Elder Justice Roundtable: Short Papers

Ann W. Burgess, Elizabeth B. Dowdell, and Robert A. Prentky

Pilot Study of 20 Sexually Abused Nursing Home Residents
Demographic Characteristics of Victims

Eighteen of the 20 sexually abused residents were Caucasian, widowed females older than age 80, a profile consistent with nursing home populations in general. Sixteen of the residents were white, 3 were Hispanic, and 1 was black. Fourteen residents were widowed, four were single and never married, and two were married. Ages of the residents were as follows: younger than 70: 16, 33, 55, and 63; in their 70s (n=5); in their 80s (n=9); and in their 90s (n=2).

All residents were in a long-term nursing home facility and required skilled nursing intervention. Although 5 residents were able to ambulate on their own, the other 15 were confined either to bed or to a wheelchair.

Mental Status
Although the majority of the residents suffered from a primary diagnosis of dementia or Alzheimer's disease (n=12), other cognitive and neurological disorders included cerebral vascular accident (n=3), brain trauma from gunshot wound (n=1) and motor vehicular accident (n=1), polynuclear palsy (n=1), amyotrophic lateral sclerosis (n=1), and major depression (n=1). Many had multiple physical disease diagnoses, such as stroke, cataracts, hypertension, diabetes, and congestive heart failure.

Method of Disclosure
Because of their dependent status and their cognitive limitations, residents did not have the ability to report abuse directly to law enforcement. Rather, the abuse had to come to someone else's attention or the resident had to bring it to someone's attention in order for the abuse to be noted. In the sample of 20, 4 major methods of disclosure were observed: (1) informing a family member (n=7); (2) informing a staff person (n=3); (3) abuse witnessed by staff or suspected by staff (n=7); and (4) clues detected by staff (n=4). Some cases included multiple methods of disclosure.

Perpetrator Identification
Although the majority of the residents had serious cognitive deficits, only three perpetrators went unidentified. Some residents were able to give a full description.

Physical and Forensic Evidence
The standard procedure in suspected sexual assault cases is to conduct a forensic rape examination. In the nursing home cases reported here, the examination often was difficult because of (1) the resistance of the resident to the pelvic exam (e.g., "legs drawn up and resists any movement of legs"); (2) not being able to visualize the pelvic area or complete the examination due to severe leg contractures (e.g., "legs contracted and would not open"); (3) difficulty in communicating and explaining the exam with demented and cognitively impaired residents (e.g., "Needed daughter present to communicate with mother"); and (4) difficulty obtaining reliable and accurate victim report of the assault, injuries sustained, and regions of pain or discomfort (e.g., "When asked if she hurt anywhere or if anyone hurt her, she laughed and mumbled").

In 10 cases, no examinations were conducted, usually because of the delayed reporting, not believing the resident, or failing to follow protocol. Of the 10 exams that were conducted, 6 revealed some type of positive evidence ("intercourse, nontraumatic with copious amount of discharge"); 2 had vaginal bleeding but no sperm were noted; and 2 revealed no physical or forensic evidence. The primary evidence relating to a sexual assault included presence of semen and bruising in the pelvic area. Secondary evidence included vaginal or purulent discharge, evidence of a sexually transmitted disease, or positive findings of blood.

In four cases, there was redness and swelling noted in the vaginal area. The force of the assault, in 4 cases, left serious bruising. Forensic examination of an 89-year-old widow revealed separation of the symphysis pubis bone, an inguinal hematoma, and swelling and bruising to the right labia. It was difficult to examine the resident because she resisted any movement of her legs. Her groin was severely bruised, and she had a purulent vaginal discharge. She remained in fetal position, moaning in pain. She would not allow her blood pressure to be taken and would draw up her legs.

Rape exams were not completed on the two male residents. In one case, the doctor had heard rumors of abuse of this resident around the hospital but paid no attention because he did not think that the rumors were likely to be true. He had no training or experience in assessing sexual abuse of males. The second case was viewed as involving consenting sexual contact.

Discussion
In this study, 20 residents of nursing homes who had been sexually assaulted were examined. These residents predominantly were elderly victims who exhibited rape-related trauma symptoms, general symptoms of traumatic stress (e.g., fear, confusion, hypersomnia, lack of appetite, withdrawal), and an exacerbation of symptoms related to their primary diagnoses. These preliminary findings suggest that the presence of a preexisting cognitive deficit, such as a dementia, markedly delays information processing and impairs communication in a highly vulnerable population, which potentially compounds the trauma of the sexual assault. From both a clinical and theoretical perspective, there is every reason to believe that vulnerability due to physical frailty and emotional fragility places elderly victims at unusually high risk for severe traumatic reactions to assault. These victims simply are not equipped, either physically, constitutionally, or psychologically, to defend against and cope with the proximal effects of assault. Perhaps the single most profound result of the sexual assaults against these elderly victims is that 11 of the 20 victims died within 12 months of the assault. Because more than half of these victims were age 80 to 95 at the time of the assault, it cannot be asserted that the death was a distal effect of the assault. Although it is impossible to determine in each case whether the assault accelerated death, the fact that more than half of the victims died, not from the assault itself but within months of the assault, is clearly noteworthy.

Rape trauma syndrome, which includes both acute and long-term symptom responses to traumatic sexual assault, has two distinct variations: compounded rape trauma and silent rape trauma (Burgess and Holmstrom, 1974). In compounded rape trauma, victims have a past and/or current history of psychiatric, psychosocial problems that compound the effects of the sexual assault. In silent rape trauma, expression of assault-related symptomotology is muted, undetected, or absent. It was clear from this review of these 20 cases that the nursing home victims were subject to both compounded and silent rape trauma. Most of the victims had preexisting areas of weakness or vulnerability, primarily physical and cognitive, that served to complicate the assault symptom presentation. In addition, many of the victims suffered in silence, and the assault became known only after suspicious clues or evidence were noted by staff or family.

In a study of work-related rape, Brodsky (1976) reported that there is a difference in the initial reaction of the victim if the rape occurs when walking through a high-risk area where violence is expected or if the victim is attacked in what is considered "home territory." Brodsky defined home and work settings as safe ground and emphasized that adults have a stronger reaction when that safe ground is invaded.

In translating Brodsky's notion of territorial safety to the elderly, it easily may be argued that the nursing home is, for the resident, precisely that-a home, and that the staff function as the resident's caregivers (in both a literal and figurative sense). The nursing home and its staff are perceived as "safe," and violations represent a more profound betrayal of trust than violations committed outside the sanctity of the home.

Although this study represents a preliminary examination of what appears to be yet another area of "hidden" rape, the findings have obvious clinical, forensic, and policy implications. All nursing home personnel should be trained rigorously to identify signs and symptoms of assault-related trauma and to be vigilant to suspicious, preassault behaviors, including the same grooming and manipulation observed with most other sex offenders (Burgess, Prentky, and Dowdell, 2000; Prentky and Burgess, 2000). In particular, staff must be trained to detect the emergence of symptoms, including noteworthy changes in baseline behavior in victims who are likely to exhibit symptoms in a muted or "silent" fashion.

A thorough physical, cognitive, and psychosocial assessment must be completed at the time of admission to the nursing home. These assessments are particularly critical because they provide nursing staff and other caregivers with a baseline from which to judge behavioral changes. The American Nurses Association (1991) standards mandate that nurses take action when a patient's condition deteriorates. A major area of litigation results from failure to assess and respond properly to untoward changes in the condition of a patient.

Perhaps the most disturbing observation made was the frequently noted lack of sensitivity of nursing home staff to the gravity of the assaults on the residents. Responses ranged from cynical disbelief that anyone would sexually assault an elderly individual to what can be described as a perverse sense of amusement. There is a well-known pattern of bystander apathy and bystander inaction in response to crime (Shotland and Goodstein, 1984), and the same pattern appears evident in this case. However, one major difference is that these "bystanders" are not strangers who happen on a victim in the street. These bystanders are professionals charged with the care and protection of these residents.

Although this study has obvious limitations, most notably a small forensic sample that may not be generalizable to nonforensic samples, the findings are disturbing. As more is learned about this new subgroup of rape victims, four critical prevention areas require focus:
Screening procedures for hiring new staff.

· Training regimens for staff.
· New guidelines for conducting rape trauma examinations with elderly patients.
· Recommendations for increasing the safety of the nursing home environment.

References
American Nurses Association. Standards of Clinical Practice. Washington, DC: Author, 1991.

Brodsky, C. "Rape at Work," in Sexual Assault: The Victim and the Rapist, ed. M.J. Walker and S.L. Brodsky, Lexington, MA: Heath, 1991, 35-52.

Burgess, A.W. Violence Through a Forensic Lens. King of Prussia, PA: Nursing Spectrum, 2000.

Burgess, A.W., E.B. Dowdell, and R.A. Prentky. "Sexual Abuse of Nursing Home Residents." Journal of Psychosocial Nursing 38 (6) (2000): 10-18.

Burgess, A.W., and L.L. Holmstrom. "Rape Trauma Syndrome." American Journal of Psychiatry 131 (1974): 981-986.

Burgess, A.W., R.A. Prentky, and E.B. Dowdell. "Sexual Predators in Nursing Homes." Journal of Psychosocial Nursing 38 (8) (2000): 26-35.

Crowell, N.A., and A.W. Burgess. Understanding Violence Against Women. Washington, DC: National Academy Press, 1996.

Prentky, R.A., and A.W. Burgess. Forensic Management of Sexual Offenders. New York: Kluwer Academic/Plenum Publishers, 2000.

Shotland, R.S., and L.J. Goodstein. The Role of Bystanders in Crime Control. Journal of Social Issues 40 (1) (1984): 9-26.

Kerry P. Burnight, Ph.D.
University of California Irvine
College of Medicine
Assistant Clinical Professor

Elder Justice: Medical Forensic Issues Concerning Abuse and Neglect

What Areas of Further Research Would Promote the Detection and Diagnosis of Elder Abuse and Neglect and Forensic Application Thereof?

For hundreds of thousands of Americans, old age is unnecessarily, and at times, excruciatingly painful and humiliating as a result of elder abuse and neglect. As attendees of this roundtable, we have the opportunity to take a step forward in addressing a critical but underdeveloped area: the medical forensic issues concerning abuse. Our understanding, and therefore our ability to adequately address the problem, has been limited by the coupling of inconsistent definitions and systems; the complex, multifaceted nature of the problem; limited awareness/understanding on the part of the medical community; and the lack of support for systematic research. Areas of further research that would promote the detection and diagnosis of elder abuse and neglect and forensic application thereof include the following.

Detecting Elder Abuse and Neglect
The first step in helping the victims of abuse is finding them. From a medical perspective, there are seniors who have at least some contact with a healthcare provider and those who do not. Seniors in both groups are the victims of abuse and neglect, but research on the best identification strategy is dependent upon the group.

Seniors who have some contact with a healthcare provider. Despite the fact that the medical community sees tens of thousands of patients each day, healthcare providers account for a small percentage of the reports to adult protective services. Systematic research on the victim, perpetrator, and situational indicators (physical and psychological) of elder abuse and neglect could provide the basis of a sound, standardized medical screening tool for elder abuse and neglect.

Seniors who have no contact with a healthcare provider. Accurate screening by healthcare providers would not benefit those who do not receive health or social services. As millions of American seniors are enrolled in medicare health maintenance organizations, one approach to understand abuse in "invisible" seniors is to use managed care data to identify seniors who have not seen a healthcare professional in a specified amount of time. A sample of identified seniors could be evaluated to look for abuse and neglect that would not otherwise come to the attention of mandated reporters.

Diagnosing Elder Abuse and Neglect
To determine whether injuries observed in examination are consistent with the history presented, we need to understand mechanisms of injury in the geriatric population. For example, while bruises are a common manifestation of physical abuse, they are also a normal physical finding in geriatric populations. Research on bruising (cause, duration, and color resolution studies) would help health providers in their assessment of accidental and inflicted bruises. There is also a need for medical forensic research on the circumstances surrounding the development of stage I, stage II, stage III, and stage IV pressure ulcers and the validity of the "spontaneous fracture" phenomenon. One way to understand the mechanisms of injury in older adults would be to establish a national database of witnessed, documented injuries in older adults. This database would be valuable in understanding how accidental and intentional injuries are likely to present in the geriatric population.

Documenting Elder Abuse and Neglect
To accurately document elder abuse and neglect, we need to systematically identify the elements of a well-documented and interpreted injury or condition. It would be interesting to determine to what extent physicians use cameras to document injuries and how greater use of photographic documentation may impact treatment and prosecution outcomes. This type of research would be instrumental in the development of a standardized elder abuse documentation form designed to improve the treatment and prosecution of cases of elder abuse.

Reporting Cases of Suspected Elder Abuse and Neglect
There is a need for research that examines the relationship between adult protective services (APS) and the medical community. It is critical to understand what type of medical expertise is most helpful to APS. Does the healthcare community have the expertise needed by APS? To what extent are experts in the healthcare community available to APS? How could we increase APS access to the expertise of the healthcare community?

It would be useful to determine whether there are systematic differences in the types of cases of elder abuse and neglect that are not currently being reported to APS. What role could the healthcare community play in finding and reporting such cases?

Testifying in Cases of Elder Abuse and Neglect
Research is needed to build our understanding of the role of medical forensic information in prosecution. For example, what medical documentation factors are associated with convictions for elder abuse and neglect? What factors facilitate or impede disclosure of medical information? Do referrals to a multidisciplinary medical elder abuse team impact victim outcomes or conviction rates? What types of medical expertise, evidence, or documentation would be most helpful to the law enforcement and legal community? Does the healthcare community currently have the expertise needed by law enforcement and the legal community? To what extent are medical experts available to the law enforcement and the legal community? How could access to needed medical input/expertise be increased?

Marie-Therese Connolly1
Nursing Home Initiative Coordinator
U.S. Department of Justice

Elder Abuse and Neglect Prevention Efforts Through the Nursing Home Initiative

The Department of Justice Nursing Home Initiative was launched in late 1998 amidst reports of serious quality deficiencies in a significant percentage of the nation's nursing homes. In early 1999, a Department-sponsored focus group charged with recommending steps to reduce abuse, neglect, and fraud in nursing homes urged enhanced enforcement, training, and coordination across the board. Although the Nursing Home Initiative has focused on elder abuse and neglect in institutional settings, through it we also have attempted to undertake projects that will promote prevention of elder abuse and neglect in whatever setting it occurs. The Department's activities relating to medical forensic issues have included the following:

Stepped-up enforcement. Although there is no Federal elder abuse and neglect statute, the Department does pursue civil, criminal, and civil rights cases raising claims of elder abuse and neglect, primarily in institutional settings. These cases primarily are pursued under false statement and financial fraud theories. The Department, however, has sent Congress a new proposed Federal abuse and neglect bill to supplement and fill gaps in current Federal authority. This proposed statute would provide criminal, civil, and injunctive remedies where patterns of violations result in harm to residents.

Under the civil False Claims Act (FCA), an entity is liable for submitting false claims for payment of Federal funds. In recent years, the Department has begun to pursue FCA "failure of care" cases, where the Medicare program was fraudulently billed for services that were not rendered or were so grossly deficient so as to be tantamount to no care at all. The failure of care cases brought to date have involved serious injury or death of residents. The defendants were required not only to pay monetary damages but also to enter into agreements intended to protect residents-for example, by imposing a temporary monitor and requiring specific improvements in problem areas. The first failure of care cases involved individual facilities or smaller chains. We also are now involved in financial fraud and failure of care cases against some of the largest chains (with 300 to 450 facilities), several of which recently have filed for bankruptcy. In those cases, we are working closely with the Department of Health and Human Services, Office of Inspector General (HHS/OIG), and the healthcare Financing Administration (HCFA), to ensure implementation of agreements, between the corporation and OIG, that include temporary monitoring and systemic quality improvement measures to decrease resident abuse and neglect.

Similar cases also are being pursued against public facilities under the Civil Rights of Institutionalized Persons Act (CRIPA) for injunctive remedies. In addition, one Federal criminal case was brought against individuals who falsely stated that a resident's injuries-from which she died within 24 hours-were caused by a fall out of bed.

Medical forensic evidence in failure of care cases. Evidence of abuse and/or neglect is critical in failure of care cases. This evidence generally falls into two categories: resident level and systemic. Resident-level data include medical records of residents alleged to have been abused or neglected from any relevant healthcare provider and witness statements. Other potential sources of information are public safety and social service entities, and perhaps funeral homes, as well as the Minimum Data Set survey and payment records. In addition to resident-level evidence, facility or chain-level information may provide evidence of systemic abuse or neglect, such as:

· False statements about staffing levels, or about the qualifications or training of staff.

· Insufficient funds spent on food (leading to malnutrition), supplies (resulting in re-use of single-use supplies), or needed therapies (leading to diminished functioning).

· Minimum Data Set or Quality Indicators that raise red flags or indicate "sentinel events."

· Survey documents finding immediate resident jeopardy and/or consistently poor performance and/or multiple deficiencies in quality of care.

· Data maintained by ombudsmen, adult protective services (APS), advocates, frontline responders, and others, indicating historic problems at particular facilities or chains.

In the interest of effective prevention, intervention, and prosecution, it is critical that those who come in contact with potential victims of elder abuse and neglect-in any setting-are trained to detect, document, and, in accordance with applicable law, refer what they learn.

Multidisciplinary training. Between July 1999 and February 2000, the Department organized four multidisciplinary regional conferences on Nursing Home Abuse and Neglect Prevention. The broad spectrum of attendees included representatives of the Department; FBI; HHS/OIG; HCFA; State Attorneys General, Medicaid Fraud Control Units (MFCU); State survey, licensure, enforcement, Medicaid agencies; APS; State and local long-term care ombudsmen, medical examiners; VA/OIG; VA Community Health; police officers; firefighters; EMTs; physicians; nurses; social workers; and others with varied specialties.

Historically, cases raising issues of elder abuse and neglect have been handled by State and local law enforcement. The Department, however, has been stepping up its efforts in this area in partnership with HHS and our State and local colleagues. One goal of the conferences was to train Federal law enforcement on how to pursue civil and criminal cases with sensitivity to the public health considerations and the complex environment surrounding these cases.

A second goal was simply to bring together Federal, State, and local law enforcement, regulatory, social service, healthcare, and public safety entities with responsibility in the area to discuss these issues. Participants heard diverse views on investigating claims of elder abuse and neglect; what criminal, civil, administrative, and private remedies exist; examples of promising multidisciplinary efforts; and how to distinguish signs of abuse and neglect from benign causes.

Multidisciplinary coordination: State Working Groups. Another primary goal of the conferences was to form (or enhance) State Working Groups to pursue multidisciplinary efforts at the State and local levels. Often participants from the same State had never met before and were unaware of the other entities' functions or existence. Their discussions inevitably noted the chasm between those on the frontlines who respond to and care for victims of elder abuse and neglect and those responsible for enforcing laws prohibiting such conduct. Law enforcement cannot pursue a case unless it is notified of suspicions or allegations. But, even when the appropriate information is provided, these cases can be very difficult to pursue. In June 2000, representatives of the State Working Groups, various national organizations, and others met to discuss what they are doing and their successes and challenges, including the following:

· Groups are reaching out to police, ERs, firefighters, EMTs, MEs, surveyors, ombudsmen, APS, licensing, social service, and healthcare entities. One fire department is developing internal protocols for detecting and reporting suspected elder abuse.

· Some groups are meeting regularly to identify problems and solutions; some are creating referral committees to review each entity's worst cases, to analyze the data showing problem facilities, and to determine the most appropriate types of referrals or action.

· New cases have been opened based on referrals by group members and analysis of data.

· Prosecutors are reaching out to geriatricians, MEs, nurses, and other potential experts.

· One hospital is pursuing development of a forensic center that would provide expert medical opinions in cases of suspected elder abuse or neglect, similar to an existing program that evaluates cases of suspected child abuse and neglect.

· Some groups are learning to identify potential abuse and neglect in reading records.

Other States report significant challenges, including (1) coordination difficulties; (2) personality conflicts; (3) lack of clarity regarding who was responsible for what tasks and who, if anyone, was "in charge"; (4) limited scope and unevenness among group members' knowledge; (5) limited sharing of vital information due to unwillingness by some, or due to privacy and law enforcement prohibitions; (6) concern by some about law enforcement's involvement in elder abuse and neglect cases; (7) the size or demographics in some States; and (8) the lack of support or funding for such an effort from any source.

Despite these challenges, the State Working Groups have shown great enthusiasm and pent-up demand to develop better ways to address these issues. For example, one group expected a handful of people to attend the first meeting. Instead, they had 75 participants from about 25 different entities. The participants welcomed a forum to discuss their efforts, obtain better access to law enforcement, and develop a multidisciplinary response team. In fact, many of the State Working Groups' activities relate to improving the response to elder abuse and neglect, regardless of the setting.

While these efforts are a beginning, much remains to be done. Multidisciplinary efforts are as important at the national policymaking level as they are at the grassroots level. This discussion presents a valuable opportunity to identify recommendations and priorities on how to proceed.

Carmel Bitondo Dyer
Baylor College of Medicine/Harris County Hospital District
Associate Professor of Medicine/Director, Geriatrics Program 

How Can We Identify the Physical and Psychological Markers of
Abuse and Neglect?

How Should We Educate the healthcare Profession
About These Forensic Issues?

The effort by the Department of Justice to examine the issue of abuse and neglect of older Americans is an admirable one. While some look only to the child abuse literature for clues to help deal with elder mistreatment, it is clear to gerontologists that not all the precepts apply to older adults. Children are assumed to lack capacity; adults are considered autonomous until proven otherwise. Children are on a trajectory of growth and development, whereas aging elders, who have made their contributions, become increasingly vulnerable.

A number of theories about the origins of elder mistreatment exist: overburdened caregivers, dependent elders, mentally disturbed caregivers, a childhood of abuse and neglect, or the marginalization of elders in society are all possible etiologies for this public health phenomenon. Despite the fine work done by protective service agencies and other social service organizations, the numbers of mistreated elders continue to rise. Perhaps there is an additional explanation, and perhaps physicians can help.

The Texas Elder Abuse and Mistreatment Institute is collaboration between the Texas Department of Protective and Regulatory Services-Adult Protective Services (APS) Division and the Baylor College of Medicine Geriatrics Program at the Harris County Hospital District. Together, we have directly cared for nearly 300 mistreated elders. Our data show that the majority of APS clients referred are suffering from depression and dementia. Clearly these two disorders can lead to elder self-neglect, but what about elder abuse or criminal neglect? Our analysis of the TDPRS-APS database shows that persons who suffer from self-neglect or medical neglect were more likely to be victims of physical, verbal, or sexual abuse. We believe that the depression and dementia seen in greater numbers of mistreated persons than in the general older population put elders at risk for becoming victims of mistreatment. One of the first steps in identifying the markers of mistreatment is for healthcare professionals to recognize that these risk factors include the classic geriatric syndromes, such as depression and dementia.

The best way to diagnose underlying geriatric syndromes is through the standard well-validated approach called geriatric assessment. Comprehensive assessments of cognitive, mental, and emotional health as well as functional ability and medical illness are evaluated routinely. Geriatric assessment is best performed by interdisciplinary teams traditionally consisting of nurses, social workers, and physicians. The TEAM Institute clinical interdisciplinary team includes the traditional members as well as APS specialists. The APS specialists are able to perform in-home investigations and obtain more information from collateral sources in addition to the comprehensive geriatric assessment performed by the medical team. Together we develop joint care plans of intervention and ongoing followup. We believe this approach results in better patient/client outcomes.

If risk factors for abuse and neglect, such as depression, dementia, and functional loss, can be treated and even reversed, the cycle of abuse or neglect can be broken. If these disorders are detected early rather than late, the use of comprehensive geriatric assessment of frail elders may even prevent elderly victimization.

Geriatricians are trained to perform geriatric assessment and to intervene and treat the disorders they detect. Since there are only 9,000 board-certified geriatricians in the country, it is critical for all physicians who treat adults to be able to recognize elder mistreatment and identify the risk factors. Medical, nursing, and social work students should learn as much about elder abuse as they do about child abuse and domestic violence in their respective training programs. Once elder abuse and neglect is detected, patients can be referred to geriatric teams for treatment.

At Baylor College of Medicine, every third-year student (the total number of students is 167 per year) accompanies APS specialists on one or two in-home investigations. An additional 130 trainees a year are exposed to our work at the TEAM Institute. Several others at Cornell University, University of California-Irvine, the University of Medicine and Dentistry of New Jersey, and the University of Minnesota are teaching physicians about medical-APS teams, but the principles of elder abuse and neglect need to be integrated into curricula across the country. Funding for educational programs is critically needed in every State.

Most of the research in elder mistreatment has been done by social scientists. My colleagues and I have contributed to the literature, but more medical research is needed to make the strong case to academic centers. We need data to prepare curricula that are evidenced based. There is a small but dedicated cadre of researchers in the field; the support of the Department of Justice will be an important first step in raising the national awareness of the serious public health problem of elder mistreatment.

Carl Eisdorfer, Ph.D., M.D.
Professor and Chairman
Department of Psychiatry and Behavioral Sciences
School of Medicine, University of Miami

Donna Cohen, Ph.D.
Professor
Department of Aging and Mental Health
Florida Mental Health Institute
University of South Florida

Homicide-Suicide in Older Persons:
Acts of Violence Against Women

Homicide-suicide (HS) incidents in the older population are intentional acts of violence, directed almost entirely against women. They are not suicide pacts or compassionate HSs where the perpetrator and victim(s) are old and sick. Recent research indicates that these HSs are violent events, usually always carried out by older men, against unwilling or unknowing spouses or older relatives. They are acts of depression and desperation, other forms of psychopathology, or domestic violence. The perpetrators have usually thought about or planned the dyadic deaths for months or longer, and there are clear warning signs that, if detected, could help prevent these tragedies.

Our descriptive epidemiological research in Florida has shown that rates in the population age 55 and older are twice as high as younger persons (Cohen, Llorente, and Eisdorfer, 1998). HSs also account for about 3 percent of all suicides and about 12 percent of all homicides in the older population. Applying these Florida figures to United States data, we estimate that about 200 HSs occur every year in persons age 55 and older, and most involve older men killing spouses or lovers. Therefore, at least 400 deaths are due to successful homicide-suicides each year (Malphurs, Eisdorfer, and Cohen, in press).

HS rates among the older population appear to be increasing in Florida as well as other parts of the country (Cohen, 2000; Eisdorfer and Cohen, 1999). Our Florida studies also suggest that one HS is botched (i.e., one person survives, usually the perpetrator) for every five that are successful. When HSs are unsuccessful, they leave the perpetrators to face criminal charges and prison sentences, but there is significant prosecutorial and judicial discretion (Cohen, 2000; Cohen and Wareham, 1999).

Therefore, clinical, social, forensic, and legal issues need to be addressed to improve our capabilities to intervene and prevent these tragedies. There are important roles for healthcare professionals, forensic examiners, law enforcement officers, and family members and professionals working in aging, mental health, and public health agencies to improve detection, intervention, and prevention (see the Violence and Injury Prevention Web site: www.fmhi.usf.edu/amh/homicide-suicide/index.html). Recommendations should be developed for the consideration of mitigating circumstances during criminal proceedings after unsuccessful HSs, and we need to develop more effective ways to detect and protect older women at risk for domestic violence.

Clinical Patterns
About 85 percent of HSs involve spouses or consorts, and the remaining victims are siblings or other family members. There are at least three types of spousal/consortial HS: dependent-protective, aggressive, and symbiotic (Cohen, 2000; Cohen and Eisdorfer, 1999). A common feature of all three is a perception by the perpetrator of separation and an unacceptable threat to the integrity of the relationship.

One-third of older HSs are the aggressive subtype where there is a history of verbal and/or physical conflict and/or domestic violence. The male perpetrators are about 10 years older than the victims. Neither the perpetrator nor the victim has a physical illness. What usually triggers the HS is when the victim talks about separation or divorce, threatens to do so, or is making plans or actively moving out of the home. The action is usually a surprise attack, the homicide is usually violent, and the victim is shot or stabbed multiple times.

Half of spousal/consortial HSs are the dependent-protective subtype. The husband is usually 2 to 4 years older than his wife, he may or may not have a serious illness, but in most circumstances he is caring for a wife who is chronically ill. There is evidence of serious depression, including helplessness, hopelessness, and vital exhaustion, which in most circumstances has gone undetected and untreated despite frequent medical care contacts. Most of the men have seen a physician within a few weeks of committing the HS.

Twenty percent of older HSs are the symbiotic subtype. In these cases, the male perpetrator is usually a few years older than the victim, and both the husband and wife are usually sick. There is no suicide note signed by both parties, but neighbors and/or family members have reported that both individuals had talked about wanting to die or being better off dead.

One of our most distressing findings is evidence that the older women who are killed are not knowing or willing participants (Cohen and Eisdorfer, 1999). Most are shot in their sleep or in the back of the head or chest. It appears that HSs are unilateral decisions by men with controlling personalities with no evidence from surviving informants that the husband or wife had spoken about wanting to be dead or to be killed.

Intervention and Prevention
There are often many warning signs of the pending violence. Predisposing risk factors include advanced age and a long-lived marriage where one or both members of the couple have real or perceived multiple health problems as well as depression and other psychiatric problems in the perpetrator. Potentiating factors include a perpetrator with a controlling or dominant personality, the perpetrator as a caregiver, marital conflict, domestic violence, and family discord. Precipitating risk factors may include a real or perceived change in the perpetrator or victim's health, pending move to a nursing home, social isolation (staying home and rarely leaving the house), talk of divorce, pending separation, and increased use of alcohol.

These predisposing, potentiating, and precipitating risk factors have important implications. Although HSs have complex motivations, the common theme is an intense attachment of the older perpetrator to a relationship that, when threatened by separation or loss, leads to violent, lethal action. Clinicians should assess the risk for homicide-suicide in all older patients where the following exist: (1) a history of ideation about suicide or violence; or (2) older couples who have been married a long time and one or both have health problems or evidence of domestic strife or discord. Assessment can be complicated for many reasons, especially since the victim, rather than the perpetrator, may be the patient. The perpetrator may also resist evaluation.

The strong evidence of undetected and untreated depression in older perpetrators and the existence of domestic violence in about one-third of older HSs underscores the importance of careful interviews when one or both members of an older couple present for medical appointments. Since the de facto mental healthcare system for older people consists of primary care physicians, substantial efforts are needed to increase their knowledge in recognizing and treating depression as well as ways to combat hopelessness in older people and their caregivers.

Interventions should include intensive treatment of depression and other psychiatric problems when appropriate, removal of guns or other lethal weapons, social support for spouses and families in caregiving situations, and appropriate interventions to deal with marital conflict-especially where the older woman is a potential victim of aggressive, lethal behavior. Intervention is complicated and should be done on a case-by-case basis. Separating the perpetrator and victim may be appropriate to diffuse the tension and protect the victim. A careful clinical plan is essential, however, since separation is often the trigger for violence.

Homicide-suicides are traumatic events that change the lives of family members in many ways and for a long time. Short- and long-term reactions are influenced by many factors, including the history of family relationships, the nature and level of family members' involvement with the perpetrator and the victim, personal coping styles, religious beliefs of family, culture, and influence of friends. Similarly, contact with law enforcement, medical examiners, and journalists in the investigative phases of the incident can affect outcomes. Supportive or counseling services should be made available to survivors.

References
Cohen, D. "An Update on Homicide-Suicide in Older Persons: 1995-2000." Journal of Mental Health and Aging 6 (3) (in press).

Cohen, D. "Homicide-Suicide in Older Persons." Psychiatric Times XVII (1) (2000): 49-52.

Cohen, D. "Homicide-Suicide in the Aged: A Growing Public Health Problem." Journal of Mental Health and Aging 1 (2) (1995): 83-84.

Cohen, D., and C. Eisdorfer. Clinical Patterns of Spousal/Consortial Homicide in the Aged," paper presented to the 9th Congress of the International Psychogeriatric Association, Vancouver, British Columbia, Canada, August 24, 1999.

Cohen, D., M. Llorente, and C. Eisdorfer. "Homicide-Suicide in Older Persons." American Journal of Psychiatry 155 (3) (1998): 390-396.

Eisdorfer, C., and D. Cohen. "Homicide-Suicide Rates in Older People," paper presented to the 9th Congress of the International Psychogeriatric Association, Vancouver, British Columbia, Canada, August 24, 1999.

Malphurs, J, C. Eisdorfer, and D. Cohen. "A Comparison of Antecedents of Homicide-Suicide and Suicide in Older Married Men (in press). American Journal of Geriatric Psychiatry.

Nock, M., and P. Marzuk. "Murder-Suicide: Phenomenology and Clinical Implications." In The Harvard Medical School Guide to Suicide Assessment and Intervention, ed. D.G. Jacobs. San Francisco: Jossey-Bass, 1999.

A paper prepared for the meeting "Elder Justice: Medical Forensic Issues Concerning Abuse and Neglect," Washington, DC, October 18, 2000.

William E. Hauda II, M.D.
Adult Services Medical Director
Inova FACT Center
Forensic Assessment and Consultation Teams

Development of a Forensic Center for the Collection of Forensic Evidence in Abuse and Neglect Cases

Beginning in 1997, a task force consisting of Virginia physicians with expertise in child abuse and Commonwealth's Attorneys experienced in the prosecution of child abuse cases met to develop a system to improve the forensic medical response to child abuse. Concerns of the medical community focused on timely, professional, and consistent quality of care for children in Virginia. Commonwealth's Attorneys' concerns focused on the same issues as well as the need for accurate, comprehensive medical information to assist in charging decisions and prosecuting child abuse cases.

The need for an organized forensic response to child abuse cases arose out of concern regarding how child abuse cases were currently handled. Injuries to a child when treated at a doctor's office or an emergency room may generate a report to child protective services or law enforcement for suspected abuse or neglect. During the investigative phase, further medical evidence may need to be collected to determine whether abuse occurred, what charges are appropriate, and what defenses may require challenges. This forensic information is above and beyond what the treating physician may be capable of documenting and does not directly relate to the medical treatment of the child.

In Virginia, several hospitals had developed programs and services for forensic medical examinations in child sexual abuse cases under the Sexual Assault Nurse Examiner (SANE) programs. Legislation had been enacted in Virginia in the late 1980s to allow payment for the collection of forensic evidence in cases of sexual assault (Virginia Code 19.2-165.1). The money came from a fund established by the Supreme Court of Virginia as a part of its victim services. The task force addressing the forensic response to child abuse recognized that the collection of forensic evidence in child physical abuse and neglect cases would involve medical procedures and documentation similar to the examinations for sexual assault. A legislative initiative was begun to change the law to allow payment to practitioners collecting evidence in cases of child physical abuse or neglect.

The task force set guidelines on the requirements of the examination, the examining practitioner, and the site where the exam would occur. Additionally, some effort was spent to outline the costs of collecting forensic evidence, including the practitioner's time, the cost of appropriate laboratory studies, radiographs, and written documentation. In July 1999, Statute 19.2-165.1 was altered to allow payment to physicians who were collecting evidence in cases involving the abuse of children younger than age 18. The statute required the Commonwealth's Attorney to provide the authorization for payment of the costs of evidence collection.

In July 2000, the Virginia General Assembly altered Statute 19.2-165.1 to include all criminal cases where medical evidence is necessary to establish that a crime has occurred. Exactly who can perform these assessments in adults who are the victims of physical assault or neglect has not been addressed formally. Currently, a Commonwealth's Attorney has the power to designate a physician or facility to perform this service.

In 1991, INOVA Fairfax Hospital became a site for one of the first SANE programs in Virginia. Currently, more than 500 examinations are performed every year by a group of highly trained SANE nurses. This year, INOVA Fairfax Hospital became a site for Pediatric Physical Abuse and Neglect assessments, and the hospital established the INOVA FACT Center. FACT stands for Forensic Assessment and Consultation Teams, as the center provides several services, including examinations of suspected victims of adult sexual assault, pediatric sexual assault, and pediatric physical abuse and neglect. In addition, the center performs body cavity searches for evidence collection for the Fairfax County Adult Detention Center. FACT Center staff also routinely act as medical experts for the defense or prosecution in cases of sexual or physical assaults of both adults and children. The hope is that the center will expand into the area of elder abuse and neglect by developing protocols and appropriately trained staff to perform examinations and medicolegal record reviews.

Catherine Hawes, Ph.D.
Department of Health Policy and Management
School of Rural Public Health Texas A&M Health Science Center

Elder Justice - U.S. Department of Justice Roundtable
Washington, DC: October 18, 2000

There is general agreement that elder abuse and neglect are serious issues, even though we know little about the nature and extent of the problem, the causes, the long-term consequences for the victim, or how to prevent or minimize abuse and neglect. What we can say with confidence is that current research, education, social and health services, and law enforcement systems fall woefully short of what is needed to protect elders from abuse and neglect. Indeed, these systems are, at present, manifestly inadequate to address the problem.

There appear to be a number of factors that are impediments to preventing elder abuse. These include problems of detection or recognition, problems of reporting, problems of proof or attribution, and problems with the usual way such problems are "resolved." Research and education are clearly essential in each of these areas, but so are some changes in the infrastructure we rely on to address elder abuse and neglect.

Recognition/Detection
There are clear problems with detection of abuse and neglect. One cause at least is apparent-there is no agreement about what constitutes abuse and neglect, even among professionals charged with preventing it. For example, one staff member in charge of an abuse registry at a State board of nursing felt that threats, yelling, and cursing by a nursing home employee to a nursing home resident did not constitute abuse. A staff member from a similar agency in another State felt that the actions resulting in "minor bruises" for a frail resident did not constitute physical abuse. Many CNAs in nursing homes also feel that handling residents roughly (e.g., shoving, shaking) or having "startle" reactions when residents exhibit physically aggressive or other challenging behaviors does not constitute abuse but, rather, "self-protection."

· Needed. An authoritative body should define abuse and neglect as it applies to the elderly.

· Research needed. To describe the nature and scope of the problem in community and institutional settings.2
· Funding needed. (1) For education of healthcare professionals and others about what constitutes abuse and neglect; (2) for a public awareness campaign about what constitutes abuse and neglect.

· Education needed. There should be additional education of staff in residential LTC facilities about the effects of dementia, meaning of behaviors, and effective means of addressing behaviors.

Understanding why health professionals do not recognize potential cases is more complex. For example, elders are often admitted to hospitals or seen by primary care physicians with evidence of deplorable hygiene, injuries (including bruises, lacerations, and fractures), skin breakdown, dehydration, and malnourishment. However, even when the problem is so grave that it prevents or delays planned medical procedures (such as surgery), or when a nursing home resident has unambiguous clinical indicators (such as abnormal lab values associated with long-term, severe malnutrition), healthcare professionals seldom suggest investigating the condition to determine whether abuse or neglect is involved. A variety of explanations are possible, including mistaken concepts of what is normal aging, a sense that there is nothing to be accomplished by reporting, a lack of knowledge of how to report suspicions, and so on. But the point is, we do not know why there appears to be inadequate recognition of potential abuse.

Another potential source of recognition and opportunity for prevention comes with interactions between community-dwelling elders and long-term care providers, including case managers, adult day care providers, and home health agency staff. This is particularly true in States that have a single access point for persons receiving Medicaid-funded services.

· Research needed. (1) To develop and test a set of indicators of likely abuse that could be used by healthcare professionals and others in a position to observe or interact with elders who have been subjected to abuse or neglect (e.g., morticians, EMTs). This would include research to test the indicators for sensitivity and specificity; (2) to identify characteristics of victims and perpetrators; (3) to develop and test assessment tools that could be used to identify elders who have been abused (e.g., history of injuries) or neglected, or are at high risk for abuse or neglect (e.g., dementia, behaviors, brittle support systems); (4) to identify any barriers to recognition of signs and to determine the conditions under which such indicators would be used.

· Outreach needed. To State agencies and community-based LTC providers to encourage them to screen for abuse and neglect.

· Funding needed. For the National Ombudsman Resource Center to expand their training of local ombudsmen (staff and volunteers) on detecting and reporting abuse and neglect in residential long-term care settings.
· Education needed. (1) Of healthcare professionals, particularly in emergency rooms, on normal aging and how to detect abuse and neglect; (2) of hospitals on appropriate treatment of older persons (since abuse in hospitals also occurs).

Reporting
Reporting of abuse and neglect is a disaster at nearly all levels. As with much family violence, abuse of elders by family members remains a secret. But even when the abuser is not a family member, there is a lack of reporting. Families and residents in residential long-term care settings are reluctant to complain and to report problems. Workers in these facilities are reluctant to report abuse and neglect when they observe it. And, as noted, healthcare professionals who are in a position to observe the consequences of abuse or neglect tend to underreport. Moreover, there may be a mix of reasons, including organizational imperatives, that militate against reporting by healthcare professionals.

Yet even if they do report to entities identified to address complaints of abuse or neglect, the response is sometimes inadequate. For example, some officials who receive allegations about abuse or neglect in nursing homes, such as ombudsmen and even State agencies (e.g., State survey agencies, boards of nursing), do not report the allegations to law enforcement or suggest the complainant do so, even when the incidents involve such law breaking as rape or assault. In addition, some officials charged with handling complaints have little training in forensics and investigative techniques. For example, some State agencies do not pursue allegations of abuse when the incident is classified as "of unknown origin." Thus, for example, if there is no alleged perpetrator named, they may not pursue investigations of an incident in which there was clearly abuse (e.g., a nursing home resident with dementia has been beaten during the night shift). Further, State agencies feel trapped in a "he said/she said" situation, in which the allegation by a resident or family of someone in a residential LTC facility typically loses if there is no other witness. This was the kind of situation faced by victims of rape, but in nursing home cases, it often results in the case not even being investigated because the agency concludes it cannot "substantiate" the allegation. Finally, State agencies report that local law enforcement is disinterested in nursing home cases, ignorant of how to investigate cases, and disinclined to prosecute.

· Research needed. (1) That explores the reasons for reluctance to report allegations of abuse and neglect when evidence is observed; (2) to determine the extent to which there is knowledge of whether reporting is required and how such reporting should be done; (3) demonstrations of programs to improve reporting and evaluations of their effects; (4) that examines the effect of State laws on mandatory abuse reporting on how incidents are handled and whether law enforcement is appropriate involved.

· Education/training needed. (1) Of those who investigate allegations involving abuse of persons living in residential LTC settings (e.g., nursing homes, board and care homes); (2) for nurses, physicians, EMTS, social workers, and public health professionals on how to recognize and respond to potential cases of abuse and neglect.
· Initiatives needed. To increase coordination between those typically charged with investigating allegations (e.g., State survey agencies, ombudsmen, boards of nursing, adult protective services) and local police and prosecutors.

Attribution
Even if detection and reporting were improved, the problem of proof would remain. This is a profound problem in for elders in both community and residential LTC settings. There is a tendency, in effect, to blame the victims of elder abuse by regarding their "problems," such as pressure ulcers, fractures, wandering off and being injured, undernourishment, and so on, as inevitable consequences of aging and having chronic diseases. Indeed, this is the argument advanced by defense attorneys in civil cases. It is important to note that epidemiological/health services research can contribute to this.

Another complication in cases is the move toward respecting the autonomy of elders and their choices, some of which may involve accepting risks of negative outcomes as a corollary of maintaining the independence and quality of life the elder desires. Indeed, in assisted living, there is a move toward explicit "risk contracts" between the facility and a resident (although there are some concerns about the nature and fairness of some contracts). Thus, some negative outcomes or injuries may be a result of explicit choices by the elder or a caregiver that are intended to enhance the elder's quality of life. Distinguishing the effects of abuse and neglect from either the natural consequences of aging and of chronic disease or the consequences of genuine autonomy-enhancing choices is difficult.

A final issue related to attribution and elder abuse is specific to those elders living in residential LTC settings. There is a tendency in current State and Federal regulations and investigations to focus on an individual perpetrator, usually a CNA, while ignoring the facility practices that led inexorably to the abuse or neglect. However, prevention of abuse and neglect necessarily involves identifying those facility practices, taking steps to hold individual facilities accountable, and devising interventions to eliminate those practices.

· Research needed. That delineates between negative outcomes associated with disease processes that cannot be reversed or whose trajectory cannot be altered and those associated with inadequate care, including abuse and neglect.

· Development and funding needed. For forensic centers that can support clinical case findings and train multidisciplinary teams and coroners.

· Education needed. (1) In medical schools and residency programs for physicians an geriatrics, normal aging, and how to recognize abuse and neglect, as well as preventable decline from other sources; (2) for investigators on how to use both individual, resident-level data (e.g., medical records) and also facility-level data (e.g., cost reports, staffing data) to support attribution of neglect and abuse to deliberate facility policies.

· Outreach needed. To the healthcare community for expert witnesses.

Resolution
Issues related to resolution and prevention must also be addressed to achieve justice for elders. Little is known about existing efforts to prevent abuse and neglect, including the effectiveness of mandatory abuse reporting laws and nurse aide registries of persons banned from nursing home employment for abusing or neglecting residents. Similarly, there is no systematic and comprehensive compendium of existing community interventions to prevent abuse and neglect, even though there have been some initiatives funded by such Federal agencies as the Centers for Disease Control and Prevention and national and local foundations. For example, there is a DHHS Secretary's working group on elder abuse, but there is scant information available about their activities or conclusions. Moreover, there have been few, if any, rigorous, well-funded evaluations of the effectiveness of program interventions designed to prevent abuse and neglect.

Finally, we need to address the conundrum that may be faced by frail, dependent community-dwelling elders who have been victimized by a family caregiver. The result of any prosecution of the perpetrator may well have a negative outcome for the elder, who may be removed from the realm of the perpetrator but find himself or herself also losing the ability to live in the community. This is particularly true, given the paucity of long-term community-based services that would replace a family caregiver. Thus, the result may be removing the elder from the "clutches" of an abusive or neglectful family caregiver but placing the elder in an institutional setting in which he or she encounters a new set of losses and risks. (Of course, such a placement could be very positive in terms of both quality of care and life for the elder.)

· Research needed. To help determine what works and what does not. Demonstration projects and well-designed evaluations of prevention strategies for both community- dwelling elderly and those who live in residential LTC settings are needed.

· Infrastructure needed. A Department of Justice task force that will maintain and focus activities on elder justice in the area of preventing abuse and neglect.

Candace J. Heisler
San Francisco District Attorney's Office
Consultant and Trainer

The Criminal Justice System and healthcare Professionals: A Critical Collaboration to Protect Victims and Detect Abuse and Neglect

Investigation and prosecution of elder abuse and neglect are complex issues for the criminal justice system. Most peace officers and prosecutors lack knowledge about, understanding of, and training in the detection, investigation, and prosecution of cases. Most agencies do not consider abuse and neglect of the elderly an agency priority. Few have dedicated staff to handle these specialized cases. Referrals from other agencies and disciplines are anything but common.

Yet the reality is that as this country ages, the number of vulnerable seniors continues to increase. Thanks to medical advances, seniors are living longer than ever before. Many have amassed considerable private wealth. But these changes come at a price. Many seniors have outlived friends and spouses and are socially isolated. Changes in family structure mean that family members may be spread a considerable distance from aging parents with infrequent contact. Longevity is often accompanied by declining health marked by chronic medical and mental conditions requiring frequent visits to physicians, more medications, and longer hospitalizations. Injuries occur more easily, and medications to treat them often cause conditions that resemble injuries from abuse. Some diseases may lead to wasting. Others may result in ulcers, even with quality care. These conditions may be confused with neglect.

When criminal conduct has occurred, prompt detection, documentation, and referral are critical to permit the effective development of cases by the criminal justice system. For law enforcement, the following issues must be addressed:

1. Has a crime occurred? Are all of the necessary elements provable beyond a reasonable doubt?

2. Can the perpetrator be identified beyond a reasonable doubt?

3. Is the victim legally competent to provide evidence?

healthcare professionals play critical roles in resolving each of these issues.

In determining whether a crime occurred, healthcare professionals assist in case development by documenting injuries, preexisting conditions, and level of cognitive functioning. Toxicology screens pinpoint presence of drugs and levels. Medical evaluations document weight loss, wasting, apparent bruising, and skin breakdowns and their probable causes.

Critical tasks include patient screening, documentation, referral, and staff training.

Screening of elderly male and female patients for domestic and elder abuse and neglect in the emergency department and a variety of clinics, such as general medicine, orthopedics, and geriatrics, should be institutionalized, much like screening of women for domestic violence has become over the last several years. Screening questions need to be developed for elderly patients who are verbal. These should be administered (verbally or in writing), according to the abilities of the patient. Procedures to ensure examination away from possible abusers and disbelieving family members also should be developed.

Documentation must include written descriptions, use of body diagrams (maps), and photographing of all possible injury sites. When at-risk situations are disclosed or suspected, medical staff members need to offer community resources; make referrals, consistent with local law, to Adult Protective Services (or its functional equivalent); and provide safety planning services.

Medical facilities should evaluate which clinics are best able to meet the needs of elderly abuse and neglect patients and provide needed assessment, documentation, and expertise for the patient as well as criminal and civil justice systems. Development of geriatric assessment centers, such as in Harris County (Houston, Texas), may be beneficial. "One-stop shopping" may be in the best interest of the patient, the health facility, and the justice systems.

Medical facilities may also provide a unique and safe location for delivery of community services to patients. Medical facilities are one place an elderly abuse victim can go without arousing the suspicion of an abuser-caretaker. A hospital may be a safe place for elderly support groups to meet. Seniors often benefit from support groups that can improve patient health by reducing isolation, developing safety plans, and empowering through group therapy. Such a model has been developed in Wisconsin with considerable success.

Finally, medical professionals need updated training in the recognition, screening, and documentation of elder abuse and neglect. The training should address local reporting laws, how to work with criminal justice agencies, and State elder abuse and neglect laws. Training should be provided to every staff member whose duties include contact with the public. One such model training curriculum has been developed in California by the University of California and Children's Hospital in San Diego.

Because of severe underreporting of elder abuse and neglect, healthcare professionals are often the only professionals with contact with seniors. Thus, healthcare providers are uniquely situated to identify possible criminal victimization and stop their continuation. In most States, healthcare professionals are mandated to report suspected abuse and neglect. Yet the reality is that many are unaware of their reporting duties. Others may be aware but, for a variety of reasons, decide not to report. Sanctions for failing to report are largely nonexistent. Careful thought must be given to ways to encourage and support those who do report. Efforts to increase awareness of reporting laws and recognition of probable abuse and neglect situations must be expanded. If, after raising awareness, healthcare providers continue to disregard reporting laws, then sanctions for failure to report need to be employed.

Prompt reporting, consistent with local mandates, ensures that corroborating evidence from the victim, other witnesses, and physical evidence is collected before it can be destroyed, forgotten, or degraded.

If the elder has died, important questions of causation must be addressed. Medical examiners and coroners play a key role in detecting abuse and neglect. Their successful assessment requires (1) training of coroners, their deputies, paramedics, and mortuary personnel in recognizing suspicious elder deaths; (2) development of policies that encourage referral of all elder suspicious deaths to the coroner-medical examiner. Such policies need to encourage an "index of suspicion" when elderly persons die unexpectedly and suspiciously. Policies that discourage the autopsy of persons based solely on their age and the expense should be reviewed; (3) development of notification systems between medical examiner-coroner offices and law enforcement agencies to identify seniors who may be the subject of abuse, neglect, and/or financial exploitation investigations.

Because healthcare professionals often have ongoing and long-term contact with an elder, they are often aware of the key persons in that elder's life, such as caretakers and new friends and family. Since most perpetrators are the elder individual's family members and caregivers, identification of these persons in the medical history often provides critical evidence. In addition, medical staff may observe interactions between the elder and family member that may raise suspicion or even constitute new criminal conduct.

Finally, in every criminal elder abuse and neglect case, a determination of the victim's legal competence to testify or engage in certain disputed conduct must be made. If the victim is competent, there may be no crime. If the elder is not, then other available evidence must be assessed to see if it is sufficient to prove a crime has occurred. In either instance, medical professionals provide critical information and evidence to the criminal justice system.

Before completing this paper, a brief word needs to be spent addressing how medical professionals can improve their community's response to elder abuse and neglect through collaboration with the criminal justice system and others:

1. Health professionals can participate in multidisciplinary elder abuse teams to identify cases of abuse and neglect, help craft effective interventions, and participate in multidisciplinary training.

2. They can participate in family violence coordinating councils and task forces to ensure that the needs of elderly abuse victims are addressed.

3. They can participate in Elder Death (Fatality) Review Committees. Such teams are well established for child abuse, are evolving in domestic violence, and should be developed for elder abuse.

David R. Hoffman
United States Attorney's Office
Assistant United States Attorney

The Role of Forensic Evidence in Successful Prosecution of Elder Abuse3

Elder abuse has been defined to include physical assault, emotional abuse, active and passive neglect, and financial exploitation. I will focus on the issue of neglect, especially in an institutional setting.

Too many frail older adults are victims of active neglect. The medical community (i.e., medical directors of long-term care facilities, emergency room personnel, EMS personnel, or any other first responder on the medical front) is an essential partner in identifying and reporting medical conditions that evidence neglect. Active neglect, including the failure to keep older adults nourished and hydrated by paid caregivers, is rarely prosecuted by law enforcement on any level-Federal, State, or local. The prime reasons are a lack of detecting, documenting, and reporting of appropriate cases; a lack of expert medical testimony to support such prosecutions; and a lack of training of law enforcement personnel to successfully prosecute such cases.

All too often, the defense of inevitability is offered by potential wrongdoers whose story in any other situation would be wholly discounted. For example, an older adult residing in a nursing home loses a significant amount of weight; develops multiple pressure ulcers at various stages, including stage 4; and dies of sepsis as a result of the pressure ulcers. The facility states that the older adult refused to eat, refused a feeding tube, and that nothing would have prevented the inevitable outcome because there were so many underlying medical conditions associated with the older adult. Her attending physician was also the medical director for the long-term care facility. Her nursing home records, however, reveal that there was no documented refusal to eat, no refusal of a feeding tube, and very little regarding multiple conditions, except for possible cancer that had not, in fact, been diagnosed by any physician. No charges are ever brought because no case is ever identified for investigation.

Unfortunately, this scenario is not all that uncommon. While there are clear triggers for reporting of this case to law enforcement and grounds for investigation into the care that was rendered to the older adult, this type of case is often not reviewed by law enforcement. Recognition of forensic indicators, such as pressure ulcers and a lack of an underlying medical "wasting" condition, is critical to the identification of potential criminal or civil actions pertaining to the care rendered to some of the most frail and vulnerable members of our society.

Ian Hood, M.D., J.D.
Philadelphia Medical Examiner's Office
Deputy Medical Examiner

The Forensic Pathologist's Role in Investigation of Suspected Abuse or Neglect of Care-Dependent Persons

Intentional Physical Abuse
Physical abuse of elderly and other care-dependent persons is increasingly recognized in the nursing home setting and the injuries are the same as in any other case of battery, but the fragility of the victims has special implications for the interpretation of their injuries. Because of their fragility, such victims can die from mechanisms that would not seriously injure a more robust person. This may be offered as a defense. Rough handling by a relative nursing an elderly person might not be actionable, whereas the same action by a paid attendant (where a fiduciary relationship exists) would be. Gripping by the shoulders and shaking a young person may be unwise but legally permissible, but the same action directed toward a frail, elderly, incapacitated person can lead to death from head injury and can be criminally actionable.

Head injury. The frail elderly are particularly susceptible to the development of subdural hemorrhage between the brain and inner skull because of senile atrophy of the brain; this has led to the phenomenon of so-called "spontaneous" subdural hematoma in the medical literature, but most subdural hematomas are now considered to be due to minor and unremembered trauma. The frail elderly are also prone to falling as a result of transient ischemic attacks and osteoarthritis, and this has sometimes led to accusations of assault because of the proliferation of bruises and other injuries. However, the distribution and nature of injuries from falls does differ from that typically seen in a beating. Senile ecchymoses are very common in elderly persons and are also frequently mistaken for blunt trauma.

Delayed deaths. Delayed death is a common problem among the elderly, where quite minor trauma may set in motion a chain of events that leads to death in such compromised patients. The pathologist can assist in distinguishing between exacerbation of an underlying condition by an external physical event versus an independent intervening event, a distinction that is critical in deciding to press charges. The pathologist can establish the preexisting state of health of the victim and is critical in establishing that a battery caused death and not any underlying diseases, even though the underlying diseases may have been destined to cause death in the not-too-distant future. Accurate testimony is essential in successfully prosecuting cases where death was caused by either exacerbation of an underlying condition by trauma, or the death was contributed to by trauma but was also due, in part, to the underlying condition of the decedent.

Sexual abuse of incapacitated persons. Because such victims are often unable to complain of what was done to them, the incidence of this phenomenon is likely greater than statistics would suggest. Any vaginal or rectal bleeding found on postmortem examination of an elderly decedent must have its cause established.

Neglect
Decubiti and contractures. Often taken as the hallmark of neglect, the presence of these conditions is not probative of neglect; rather, their nature, distribution, and extent, and any evidence of management, must be taken into account in addition to the nature of the victim in whom they have occurred. In extremely compromised, frail, elderly individuals with combinations of such conditions as peripheral vascular disease, diabetes mellitus, stroke, and dementia, it may be virtually impossible to avoid decubitus formation on areas of the body that have bony prominences but must also support the body weight. Most notably, these include the hips and sacrum. Decubiti appearing elsewhere suggest inadequate management of a patient left for long periods with one leg crossed over the other or an arm crossed on the body without adequate padding, and there is little excuse for the development of decubiti over heels, prominences of the ankles, or knees. Ulcers that form on the labia of elderly women adjacent to indwelling urinary catheters are also suspect as indicative of improper management. Unlike intentional physical abuse, the underlying state of the victim does have an impact on the culpability of potential perpetrators when neglect is suspected as harming or killing a care-dependent person. Establishing a particular perpetrator is the major difficulty at present in attempting to bring criminal charges of manslaughter in such cases.

Contractures. The interpretation of these is also dependent on the condition of the victim who has them. They may be unavoidable in certain neurological conditions but are also usually predictable, and preventive measures can and should be undertaken. Allowing fixed contractures to develop, even in a predestined individual, without consultation and active management, is evidence of neglect and often leads to trading of accusations between professional medical staff, nurses, and physiotherapists. They are particularly likely to be the subject of fraudulent billing of intensive interventional physiotherapy for full range of movement of joints that subsequently turn out to have had no range of movement for months or years.

Malnutrition and dehydration. Examination at autopsy can establish the existence of these conditions, and, in the absence of any other more competent cause of death, they may indeed be the cause of death. Whether they arose from neglect or inadequate management requires careful review of records (adequacy of recordkeeping is a major issue in this area but is outside the role of a pathologist). Malnutrition is an important predisposing factor in many individuals whose deaths are due to other more immediate causes and may reflect improper management, but these conditions are also an acceptable method of managing terminal patients with family consent, particularly where the family has indicated unwillingness to have a nasogastric or PEG tube inserted.

Fractures. The occurrence of fractures in a frail, elderly individual is not proof of actionable neglect or abuse, but prolonged failure to detect them or mismanagement of them may be. They are often difficult to detect in nonambulatory, nonverbal patients, and some delay is understandable and acceptable. Investigation of the circumstances in which any particular fracture may have occurred is required to determine whether negligence or malfeasance was operative in causing them. At autopsy, a forensic pathologist can sometimes establish the mechanism by which a fracture was caused (a radiologist may do the same in a living patient) and can also assess the strength/fragility of both the bones that were broken and the general osteological strength of the patient. This may be important in establishing culpability. There is currently much debate about whether elderly frail, osteoporotic patients sustain fractures as a result of falling or suffer "spontaneous" fractures that then cause them to fall. An important concept to grasp is that of the pathological fracture. This term is applied to fractures in bones as a result of the existence of some underlying condition in the bone, most commonly a metastatic tumor, resulting in its fracture with minimal if any trauma. It is not uncommon for elderly individuals, especially men with prostate cancer, to have underlying malignancies that have metastasized to bone, and these may lead to fractures from no more activity than rolling over in bed.

General Medical Management
A pathologist may be able to document some evidence that reflects improper management (for instance oral antibiotics given to treat a loculated fibrinous empyema), but this usually requires other expert opinion from clinicians in a position to comment on adequacy of medical management. Autopsy findings by a pathologist may also incidentally document a discrepancy between management received or, more commonly, not received, by a patient and that documented as given.

Ethical/legal issues. Pathologists often examine cases in which it is obvious that the patients' deaths were mismanaged rather than their illnesses. This is often the result of lack of proper prior directives on the part of the patient, uncertainty as to their roles on the part of the relatives and medical staff, and what the law requires of them in the circumstances. There is no consensus on what "comfort care" means, and medical staff and relatives are reluctant to undertake what they perceive as managed death of a patient even when it may be ethically, medically, and legally indicated.

Mark Lachs, M.D., M.P.H.
Weill Medical College-Cornell University
Co-Chief, Division of Geriatrics and Gerontology
Cornell University

Selected Clinical and Forensic Issues in Elder Abuse

A number of medical and social factors make the detection of elder abuse more difficult than other forms of family violence. The most problematic is the higher prevalence of chronic diseases in older adults. Signs and symptoms of mistreatment may be misattributed to chronic disease, leading to "false negatives" (e.g., fractures ascribed to osteoporosis instead of physical assault). Alternatively, sequelae of many chronic diseases may be misattributed to elder mistreatment, creating "false positives" (e.g. weight loss in a patient due to malignancy ascribed instead to intentional withholding of food).

Certain injuries in children of certain ages are "diagnostic"-little else can produce radiological findings such as these-and the findings must therefore be caused by child abuse. It is unknown if there are diagnostic injuries of elder abuse given the higher prevalence of chronic disease. Part of the research agenda in elder abuse should include studies to determine whether such injuries exist.

"Ageism" in society generally, and in medical practice specifically, is probably also a barrier to detection. Ageism in the medical encounter creates a therapeutic nihilism with respect to the capacity and potential of older people. For example, the death of a child from any cause (and especially from child abuse) is big news; children are not supposed to die. Unfortunately, the death of an older person is not especially noteworthy in our youth-oriented culture. The subtle complacency that these attitudes create may discourage an appropriately detailed evaluation when elder abuse may be the cause.

There are essentially no data on rates of underreporting in elder abuse, although some studies provide some indirect information. Among healthcare professionals, physicians tend to be rarest reporters of elder abuse to State agencies, and one survey of adult protective service professionals suggested that doctors were the least likely group to uncover new cases, after social workers, nurses, paramedical personnel, and other health professionals. Another study indicated that elder abuse victims have substantial interaction with emergency departments, and that these may be missed opportunities for detection. Screening instruments to rapidly identify those at high risk is another area worthy of research efforts.

A recent well-publicized case of child abuse involved the exhumation of two young children who died in the early 1960s under mysterious circumstances. The findings of that exhumation were unmistakable injuries of child abuse; the death certificates listed SIDS and other diagnoses as the cause. This story is instructive in that the state of clinical science surrounding elder abuse in the year 2000 is about where child abuse was in the 1960s.

Erik J. Lindbloom, M.D., M.S.P.H.
University of Missouri
Assistant Professor of Family Medicine

How Can We Identify the Physical and Psychological Markers of Abuse and Neglect?

My interest in this area revolves around the identification of dangerous situations before severe abuse and/or neglect takes place. In my practice and in review of the literature, I have found it helpful to divide the "warning signs" into victim and perpetrator factors. Victim factors include obvious physical signs, such as unexplained bruises, burns, lacerations, or fractures. During a comprehensive visit with any of my older patients, I make an effort to perform a head-to-toe skin exam to detect any of these findings. If there is reluctance on the patient's part, I usually reassure them by explaining that I am looking for any abnormal skin findings, including signs of skin cancer. A potentially subtler marker for mistreatment is frailty. Easier to recognize than it is to concisely define, frailty is a state in which the body and mind have difficulty responding to stressors. Stressors could include disease, change of environment, personal care issues, or any form of mistreatment. A frail elder has been shown in numerous studies to be at higher risk of mistreatment, whether through increased dependence on the caregiver or through increased stress of the caregiver. I assess the patient's degree of frailty by reviewing recent past medical history (particularly looking for signs of chronic disease or incontinence), inquiring about independence in activities of daily living, and performing functional assessments such as gait and fall risk evaluations.

I believe the most significant psychological or neurological marker for the potential mistreatment victim is cognitive impairment. Strong evidence exists that cognitive impairment can lead to abuse and neglect, secondary to behavioral changes, inability to defend, or increased dependence. In addition, the delirious or demented victim is less likely to report instances of mistreatment, making cognitive impairment a huge risk factor for unrecognized abuse and neglect. In addition to screening for cognitive impairment in my older patients, I also screen for depression and substance abuse. Although there is more evidence supporting these issues as perpetrator risk factors, a few studies also report them as markers for the victim as well.

Perpetrator factors can be subtler and less specific, but I consider the caregiver evaluation as important as the patient evaluation during an initial office visit. In addition to screening for depression and substance abuse as mentioned above, I inquire about other mental illness, behavioral issues, or legal problems. Also important is the current relationship between the patient and caregiver. Is there a history of mistreatment (in either direction) in the past? Does the caregiver live with the patient full time? How stressed is the caregiver feeling? Is the caregiver financially dependent on the patient? These are all questions that may suggest an environment at higher risk for mistreatment.

What Areas of Further Research Would Promote the Detection and Diagnosis of Elder Abuse and Neglect and Forensic Application Thereof?
I think the key to future research is multidisciplinary collaboration. In the past, a medical research project may have been considered multidisciplinary if it included two different medical specialties. In more recent years, multidisciplinary teams in geriatric medicine have included physicians, nurses, nurse practitioners, social workers, psychologists, nutritionists, and home care providers. Meaningful research projects in the field of elder mistreatment should continue to cast a wider net of inclusion, using expertise from such fields as sociology, law enforcement, adult protective services, forensic science, and bioethics.

Consensus opinion is needed to help establish what constitutes elder abuse and neglect. There have been definitions published in the past, but gray areas still remain. In my own research, I have come across several instances that cannot be definitively identified as mistreatment. For example, if an older adult with dementia is an unrestrained passenger in a motor vehicle accident, is the caregiver and/or driver guilty of neglect? What if a mildly demented elder is allowed to drive back and forth to the store, even though a physician has expressed concern about that individual's driving ability? Is the caregiver responsible if an accident occurs? These are just some examples that may cause debate, but they probably would not be as unclear if the person in question was a child and not an older adult. The ambiguity and responsibility surrounding guardianship is an area of study that may help clarify some of these tougher situations.

I am also concerned, along with colleagues in my department, that research into elder mistreatment does not lead to an overly aggressive approach to elder death investigations. Given that the vast majority of deaths of those over age 65 are not the result of abuse or neglect, we must constantly sharpen our focus to include only those situations with substantiated risk factors or suspicious circumstances. Otherwise, we run the risk of overwhelming family members, friends, and other care providers who are already grieving a traumatic event. Continuing dialogue is needed among all fields listed above as we hope to advance public awareness and research of elder mistreatment. This elder justice roundtable is definitely a step in the right direction, and I look forward to participating.

Laura Mosqueda, M.D.
University of California, Irvine College of Medicine
Director of Geriatrics/Associate Professor of Family Medicine

"Medical Forensic Issues in Elder Abuse": Attempting to Define the Issues

Clinical forensic medicine relates to any area in which medicine, law enforcement, and the judiciary come into contact. It is a more well-developed science in other countries (notably the United Kingdom); the United States lags behind in knowledge, application, and acceptance of this field.

Elder abuse is a particularly difficult and complicated area within clinical forensic medicine. There are so many types of abuse, so many characteristics of the victim, so many characteristics of the perpetrator, so many socioeconomic contributors, so many cultural issues. How does one make sense of this entanglement?

The field of forensic medicine takes us beyond the objective physical findings that we, as medical clinicians, are used to seeing and documenting. A forensic approach challenges us to ask more questions:

· How did this happen?

· Why did this happen?

· Are these explanations plausible?

· Are these explanations acceptable?

· What other information (history, physical examination, laboratory studies, etc.) may support or refute the likelihood that this was the result of abuse?

(For purposes of this discussion, "abuse" will encompass physical, sexual, psychological, and financial abuse; abandonment; and neglect).

Markers of Abuse
One aspect of forensic medicine involves identifying markers/evidence of possible abuse. healthcare professionals are taught how to evaluate an injury from a routine medical perspective, but we are not taught how to analyze it from a forensic perspective. Does the mechanism of injury Satisfactorily correlate with the injury seen? Are there certain markers that always indicate abuse? Or do we look for a combination of the type of physical finding (bruise, pressure sore, fracture, etc.), the location of the finding (expected/unexpected), and the explanation (acceptable/nonacceptable) for the finding to make a conclusion about the likelihood of abuse?

When Is a Physical Finding Evidence of Abuse?
This is a particularly vexing question when the victim is an older adult. Sometimes it is obvious: cigarette burns on an arm, ligature marks on the wrists. But more often it is not obvious: the frail 82-year-old man on coumadin who comes in with multiple bruises; did he really fall, or did his short-tempered son push him down when he didn't move quickly enough? To complicate matters further, the victim often has a dementing illness that may render him incapable of giving a reliable history.

When the victim is quite frail, it may take minimal force to produce grave consequences. For example, a "small" shove from a caregiver may cause a fall that results in a subdural hematoma; this same shove may cause no harm whatsoever to a person who is robust. An elder with dementia may easily be pushed into delirium when benzodiazepines are improperly administered. So, the same action that produces significant injury to one person may cause little or no harm to another. We also know that many injuries occur despite excellent care, particularly in the most vulnerable elders. healthcare providers must learn what clues will distinguish an injury that is the result of abuse from an injury that was not reasonably avoidable.

Death Review
When an elder dies, there is a tendency to accept this as a natural act. What triggers ought to make us reconsider how "natural" the death was? Who is responsible for asking this question? Who is then responsible for deciding how vigorously to pursue the answer?

There may be some markers that we can agree ought to trigger an investigation: stage IV pressure sores, multiple bruises in unusual locations, unexplained dehydration, or malnutrition. An investigation must involve more than the coroner because a pressure sore caused by neglect looks no different from a pressure sore that arose despite all reasonable efforts to prevent its occurrence. Medical records will need to be reviewed with the hope that the primary care provider documented adequately the sequence of events leading to the sore. Information about the living situation will need to be gathered to understand who was responsible for the care of the elder and the circumstances under which he received care. But will the law enforcement/judiciary system think it is "good enough" if the medical team concludes the sore was unacceptable or unexplainable without being able to say it contributed to the elder's death? Will they still do an investigation and go forward with a prosecution?

When can we say that abuse contributed to death? Again, there may be obvious circumstances, such as a blow to the head that leads to a cerebral bleed and death in a matter of hours. But what about the kick to the abdomen that leads the person with Alzheimer's disease to stay in bed for days, resulting in deconditioning and an earlier-than-expected death? It would be hard for any one member of an interdisciplinary team to prove that the abuse caused an early death. I wonder: If there were better communication and coordination among the members of the team, would some of these cases go on to investigation and successful prosecution?

An Interdisciplinary Team Model
While I have read about many of these issues as they are described in the literature, my experience with an interdisciplinary team has taught me their real-world importance. Our medical response team consists of a geriatrician, psychologist, pharmacist, social worker, and gerontologist. The geriatrician attends two monthly meetings that are organized by county agencies. One is a multidisciplinary team, also attended by the district attorney, ombudsmen, adult protective services (APS), public guardians, police officers, and a psychologist. It is organized and run by APS and its purpose is to review high-risk physical abuse and neglect cases. The other is a fiduciary abuse specialist team, attended by the district attorney, ombudsmen, APS, public guardians, bankers, real estate attorneys, agents from Medicare and Medicaid offices, and a police officer from a fraud unit. Our medical team has been involved with 40 cases through these meetings. In addition, we provide consultation to our local APS, district attorney, and law enforcement personnel. This consultation may take the form of answering a question over the telephone, reviewing a case and offering advice through an e-mail system, and/or evaluating the alleged victim either in the home or office. We have found it beneficial to go to the home whenever possible for the evaluation; this is usually done by the physician and/or psychologist. The physical and emotional environment of the home are important components of our assessment. The team meets weekly to discuss all new cases from the prior week and to review the progress of ongoing cases. We are collecting data at various stages of the process and are developing tools for intake and assessment.

My intimate involvement with a multidisciplinary team "in the trenches" of elder abuse has convinced me of the urgency to get a better grasp of the issues described in this paper, to define the research questions implied, and to find a way to simplify the issues so that we answer some of the basic questions without oversimplifying them so that the answers are not valid.

Education
Education of healthcare professionals is a key component to improving our forensic abilities in elder abuse. At the University of California-Irvine, all family medicine residents are required to spend part of their rotation with APS workers. We have found this to be an excellent method to raise awareness of elder abuse and build an understanding of the role of social service agencies. We have also collaborated with Children's Hospital of San Diego and the University of California-Davis to create a day-long course on elder abuse. This course is designed for healthcare providers who are expert in geriatrics; i.e., it assumes a high level of geriatrics knowledge prior to the course. It then focuses on forensic aspects of elder abuse: How to recognize, document, report, and testify. It is taught by a geriatrician, pediatrician (expert on forensic medicine), adult protective service chief, and prosecutor.

These and other educational efforts are important first steps to building a cadre of experts who will be available to the seniors and agencies in their communities.

Conclusion
Intelligent, thoughtful, educated guesses as to models that are likely to work must be attempted and studied while we pursue the research and education efforts. Multidisciplinary teams, based in part on those used in child abuse and domestic violence, ought to be created for the purposes of evaluation and treatment as well as prevention. The teams must address the perpetrator as well as the victim. All attempts must be made to bridge the cultural divide between healthcare providers, social workers/scientists, law enforcement, and the judiciary system. Until these teams are formally in place, we will continue to have a fragmented system that leaves some of our most vulnerable citizens without decent care.

The U.S. Department of Justice has an opportunity to advance this field of elder abuse by drawing attention to the topic, collaborating with other governmental and nongovernmental agencies, and putting its significant resources (financial and intellectual) into systems that will serve our elders and their families. I hope this forum is the beginning of a process that will move steadily forward.

Lisa Nerenberg M.S.W., M.P.H.
Consultant

Detecting and Diagnosing Elder Abuse and Neglect

Medical professionals' critical role in detecting and proving elder abuse has long been recognized. Medical professionals' expertise in distinguishing accidental or unavoidable injuries from those that are inflicted, evaluating the plausibility of defenses, and identifying health and medical conditions that signal abuse or risk, has been crucial in prosecuting offenders. It is very encouraging to see the significant progress that has been made in the development of medical forensics and how this information is being shared with protective service personnel. We are starting to see forensics experts consulting with adult protective services (APS) units and making presentations at protective service training events.

As important as medical markers are, however, they cannot be evaluated or interpreted alone. Other factors, including decisionmaking capacity and the psychological dynamics that often come into play, may be critical in determining whether or not crimes have been committed. I would like to expand the scope of the discussion to include some of these factors.

Evaluating criminal conduct often requires us to examine the victim's mental capacity. In some alleged sexual assault cases, for example, determining whether or not a crime was committed gets down to determining if the alleged victim possessed sufficient decisionmaking capacity to exercise informed consent. We know that there are no simple tests for decisionmaking capacity and that medical diagnoses alone are not enough. Our legal system requires us to evaluate capacity in functional terms, that is, on the basis of specific types of decisions. Much work remains to be done in determining how to assess capacity for specific decisions; we are farther along in some areas than others. For example, the recent interest in durable of powers of attorney for healthcare has helped us achieve some agreement about healthcare decisionmaking, but there is less agreement about other decisions, including the decisionmaking capacity needed to consent to sexual relations, to give gifts, and to get married.

Psychological dynamics and processes also need to be explored. We have seen a great deal of interest in undue influence recently as professionals come to recognize that certain crimes cannot be evaluated as discrete incidents. Rather than taking a snapshot approach to investigating a particular criminal act, we sometimes have to roll back the cameras to understand what led up to it. Undue influence offers an explanation for how perpetrators can exercise calculated and deliberate programs of control and manipulation over their victims over time. Just as understanding domestic violence requires that we understand power, control, and patterns of escalating violence, similarly, in elder abuse, we often need to look at the control and manipulation that preceded the criminal act.

Physical abuse and neglect often have financial motives, which also need to be taken into account. Medical practitioners are likely to identify cases in which patients have been given dangerous doses of medications. How they evaluate a situation will vary depending on whether the person administering the medication was a well-intended but poorly trained caregiver, an adult child who stands to inherit, or the patient's wife of 2 months. All professionals who evaluate and investigate abuse need to understand the "bigger picture"-the context in which abuse occurs.

Training Needs of Law Enforcement Personnel
One of the primary challenges in training law enforcement about abuse is providing personnel with up-to-date information and skills as our knowledge base grows. Although many researchers have expressed disappointment in how little progress has been made in advancing the research on abuse, the same cannot be said for professional practice and law enforcement's response. When I wrote a curriculum for law enforcement 7 years ago, our understanding of the problem and how to investigate was nothing near what it is today. We did not know about the patterns of domestic violence against older women, or about "sweetheart scams," or suicide-homicides, or how to investigate and prosecute abuse and neglect in nursing homes, or about the myriad forms of financial abuse and how to prove them.

Law enforcement personnel need information about breakthroughs as soon as it becomes available. Police also need tools and training in how to make quick evaluations because they often do not have much time with alleged victims. Just as some police officers have started using simple screening tools, like the mini-mental status exam, to get a quick "read" on capacity, they also need training in how to identify gross indicators of neglect. A colleague recently told me about an egregious case of elder neglect that was discovered by an animal care and control worker in the course of investigating a complaint of animal abuse. A social worker who was also involved had failed to recognize the critical state the woman was in. Humane workers are very skilled at making quick assessments of gross neglect on the basis of nonverbal indicators, but few nonmedical service providers who work with the elderly, or police, have received any training in this area.

Problems with gaining access to information about specific cases has been another problem for law enforcement. Several participants have mentioned the importance of death reviews and coroners' investigations. I am pleased to say that we are making some progress in California. Last month, our governor signed a bill (AB 1836) that will require medical practitioners to submit medical records to coroners investigating abuse. Currently, coroners can request the information, but if it is refused, they have to go to court to get orders, leading to delays and added trauma to decedents' families. We are also starting to see the development of death review teams for elder abuse.

Training Needs of healthcare Professionals
Again, I would like to broaden the discussion to include the training needs of social service providers as well as healthcare professionals. The needs of both groups overlap, and much of the training that occurs in elder abuse is done in multidisciplinary settings. I also believe this multidisciplinary approach is appropriate owing to the interplay of medical, social, and legal factors in abuse cases.

All professionals who are likely to observe abuse need basic information about how the criminal justice system works. When I see talented trainers like Candace Heisler train health and social service providers in what prosecutors need to prove cases, you can see the lights go on. Once they understand concepts like the elements of a crime, how each element can be proven, standards of proof, and intent, they begin thinking in those terms. They further begin to recognize the critical importance of the information and knowledge they possess and start to see themselves as partners in the criminal justice process.

Health and social service providers also need training to help them understand how courts assess legal standards of capacity and decisionmaking. They need to understand that medical diagnoses are not sufficient. They further need to work with attorneys and law enforcement in translating medical diagnoses into meaningful legal determinations.

Whenever possible, we need to capitalize on work that has already been done. Our colleagues in domestic violence have made tremendous strides in educating medical professionals, particularly emergency room personnel. We can build upon that work by adding segments on elder abuse to existing training programs. We also need to enlarge the range of health and medical professionals who receive training, to include geriatricians, cardiologists, rheumatologist, podiatrists, and others.

I would like to end by making a few comments on training needs in general. Adding elder abuse content to the curriculums of police academies and professional training and education programs is extremely important but it is not enough. Training needs to be ongoing and interactive. I am a strong proponent of multidisciplinary teams because professionals from different fields need opportunities to learn more about each other's expertise, the interface of their expertise, and how their knowledge and skills can be combined to increase our understanding and effectiveness. To advance forensics expertise in elder abuse, we need to use the same strategy we have used from the beginning-bringing together experts from different disciplines to discuss cases and determine how their knowledge and skills can be combined. As I mentioned earlier, we are starting to see forensics experts begin to work with social service providers, but more of this is needed. We also need to expand the range of expertise in these discussions and develop new areas of expertise. In addition to medical professionals and toxicologists, we need to include forensics entomologists, dentists, podiatrists, and many others. As more nursing homes are prosecuted for neglect, we need to develop expertise in evaluating the quality of care. To evaluate poor care, we need to understand good care.

I would like to see DOJ explore the use of computer technology to facilitate this type of ongoing interaction. Databases of experts could be developed to help prosecutors, police, and forensics experts "find" one another to share their expertise and experiences. Computer technology could also be used to identify expert witnesses across the country and provide easier access to relevant case law in elder abuse.

Joanne Marlatt Otto, M.S.W.
Colorado Department of Human Services
Adult Protective Services Administrator

Detecting and Diagnosing Elder Abuse and Neglect (Forensic Markers)

In many States, the markers or indicators of abuse and neglect that result in legal proceedings do not differentiate between whether or not the abuse occurred in a community or an institutional setting. However, there is often a very different interpretation and response to abuse and neglect, depending on where it occurred. Physical and sexual abuse and financial exploitation are more likely to result in legal intervention when they occur in the community. In some States, caregiver neglect has also recently been included in adult protective services statutes as well as in criminal codes. Since most States mandate the reporting of elder abuse, incidents of abuse that occur in the community often are reported to adult protective services (APS) and/or law enforcement. These reports may result in prosecution, although there are no national data to show how often prosecution occurs or is successful.

On the other hand, when any of these forms of mistreatment occur in an institution, it is unusual for criminal proceedings to occur. While theft, gross neglect, physical and sexual assault, and unexplained death may be reported to State regulatory agencies (often following an internal investigation conducted by faculty staff), law enforcement is seldom called. If the event is reported to APS and/or law enforcement, the report usually occurs long after the incident occurred, resulting in the loss or destruction of essential evidence. Legal proceedings resulting from institutional mistreatment are more likely to result in civil litigation than criminal prosecution.

Determining when abuse and neglect are not the result of other conditions often requires medical expertise. Severe bruising may be the result of abuse-or may be caused by the aging process, disease, and/or medications. Sometimes, indepth medical evaluation and testing need to be conducted before abuse can be ruled out. The best way to determine when explanations of mistreatment are contrived to conceal abuse and neglect is to evaluate whether the explanation of the injury is consistent with any known physical or medical cause or condition. An example of this would be bilateral bruising in which the same patterns appear on both sides of the victim's body, indicating that the abuser grabbed or shook the victim with both hands.

According to the National Elder Abuse Incidence Study, only 8.4 percent of the reports to APS came from physicians, nurses, or clinics. This figure is surprisingly low, considering that most older people have frequent contact with physicians and are examined and tested regularly.

Applying the Forensic Science: the Integration of Medical Forensic Evidence With Law Enforcement
Prosecution would be enhanced if law enforcement made more frequent and timely requests to healthcare professionals, such as forensic nurses, for evaluation of physical evidence. Some healthcare professionals need training on testifying in court so that the information will be understandable and convincing.

The role of APS is often that of first responder. In that capacity, APS needs to quickly identify medical and criminal issues and report them to the appropriate entities. As the investigation unfolds, APS continues to have an important role in ensuring victim safety, arranging for appropriate services such as homemakers and meal delivery, providing emotional support to victims, and coordinating the efforts of all the professionals involved in the process. Local multidisciplinary teams are ideal vehicles for this coordination, since a variety of community agencies are represented and can be called upon to make recommendations and provide additional resources.

From child abuse programs we have learned that safety of the victim is paramount, that perpetrators frequently conceal or deny the abuse, and that victims of all ages and abilities are often able to provide valuable information if an investigation is handled with patience and skill. From the area of domestic violence, we have learned that often victims can take some responsibility for their own safety if they are given the information on how to do this.

An important first step in diagnosing and pursuing cases of abuse and neglect would be the participation of physicians, nurse practitioners, and/or forensic nurses on local multidisciplinary teams. While there are an increasing number of these teams in many communities across the country, it has been difficult to involve many healthcare professionals in the teams on an ongoing basis. Often the problem is that there are no funds to reimburse these professionals for their time. Making Department of Justice funds available through grants for this purpose would provide an incentive for their participation. In addition, teams of regional experts in medicine, law enforcement, coroners and forensic examiners, APS and the courts also could be trained to provide forensic case reviews and make recommendations on an ad hoc basis.

Educating the healthcare Profession on Forensic Issues Surrounding Elder Abuse and Neglect
While elder abuse reporting laws vary from state to state, the indicators of abuse and neglect are remarkably consistent:

· All healthcare professionals should be trained on the civil and criminal laws relating to elder abuse and neglect, as well as indicators, reporting requirements, and services available.

· Medical residents and nursing students could be assigned to work with adult protective services as part of their residency or field placement experience, and participate on community multidisciplinary teams.

· Community bioethics committees could invite healthcare professionals to do presentations and become active members.

· Scholarship incentives could be provided to encourage students to specialize in geriatric medicine.

· Schools of Social Work could invite healthcare professionals to teach courses and work on collaborative research projects.

· National organizations, such as the American Medical Association, National Sheriffs Association, National Organization of Chiefs of Police, and National Association of Adult Protective Services Administrators, could be invited to participate in policy forums and encouraged to develop more cross-training conferences.

Improving the Forensic Science of Elder Abuse and Neglect: The Research Agenda
· Little is known about the actual incidence of deaths resulting from elder abuse and neglect.

· Research is needed on how often healthcare professionals encounter elder abuse and neglect, why they do or do not report, and what their experience has been if they do report.

· Another much needed area of research is the financial cost of elder abuse to emergency services, hospitals, Medicare, Medicaid, and insurance carriers.

· A study of the number of cases of elder abuse and neglect that have been successfully prosecuted would be very helpful.

· More training at the graduate level as well as increased public awareness could do much to overcome the invisible nature of this issue. Since victims themselves do not self-report or advocate for services, it is the responsibility of professionals in healthcare, law, social work, aging and other disciplines to do so on their behalf.

Gregory J. Paveza, M.S.W., Ph.D.
USF-School of Social Work
Associate Professor

Educating the Health Professions

When considering the issue of educating the healthcare profession, I believe it is important to remember that we are talking about several different professions, not just physicians, including physician assistants, nurses, social workers, psychologists, and dentists. Depending on the setting, these are often the firstline contacts for older adults. Beyond this group are occupational therapists, physical therapists, recreation therapists, respiratory therapists, home health aides, and many more who come in contact with older adults. It is important to recognize that each of these healthcare professions has a different controlling authority that dictates the nature of the curriculum to be taught to its students.

From an educational standpoint, it is important to recognize that these accrediting bodies tend to view educational needs from the broadest perspective (that is, their view tends to be the basics a person must know to practice at the entry level). The accrediting organization provides guidelines for that level of education. The specific nature of those guidelines varies widely from the professions that specify elements of the curriculum (medicine and social work, for example) to professions that are relatively loose as to what must be specifically taught (psychology, for example). Regardless of the types of guidelines, however, the accrediting body does, on some regular basis (every 5 to 7 years), reexamine the curricula and ensure that a particular school is meeting the guidelines. Curricula tend to reflect the current sense of best practices or well-established beliefs about what should be the core elements. Thus, movement in curricula tends to be slow and often behind what may be the perceived need for a profession to have specialized training in a field.

Dependency on waiting for accrediting bodies is likely to result in little immediate change and certainly does not address the broader need for professional education on forensic issues. This then suggests that an alternative must be found for training.

Continuing medical education (CME) or continuing education (CE) for the other healthcare professions offers an alternative. However, choices of programs in CME or CE abound. Practitioners tend to gravitate toward programs that reflect the individual practitioners' own interests. Unfortunately, elder abuse and elder mistreatment in general tend not to be among the topics most likely to draw persons to programming. Moreover, when persons do choose to take training in elder abuse, participants often are seeking information about the current laws and the current system. This was brought home to me from personal experience. For 3 years as part of a summer training program offered by a major national aging organization, I offered CE training in elder abuse. The focus of this training was on identification of elder mistreatment, gathering and preservation of evidence, and serving as an expert witness. There was also some additional focus o