the elderly. J. Gerontologie Nursing 1995; 13(10):8-15.

3. Levy D, Hanlon D, Townsend R: Geriatric trauma. Geriatric Emergency Care 1993; 9(3): 601-20.

4. Finelli F, Champion HR, Morelli S, et al: A case-controlled study of major trauma in geriatric patients. J Trauma 1989; 29:541-8.

5. Murphy SL: Deaths: Final data for 1998. National Vital Statistics Reports, vol 48 no. 11. Hyattsville, Md: National Center for Health Statistics, 2000

6. Champion E, Mulley AG, Goldstein RL, et al: Medical intensive care for the elderly. JAMA 1991;246{18):2052-6.

7. Lachs MS, Williams CS, O'Brien S, et ni: The mortality of elder mistreatment. JAMA 1998;280(5):428-32.

8. Office for Victims of Crime Publication: Elderly Victims 2001. Found at www.ojp.usdoj.gov/ovc/publications. Accessed june 28, 2004.

9. Sheridan D: Domestic violence a critical public health problem. Presentation at the University of Pennsylvania School of Nursing, April 2004.

10. Susman M, DiRusso SM, Sullivan T, et al.: Traumatic brain injury in the elderly: increased mortality and worse functional outcome at discharge despite lower injury severity. J Trauma 2002;53(2):391.

11. Hogue C: Injury in later life: epidemiology. J Am Geriatric Soc 1992; 30{5):183-190.

12. Pentland B, Jones PA, Roy CW, et al:, Head injury in the elderly. Aging 1996;15(4):193-201.

13. Fogelholm R, Helskonon O, Waltimo (D): Chronic subdurals in adults: influence of patient's age. J Neurosurg 1995;42(9):43-6.

14. Ramin SM: Sexual assualt in postmenopausal women. Obst Gynecol 1992;80(5):860-4.

15. Cartwright PS: Factors that correlate with injury sustained by survivors of sexual assault. Obstetrics and Gynecology 1987;70(l):44-6.

16. Cartright PS, Moore RA: The elderly rape victim. Southern Medical Journal 1989; 82(8)988-9.

17. TyraPA: Older women: victims of rape. J Gerontol Nurs 1993;19(5):7-12.

18. Slaughter L, Brown CR: Patterns of genital injury in female sexual assault vicitms. Am J Obstet Gynecol 1997; 176(3): 609-16.

Kathleen Brown, RIM, PhD, NPG

George E. Streubert, MD

Ann W. Burgess, RIM, DNSc, CS

AUTHOR DISCLOSURE

The authors have disclosed that they have no significant relationship or financial interest in any commercial companies that pertain to this education activity.

ABOUT THE AUTHORS

Dr. Brown is a Nurse Practitioner in Women's Health and Faculty at the University of Pennsylvania School of Nursing, Philadelphia. Dr. Streubert is in private radiology practice in Bethlehem, Pa. Dr. Burgess is Faculty at Boston College School of Nursing.

Copyright Springhouse Corporation Aug 2004
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