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A Literature Review of Findings in Physical Elder Abuse
Canadian Association of Radiologists Journal 64 (2013) 10e14 www.carjonline.org
Health Policy and Practice / Sante : politique et pratique medicale
A Literature Review of Findings in Physical Elder Abuse Kieran Murphy, MB BCH, FRCPC, FSIR*, Sheila Waa, MBCHB, MMED, Hussein Jaffer, MHS, Agnes Sauter, MA, Amanda Chan, MSc Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
Abstract Purpose: To review the medical literature for reports on the types of physical injuries in elder abuse with the aim of eliciting patterns that will aid its detection. Materials and Methods: The databases of PubMed, CINAHL, EMBASE, and TRIP were searched from 1975 to March 2012 for articles that contained the following phrases: ‘‘physical elder abuse,’’ ‘‘older adult abuse,’’ ‘‘elder mistreatment,’’ ‘‘geriatric abuse,’’ ‘‘geriatric trauma,’’ and ‘‘nonaccidental geriatric injury.’’ Distribution and description of injuries in physical elder abuse from case-control studies, cross-sectional studies, case series, and case reports as seen at autopsy, in hospital emergency departments, or in medicolegal reports were tabulated and summarized. Results: A review of 9 articles from a total of 574 articles screened yielded 839 injuries. The anatomic distribution in these was as follows: upper extremity, 43.98%; maxillofacial, dental, and neck, 22.88%; skull and brain, 12.28%; lower extremity, 10.61%; and torso, 10.25%. Conclusion: Two-thirds of injuries that occur in elder abuse are to the upper extremity and maxillofacial region. The social context in which the injuries takes place remains crucial to accurate identification of abuse. This includes a culture of violence in the family; a demented, debilitated, or depressed and socially isolated victim; and a perpetrator profile of mental illness, alcohol or drug abuse, or emotional and/or financial dependence on the victim. Resume Objectif : Analyser la litterature medicale a la recherche de descriptions du type de blessures physiques subies dans les cas de violence envers les personnes ^agees, dans le but de definir des aspects caracteristiques qui faciliteraient la detection de tels cas. Materiel et methodes : Une recherche a ete effectuee dans les bases de donnees PubMed, CINAHL, EMBASE et TRIP afin de recenser les articles publies entre 1975 et mars 2012 contenant les expressions suivantes : « physical elder abuse », « older adult abuse », « elder mistreatment », « geriatric abuse », « geriatric trauma » ou « nonaccidental geriatric injury ». La repartition et la description des blessures relevees dans les cas de violence envers les personnes ^agees dans des etudes cas temoins, des etudes transversales, des series de cas et des etudes de cas vus a l’autopsie, au service d’urgence hospitalier ou dans les rapports medicolegaux ont ete classifiees et resumees. Resultats : L’analyse des 9 articles retenus parmi les 574 examines a permis de relever 839 blessures, reparties comme suit sur le plan anatomique : membres superieurs, 43,98 %; region maxillofaciale, dents et cou, 22,88 %; cr^ane et cerveau, 12,28 %; membres inferieurs, 10,61 %; torse, 10,25 %. Conclusion : Les deux tiers des blessures survenant dans les cas de violence envers les personnes ^agees touchent les membres superieurs et la region maxillofaciale. Le contexte social dans lequel surviennent les blessures demeure un aspect caracteristique essentiel de ces cas de violence et englobe notamment les elements suivants : culture de violence familiale; victime demente, affaiblie, deprimee ou isolee socialement; profil de l’agresseur caracterise par des troubles mentaux, l’alcoolisme ou la toxicomanie, et la dependance affective et/ou financiere envers la victime. Ó 2013 Canadian Association of Radiologists. All rights reserved. Key Words: Elder abuse radiology findings
* Address for correspondence: Kieran Murphy, MD, Toronto Western Hospital, Division of Neuroradiology, 399 Bathurst St, MCL Wing, 3rd Floor, Room 430, Toronto, Ontario M5T 2S8, Canada. E-mail address: [email protected] (K. Murphy). 0846-5371/$ - see front matter Ó 2013 Canadian Association of Radiologists. All rights reserved. http://dx.doi.org/10.1016/j.carj.2012.12.001
Radiology of elder abuse / Canadian Association of Radiologists Journal 64 (2013) 10e14
Abuse of elderly people by family members or others known to them, in their homes or in long-term care institutions, is a growing public health and criminal justice concern, principally due to the relative increase in the population segment aged older than 60 years. The worldwide population of adults 60 years and older is predicted to rise from 542 million in 1995 to 1.2 billion in 2025, and senior citizens are expected to comprise 27% of Canada’s population by 2025, up from 14% in 2009 [1,2]. The World Health Organization and the International Network for the Prevention of Elder Abuse define elder abuse as ‘‘a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person’’ [3]. Clinical and legal publications on the subject generally recognize 5 types of abuse: neglect, psychological or emotional, physical, financial or material, and sexual abuse. In 2008, the overall 1-year prevalence of elder abuse in the United States was 17.1%, with the prevalence of physical abuse reported at 1.6% in the same population [4]. According to a Statistics Canada report, 7900 incidences of elder abuse were reported to police in 2009, an increase of 14% from 2004 [2]. However, recent articles in Canada state that rates of family homicides of seniors have been relatively steady over the previous 15 years, whereas rates of family homicides in general have decreased over the past 30 years, with a rate in 2010 that was 41% lower than that in 1980 [5]. Therefore, it is not clear whether the increase in reported incidences of elder abuse are due to an actual increase of abuse or rather due to a heightened public awareness of the problem. Physical abuse is most often carried out by caregivers who are offspring, partners, or other relatives [6]. The majority of elders dwell in the community: 93% of seniors in Canada live in the community with family or relatives [7]. Therefore, elder abuse is mostly a community problem as opposed to a long-term care facility problem. It has been shown that elder abuse confers additional death risk [8]. Despite the significant and increasing prevalence given the increase in the size of this vulnerable population, elder abuse remains underreported, which may lead to an increase in morbidity and mortality from a delay in intervention. Although it would be expected that medical practitioners are ideally positioned to detect elder abuse, physicians account for only 2% of reported cases of elder abuse, for, among other reasons, uncertainty of the diagnostic validity, especially in physical abuse [9]. It is generally thought to be difficult to distinguish between accidental and nonaccidental causes of injury in the elderly, mainly because changes that occur with aging, such as osteoporosis and brain atrophy, predispose to injury from relatively minor trauma such as falls. The bulk of research on elder abuse has focused on determining the prevalence and incidence of elder abuse, identifying risk factors, and painting a profile of the perpetrators. Most of the research is carried out by social scientists and has limited practical application in medicine [10]. Few studies have dealt with the pattern or distribution of physical injury in elder abuse, an area that would be of interest to
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radiologists. This review aims to summarize the findings from reports in the medical literature for reports on the distribution and type of physical injuries in elder abuse, with the aim of eliciting patterns that will aid its detection. Materials and Methods Data Sources The databases of PubMed, CINAHL, EMBASE, and TRIP were searched from 1975, when this entity was first described in the medical literature [11], to March 2012 by using the following words and phrases: ‘‘physical elder abuse,’’ ‘‘older adult abuse,’’ ‘‘elder mistreatment,’’ ‘‘geriatric abuse,’’ ‘‘geriatric trauma,’’ and ‘‘nonaccidental geriatric injury’’ in the titles of articles (Figure 1). The search was carried out by a librarian and a research fellow (S.W.). Study Eligibility The inclusion criteria for studies were those that contained a description of the types and distribution of physical injuries in elder abuse. The only available articles that met these criteria were 2 case-control studies, 2 multiple crosssectional studies, 4 case series, and 1 case report. One of the case series gave details on distribution of injuries for 1 subject [12]. Due to the paucity of data on this entity, all these reports were included. Data Extraction Abstracts of articles were screened by one of the authors (research fellow [S.W.]) for information on injury distribution in abuse of elders. Reports used as the source of data for this review had varying classifications of injuries. To Literature search: PubMed, EMBASE, CINAHL, TRIP
567 papers identified through database searching from 1975 to March 2012
7 additional papers identified from bibliographies of papers reviewed making total of 574 papers
565 papers excluded as non-pertinent or duplication on screening of abstracts
9 papers included in review Figure 1. Flowchart of literature search.
448 86 (10.25%) 86/839 (10.25%)
1 1
369 (43.98%) 369/839 (43.98%)
89 (10.61%) 89/839 (10.61%)
43 12 14 86 3 3 1 839 4 0 0 15 4 1 0 50 9 4 0 11
c
a
b
The number of injuries not subjects. The subject attacked by strangers was excluded. Distribution of injury given for 1 subject.
103 (12.28%) 103/839 (12.28%)
6 10 1
17 7 8 0 2 1 1 192 (22.88%) 192/839 (22.88%) 41 17 15b 48 2 1 9c 1247 Friedman et al, 2011 [15] Cham et al, 2000 [16] Akaza et al, 2003 [17] Wiglesworth et al, 2009 [20] Stavrianos et al, 2010 [31] Paranitharan et al, 2009 [32] Anetzberger et al, 1999 [12] Total
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613 64 70 0 281 32 59 2 141 15 62 15 1027 87 Abath et al, 2010 [13] Gaioli and Rodrigues, 2008 [14]
Others Total of anatomically described injuries Upper extremity Torso Maxillofacial and neck Skull or brain No. subjects or observations
Table 1 Summary of articles that describe the distribution of injuries in physical elder abuse
A total of 839 injury patterns from 1247 subjects or observations (in the case of medical reports), which fit into the 5 categories (skull and brain, maxillofacial and neck, torso, upper extremity, lower extremity) were identified in the studies that met our inclusion criteria. Four hundred and fourteen injuries were described as ‘‘multiple’’ and were categorized as ‘‘others’’ due to ambiguity [13]. A further 12 superficial injuries, 10 unspecified injuries, 2 burn injuries, and 8 musculoskeletal injuries were not clearly anatomically described and, therefore, were also put in the category of ‘‘others’’ [14e16]. One injury was also described as sexual, which, according to clinical and legal classification of elder abuse, is considered a separate category from physical elder abuse [14]. Of the 839 injuries, the distribution by anatomic region was as follows: upper extremity (43.98%), maxillofacial and neck (22.88%), skull and brain (12.28%), lower extremity (10.61%), and torso (10.25%). The largest contribution of observations (73%) was from a Brazilian cross-sectional study by Abath et al [13], in which the preponderance of injury was to the upper extremity. Most injuries reported in this study were classified as mild (93.4%), which required simple treatment [13]. The second largest contributor of observations was also from Brazil, in which Gaioli and Rodrigues [14] reviewed medical examination reports for 87 subjects and found mostly maxillofacial and upper extremity injuries. Upper extremity injuries were mostly categorized as shoulder and arm nonspecific injury (36.7%). The maxillofacial and head and the neck injuries that comprised 36.5% of the total were mostly located in the periocular and eyelid region. In this case, the injuries could also be considered as mild because victims either did not seek medical care or received primary care in 57.5% and 31% of cases, respectively [14]. Autopsy studies of confirmed cases of elder abuse in Japan showed subdural hemorrhages to be common causes of mortality. Additional findings in these deceased subjects identified signs of abuse that had occurred before the mortal injury, in the form of subcutaneous hemorrhages, especially in the head and neck region [17]. Although subdural hemorrhages were reported to be the cause of death in 5 of 15 autopsies in this report, these injuries also commonly occur, in the same age group, from accidental
Lower extremity
Results
a
summarize all the findings from these studies, physical injuries were classified according to anatomic location by using the following categories: skull and brain, maxillofacial and neck, torso, upper extremity, and lower extremity. These categories were chosen to match as closely as possible the ones used in the articles reviewed. Four reports had relatively large numbers of injuries classified as ‘‘unspecified,’’ ‘‘multiple,’’ and ‘‘superficial,’’ without descriptions detailed enough to fit into any of the above anatomic categories and, therefore, were placed in a category of ‘‘others’’ (Table 1) [13e16]. This final category was excluded from the calculations of injury distribution.
414; multiple 12 superficial injuries; 7 unspecified; 2 burns of unspecified region; 2 had no discernible injuries; 1 sexual abuse 3 unspecified 8 unspecified musculoskeletal
K. Murphy et al. / Canadian Association of Radiologists Journal 64 (2013) 10e14
Study
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Radiology of elder abuse / Canadian Association of Radiologists Journal 64 (2013) 10e14
falls from a standing position [18]. To use subdural hemorrhages as a diagnostic marker of physical elder abuse, differentiating characteristics need to be determined, possibly in location and/or severity, from accidental injury. Similarly, patterns specific to nonaccidental maxillofacial injuries need to be described because these injuries also commonly result from accidental falls on a level surface in the elderly [19]. Victims of elder abuse that resulted in traumatic injury were shown to have more severe injuries and were more likely to be sent to an intensive care unit in a case-control hospital-based study carried out in Chicago, Illinois. This study reported a preponderance of injury to the head and torso in abused elderly in comparison with controls treated in the same level I trauma units of 2 Chicago hospitals. The researchers suggested that this pattern reflected intent to kill rather than to injure. According to this study, the abused elderly were also more likely to have a neurologic or mental disorder [15]. In a survey of 17 elderly patients seen in an urban hospital emergency department in Singapore, 8 victims of abuse had experienced blunt musculoskeletal trauma, and 7 had maxillofacial or head injuries [16]. Wiglesworth et al [20] identified significant differences in the size and location of bruises in accidental injury compared with those that occurred in physical elder abuse. Their study noted that 72% of identified physically abused elders had bruises, and these were larger and more often located on the face, posterior torso, and lateral right arm compared with those that occurred in older adults who had experienced accidental bruising [20]. Upper extremity and maxillofacial injuries accounted for most of the injuries reported due to physical elder abuse. Discussion The possibility of the presence of injuries specific to nonaccidental trauma in the elderly is intriguing to medical practice and particularly medical specialties such as radiology. In the extensive literature on nonaccidental injury in children, the role of medical imaging has been established for 5 decades, starting with a description of long-bone fractures and subdural hematomas in 1946 and the classic metaphyseal lesion in 1957 by Caffey [21,22]. In contrast, no injuries specific to elder abuse, a possible equivalent of Caffey-Kempe (battered baby) syndrome have been determined. However, a pattern of the distribution of injury in physical elder abuse is emerging that would present radiologists with a starting point in determining imaging correlates. Our analysis found that the largest numbers of physical injuries were located in the upper extremity (43.98%). Pointers to physical abuse in this location include contusions and abrasions to the axilla and inner aspects of the arms that do not commonly arise from accidental trauma [21]. Mechanisms of injury could include grasping by the abuser, use of restraints, or as a result of attempted self-defence by the victim [23]. Bruising on the lateral aspect of the arm has also been reported as occurring more commonly in physically abused elders [20].
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Injuries to the posterior torso and the lower extremity, inner thigh, or dorsal or plantar aspect of the foot have also been suggested as indicators of physical elder abuse because these areas are less likely to be the point of impact in accidental injury [11,19]. Certain patterns of physical injury in elder abuse may lend themselves particularly well to identification by specific disciplines. The studies that reported most injuries that occurred in the upper extremity also noted that most of these injuries were of a mild nature [13]. Patterns of injury that occurred with this localization and severity would probably be more noticeable to clinicians in primary care, and appropriate intervention by a family physician at this point could prevent significant morbidity or mortality. However, in the autopsy series and case-control study of severe trauma [15,17], most of the injuries were to the brain, head, and neck; patterns that would be most useful in emergency department and forensic practice. Reports of injury distribution in intimate partner (domestic) violence rarely occur in the extremities as is the case in physical elder abuse, instead mostly localized to the head, neck, and face [24,25]. Although the distribution of injuries that commonly occur in physical elder abuse have been outlined, there is no convincing evidence as yet that distinguishes them from those that occurred accidentally, and, therefore, risk factors that relate to the victim, potential perpetrator, and circumstances remain crucial to accurate detection of this entity. Risk factors that relate to the victim, perpetrator, and circumstances have been well documented in the literature and provide important context in the clinical setting. Dementia and depression are documented risk factors for elder abuse, and physical abuse in particular appears to occur more frequently in the elderly with dementia, possibly due to disruptive and aggressive patient behavior that provokes retaliation [11,26]. The concept of transgenerational violence, in which abused children later abuse their parents, which perpetuates a cycle of violence, is considered a major factor in physical elder abuse [27]. Physical elder abuse appears to occur more commonly in the evenings and on weekends due to increased social interaction and increased alcohol intake by the perpetrators during this time [13]. Social isolation of the victim, except for contact with the caregiver, increases the risk of elder abuse in general. Although elderly women were thought to be the most common victims of abuse, some large surveys have reported no sex differences [10]. Characteristics of perpetrators include ongoing mental illness, alcohol and/or drug abuse, financial and/or emotional dependence on the victim, and depression [28]. Screening tools such as the elder abuse index and elder abuse suspicion index that incorporate physical findings and social factors have been developed and validated for use in the community and in busy clinics or emergency departments to assist in detection of elder abuse [29,30]. However, because it relates to radiologic and pathologic findings, more work is warranted to determine whether there are definite distinguishing factors between accidental and abuse-related injury to the head, neck, torso, or upper and lower extremities in the elderly.
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K. Murphy et al. / Canadian Association of Radiologists Journal 64 (2013) 10e14
A key limitation of this review is its dependence on level 3 to 5 evidence, that is, from 2 case-control studies, 2 cross-sectional studies, 4 case series, and 1 case report. However, it is hoped that this review will provide some basis for more robust scientific work in this relatively understudied area. The data were acquired from reports from 6 countries; however, most of the reports were small case series, case reports, or cross-sectional surveys, and, it, therefore, would be premature to draw conclusions on regional variability in patterns of physical elder abuse. It should be noted that articles varied in their references for onset of old age. Although this has not been clearly defined, the World Health Organization uses the age of 60 years as the reference [1]. However some researchers took 65 years to be the minimum age of persons considered as elderly [16,17,27]. This may have influenced the prevalence of abuse. The coexistence of different types of abuse has been reported, although not to the extent that might have been anticipated. Two articles reported neglect in 2 of 17 and 4 of 14 of physically abused elders [16,17], and one reported emotional and financial abuse having occurred in 5 and 3 of 14 patients, respectively [17]. In conclusion, two-thirds of injuries that occurred in elder abuse were to the upper extremity and maxillofacial region. Validation of the specificity of these findings to physical elder abuse is required before the radiologist can confidently raise the suspicion in practice. Therefore, the social context in which the injuries take place remains crucial to accurate identification of abuse. Acknowledgements A similar paper accepted for presentation at the annual meeting of the Radiological Society of North America (RSNA) 2012. The authors thank Panos Lambiris, University Health Network (UHN) Library Toronto, for assistance with the literature search. References [1] Krug EG, Dahlberg LL, Mercy JA, et al., editors. World Report on Violence and Health; Chapter 5: Abuse of the elderly. Geneva: WHO Press. Available at: http://www.who.int/violence_injury_prevention/ violence/world_report/en/introduction.pdf; 2002. Accessed January 21, 2012. [2] Family Violence in Canada: A Statistical Profile. 2009; Section 3: Police Reported Violence Against Seniors. Available at: http://www. statcan.gc.ca/pub/85-224-x/85-224-x2010000-eng.pdf. Accessed January 18, 2012. [3] WHO Toronto Declaration on Elder Abuse 2002. Available at: http:// www.who.int/ageing/projects/elder_abuse/alc_toronto_declaration_ en.pdf. Accessed December 18, 2011. [4] Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. Am J Pub Health 2010;100:292e7. [5] Sinha M. Family Violence in Canada: A Statistical Profile, 2010; p. 6. Available at: http://www.statcan.gc.ca/pub/85-002-x/2012001/article/ 11643-eng.pdf. Accessed July 24, 2012.
[6] Sethi D, Wood S, Mitis F, et al, eds. European Report on Preventing Elder Maltreatment, 2011. WHO Regional Office for Europe Publication. Available at: http://www.euro.who.int/__data/assets/pdf_file/ 0010/144676/e95110.pdf. Accessed July 24, 2012. [7] Turcotte M, Schellenberg G. A Portrait of Seniors in Canada. Statistics Canada, Social and Aboriginal Division. Available at: www.statcan.gc. ca/pub/89-519-x/89-519-x2006001-eng.pdf; 2006. Accessed January 30, 2012. [8] Lachs MS, Williams CS, O’Brien SMS, et al. The mortality of elder mistreatment. JAMA 1998;280:428e32. [9] Rosenblatt DE, Cho K, Durance PW. Reporting mistreatment of older adults: the role of physicians. J Am Geriatr Soc 1996;44:65e70. [10] Lachs MS, Pillemer K. Elder abuse. Lancet 2004;364:1263e72. [11] Burston GR. Letter: Granny-battering. Br Med J 1975;3:592. [12] Anetzberger GJ, Dyer CB, Barth J, et al. A case series of abused or neglected elders treated by an interdisciplinary geriatric team. J Elder Abuse Negl 1999;10:131e9. [13] Abath Mde B, Leal MC, Melo Filho DA, Marques AP. Physical abuse of older people reported at the Institute of Forensic Medicine in Recife, Pernambuco State, Brazil. Cad Saude Publica 2010;26:1797e806. [14] Gaioli CCLO, Rodrigues RAP. Occurrence of domestic elder abuse. Rev Latino-am Enfermagem 2008;16:465e70. [15] Friedman LS, Avila S, Tanouye K, et al. A case control study of severe physical abuse of older adults. J Am Geriatr Soc 2011;59:417e22. [16] Cham GWM, Seow E. The pattern of elder abuse presenting in an emergency department. Singapore Med J 2000;41:571e4. [17] Akaza K, Bunai Y, Tsujinaka M, et al. Elder abuse and neglect: social problems revealed from 15 autopsy cases. Leg Med (Tokyo) 2003;5: 7e14. [18] Nagurney JT, Borczuk P, Thomas SH. Elderly patients with closed head trauma after a fall: mechanisms and outcomes. J Emerg Med 1998;16: 709e13. [19] Yamamoto K, Matsusue Y, Murakami K, et al. Maxillofacial fractures in older patients. J Oral Maxillofac Surg 2011;69:2204e10. [20] Wiglesworth A, Raciela A, Corona M, et al. Bruising as a marker of elder physical abuse. J Am Geriatr Soc 2009;5:1191e6. [21] Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematomas. Am J Roentgenol Radium Ther 1946;56: 163e73. [22] Caffey J. Some traumatic lesions in growing bones other than fractures and dislocations: clinical and radiological features. Br J Radiol 1957; 30:225e38. [23] Croce D, Croce Junior D. Manual de medicina legal [in Portuguese]. S~ao Paulo, Brazil: Saraiva; 2004. [24] Petridou E, Browne A, Lichter E, et al. What distinguishes unintentional injuries from injuries due to intimate partner violence: a study in Greek ambulatory care settings. Inj Prev 2002;8:197e201. [25] Wu V, Huff H, Bhandari M. Pattern of physical injury associated with intimate partner violence in women presenting to the emergency department: a systematic review and meta-analysis. Trauma Violence Abuse 2010;11:71e82. [26] Dyer CB, Pavlik VN, Murphy KP, et al. The high prevalence of depression and dementia in elder abuse. J Am Geriatr Soc 2000;48:205e8. [27] Collins KA. Elder maltreatment: a review. Arch Pathol Lab Med 2006; 130:1290e6. [28] Kleinschmidt KC. Elder abuse: a review. Ann Emerg Med 1997;30: 463e72. [29] Fulmer T. Screening for mistreatment of older adults. Am J Nurs 2008; 108:52e9. [30] Fulmer T, Strauss S, Russell SL, et al. Screening for elder mistreatment in dental and medical clinics. Gerodontology 2012;29: 96e105. [31] Stavrianos C, Dietrich EM, Zouloumis L, et al. Elder abuse: two cases. Res J Med Sci 2010;4:357e61. [32] Paranitharan P, Pollanen MS. The interaction of injury and disease in the elderly: a case of fatal elder abuse. J Forensic Leg Med 2009;16: 346e9.
Health Policy and Practice / Sante : politique et pratique medicale
A Literature Review of Findings in Physical Elder Abuse Kieran Murphy, MB BCH, FRCPC, FSIR*, Sheila Waa, MBCHB, MMED, Hussein Jaffer, MHS, Agnes Sauter, MA, Amanda Chan, MSc Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
Abstract Purpose: To review the medical literature for reports on the types of physical injuries in elder abuse with the aim of eliciting patterns that will aid its detection. Materials and Methods: The databases of PubMed, CINAHL, EMBASE, and TRIP were searched from 1975 to March 2012 for articles that contained the following phrases: ‘‘physical elder abuse,’’ ‘‘older adult abuse,’’ ‘‘elder mistreatment,’’ ‘‘geriatric abuse,’’ ‘‘geriatric trauma,’’ and ‘‘nonaccidental geriatric injury.’’ Distribution and description of injuries in physical elder abuse from case-control studies, cross-sectional studies, case series, and case reports as seen at autopsy, in hospital emergency departments, or in medicolegal reports were tabulated and summarized. Results: A review of 9 articles from a total of 574 articles screened yielded 839 injuries. The anatomic distribution in these was as follows: upper extremity, 43.98%; maxillofacial, dental, and neck, 22.88%; skull and brain, 12.28%; lower extremity, 10.61%; and torso, 10.25%. Conclusion: Two-thirds of injuries that occur in elder abuse are to the upper extremity and maxillofacial region. The social context in which the injuries takes place remains crucial to accurate identification of abuse. This includes a culture of violence in the family; a demented, debilitated, or depressed and socially isolated victim; and a perpetrator profile of mental illness, alcohol or drug abuse, or emotional and/or financial dependence on the victim. Resume Objectif : Analyser la litterature medicale a la recherche de descriptions du type de blessures physiques subies dans les cas de violence envers les personnes ^agees, dans le but de definir des aspects caracteristiques qui faciliteraient la detection de tels cas. Materiel et methodes : Une recherche a ete effectuee dans les bases de donnees PubMed, CINAHL, EMBASE et TRIP afin de recenser les articles publies entre 1975 et mars 2012 contenant les expressions suivantes : « physical elder abuse », « older adult abuse », « elder mistreatment », « geriatric abuse », « geriatric trauma » ou « nonaccidental geriatric injury ». La repartition et la description des blessures relevees dans les cas de violence envers les personnes ^agees dans des etudes cas temoins, des etudes transversales, des series de cas et des etudes de cas vus a l’autopsie, au service d’urgence hospitalier ou dans les rapports medicolegaux ont ete classifiees et resumees. Resultats : L’analyse des 9 articles retenus parmi les 574 examines a permis de relever 839 blessures, reparties comme suit sur le plan anatomique : membres superieurs, 43,98 %; region maxillofaciale, dents et cou, 22,88 %; cr^ane et cerveau, 12,28 %; membres inferieurs, 10,61 %; torse, 10,25 %. Conclusion : Les deux tiers des blessures survenant dans les cas de violence envers les personnes ^agees touchent les membres superieurs et la region maxillofaciale. Le contexte social dans lequel surviennent les blessures demeure un aspect caracteristique essentiel de ces cas de violence et englobe notamment les elements suivants : culture de violence familiale; victime demente, affaiblie, deprimee ou isolee socialement; profil de l’agresseur caracterise par des troubles mentaux, l’alcoolisme ou la toxicomanie, et la dependance affective et/ou financiere envers la victime. Ó 2013 Canadian Association of Radiologists. All rights reserved. Key Words: Elder abuse radiology findings
* Address for correspondence: Kieran Murphy, MD, Toronto Western Hospital, Division of Neuroradiology, 399 Bathurst St, MCL Wing, 3rd Floor, Room 430, Toronto, Ontario M5T 2S8, Canada. E-mail address: [email protected] (K. Murphy). 0846-5371/$ - see front matter Ó 2013 Canadian Association of Radiologists. All rights reserved. http://dx.doi.org/10.1016/j.carj.2012.12.001
Radiology of elder abuse / Canadian Association of Radiologists Journal 64 (2013) 10e14
Abuse of elderly people by family members or others known to them, in their homes or in long-term care institutions, is a growing public health and criminal justice concern, principally due to the relative increase in the population segment aged older than 60 years. The worldwide population of adults 60 years and older is predicted to rise from 542 million in 1995 to 1.2 billion in 2025, and senior citizens are expected to comprise 27% of Canada’s population by 2025, up from 14% in 2009 [1,2]. The World Health Organization and the International Network for the Prevention of Elder Abuse define elder abuse as ‘‘a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person’’ [3]. Clinical and legal publications on the subject generally recognize 5 types of abuse: neglect, psychological or emotional, physical, financial or material, and sexual abuse. In 2008, the overall 1-year prevalence of elder abuse in the United States was 17.1%, with the prevalence of physical abuse reported at 1.6% in the same population [4]. According to a Statistics Canada report, 7900 incidences of elder abuse were reported to police in 2009, an increase of 14% from 2004 [2]. However, recent articles in Canada state that rates of family homicides of seniors have been relatively steady over the previous 15 years, whereas rates of family homicides in general have decreased over the past 30 years, with a rate in 2010 that was 41% lower than that in 1980 [5]. Therefore, it is not clear whether the increase in reported incidences of elder abuse are due to an actual increase of abuse or rather due to a heightened public awareness of the problem. Physical abuse is most often carried out by caregivers who are offspring, partners, or other relatives [6]. The majority of elders dwell in the community: 93% of seniors in Canada live in the community with family or relatives [7]. Therefore, elder abuse is mostly a community problem as opposed to a long-term care facility problem. It has been shown that elder abuse confers additional death risk [8]. Despite the significant and increasing prevalence given the increase in the size of this vulnerable population, elder abuse remains underreported, which may lead to an increase in morbidity and mortality from a delay in intervention. Although it would be expected that medical practitioners are ideally positioned to detect elder abuse, physicians account for only 2% of reported cases of elder abuse, for, among other reasons, uncertainty of the diagnostic validity, especially in physical abuse [9]. It is generally thought to be difficult to distinguish between accidental and nonaccidental causes of injury in the elderly, mainly because changes that occur with aging, such as osteoporosis and brain atrophy, predispose to injury from relatively minor trauma such as falls. The bulk of research on elder abuse has focused on determining the prevalence and incidence of elder abuse, identifying risk factors, and painting a profile of the perpetrators. Most of the research is carried out by social scientists and has limited practical application in medicine [10]. Few studies have dealt with the pattern or distribution of physical injury in elder abuse, an area that would be of interest to
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radiologists. This review aims to summarize the findings from reports in the medical literature for reports on the distribution and type of physical injuries in elder abuse, with the aim of eliciting patterns that will aid its detection. Materials and Methods Data Sources The databases of PubMed, CINAHL, EMBASE, and TRIP were searched from 1975, when this entity was first described in the medical literature [11], to March 2012 by using the following words and phrases: ‘‘physical elder abuse,’’ ‘‘older adult abuse,’’ ‘‘elder mistreatment,’’ ‘‘geriatric abuse,’’ ‘‘geriatric trauma,’’ and ‘‘nonaccidental geriatric injury’’ in the titles of articles (Figure 1). The search was carried out by a librarian and a research fellow (S.W.). Study Eligibility The inclusion criteria for studies were those that contained a description of the types and distribution of physical injuries in elder abuse. The only available articles that met these criteria were 2 case-control studies, 2 multiple crosssectional studies, 4 case series, and 1 case report. One of the case series gave details on distribution of injuries for 1 subject [12]. Due to the paucity of data on this entity, all these reports were included. Data Extraction Abstracts of articles were screened by one of the authors (research fellow [S.W.]) for information on injury distribution in abuse of elders. Reports used as the source of data for this review had varying classifications of injuries. To Literature search: PubMed, EMBASE, CINAHL, TRIP
567 papers identified through database searching from 1975 to March 2012
7 additional papers identified from bibliographies of papers reviewed making total of 574 papers
565 papers excluded as non-pertinent or duplication on screening of abstracts
9 papers included in review Figure 1. Flowchart of literature search.
448 86 (10.25%) 86/839 (10.25%)
1 1
369 (43.98%) 369/839 (43.98%)
89 (10.61%) 89/839 (10.61%)
43 12 14 86 3 3 1 839 4 0 0 15 4 1 0 50 9 4 0 11
c
a
b
The number of injuries not subjects. The subject attacked by strangers was excluded. Distribution of injury given for 1 subject.
103 (12.28%) 103/839 (12.28%)
6 10 1
17 7 8 0 2 1 1 192 (22.88%) 192/839 (22.88%) 41 17 15b 48 2 1 9c 1247 Friedman et al, 2011 [15] Cham et al, 2000 [16] Akaza et al, 2003 [17] Wiglesworth et al, 2009 [20] Stavrianos et al, 2010 [31] Paranitharan et al, 2009 [32] Anetzberger et al, 1999 [12] Total
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613 64 70 0 281 32 59 2 141 15 62 15 1027 87 Abath et al, 2010 [13] Gaioli and Rodrigues, 2008 [14]
Others Total of anatomically described injuries Upper extremity Torso Maxillofacial and neck Skull or brain No. subjects or observations
Table 1 Summary of articles that describe the distribution of injuries in physical elder abuse
A total of 839 injury patterns from 1247 subjects or observations (in the case of medical reports), which fit into the 5 categories (skull and brain, maxillofacial and neck, torso, upper extremity, lower extremity) were identified in the studies that met our inclusion criteria. Four hundred and fourteen injuries were described as ‘‘multiple’’ and were categorized as ‘‘others’’ due to ambiguity [13]. A further 12 superficial injuries, 10 unspecified injuries, 2 burn injuries, and 8 musculoskeletal injuries were not clearly anatomically described and, therefore, were also put in the category of ‘‘others’’ [14e16]. One injury was also described as sexual, which, according to clinical and legal classification of elder abuse, is considered a separate category from physical elder abuse [14]. Of the 839 injuries, the distribution by anatomic region was as follows: upper extremity (43.98%), maxillofacial and neck (22.88%), skull and brain (12.28%), lower extremity (10.61%), and torso (10.25%). The largest contribution of observations (73%) was from a Brazilian cross-sectional study by Abath et al [13], in which the preponderance of injury was to the upper extremity. Most injuries reported in this study were classified as mild (93.4%), which required simple treatment [13]. The second largest contributor of observations was also from Brazil, in which Gaioli and Rodrigues [14] reviewed medical examination reports for 87 subjects and found mostly maxillofacial and upper extremity injuries. Upper extremity injuries were mostly categorized as shoulder and arm nonspecific injury (36.7%). The maxillofacial and head and the neck injuries that comprised 36.5% of the total were mostly located in the periocular and eyelid region. In this case, the injuries could also be considered as mild because victims either did not seek medical care or received primary care in 57.5% and 31% of cases, respectively [14]. Autopsy studies of confirmed cases of elder abuse in Japan showed subdural hemorrhages to be common causes of mortality. Additional findings in these deceased subjects identified signs of abuse that had occurred before the mortal injury, in the form of subcutaneous hemorrhages, especially in the head and neck region [17]. Although subdural hemorrhages were reported to be the cause of death in 5 of 15 autopsies in this report, these injuries also commonly occur, in the same age group, from accidental
Lower extremity
Results
a
summarize all the findings from these studies, physical injuries were classified according to anatomic location by using the following categories: skull and brain, maxillofacial and neck, torso, upper extremity, and lower extremity. These categories were chosen to match as closely as possible the ones used in the articles reviewed. Four reports had relatively large numbers of injuries classified as ‘‘unspecified,’’ ‘‘multiple,’’ and ‘‘superficial,’’ without descriptions detailed enough to fit into any of the above anatomic categories and, therefore, were placed in a category of ‘‘others’’ (Table 1) [13e16]. This final category was excluded from the calculations of injury distribution.
414; multiple 12 superficial injuries; 7 unspecified; 2 burns of unspecified region; 2 had no discernible injuries; 1 sexual abuse 3 unspecified 8 unspecified musculoskeletal
K. Murphy et al. / Canadian Association of Radiologists Journal 64 (2013) 10e14
Study
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Radiology of elder abuse / Canadian Association of Radiologists Journal 64 (2013) 10e14
falls from a standing position [18]. To use subdural hemorrhages as a diagnostic marker of physical elder abuse, differentiating characteristics need to be determined, possibly in location and/or severity, from accidental injury. Similarly, patterns specific to nonaccidental maxillofacial injuries need to be described because these injuries also commonly result from accidental falls on a level surface in the elderly [19]. Victims of elder abuse that resulted in traumatic injury were shown to have more severe injuries and were more likely to be sent to an intensive care unit in a case-control hospital-based study carried out in Chicago, Illinois. This study reported a preponderance of injury to the head and torso in abused elderly in comparison with controls treated in the same level I trauma units of 2 Chicago hospitals. The researchers suggested that this pattern reflected intent to kill rather than to injure. According to this study, the abused elderly were also more likely to have a neurologic or mental disorder [15]. In a survey of 17 elderly patients seen in an urban hospital emergency department in Singapore, 8 victims of abuse had experienced blunt musculoskeletal trauma, and 7 had maxillofacial or head injuries [16]. Wiglesworth et al [20] identified significant differences in the size and location of bruises in accidental injury compared with those that occurred in physical elder abuse. Their study noted that 72% of identified physically abused elders had bruises, and these were larger and more often located on the face, posterior torso, and lateral right arm compared with those that occurred in older adults who had experienced accidental bruising [20]. Upper extremity and maxillofacial injuries accounted for most of the injuries reported due to physical elder abuse. Discussion The possibility of the presence of injuries specific to nonaccidental trauma in the elderly is intriguing to medical practice and particularly medical specialties such as radiology. In the extensive literature on nonaccidental injury in children, the role of medical imaging has been established for 5 decades, starting with a description of long-bone fractures and subdural hematomas in 1946 and the classic metaphyseal lesion in 1957 by Caffey [21,22]. In contrast, no injuries specific to elder abuse, a possible equivalent of Caffey-Kempe (battered baby) syndrome have been determined. However, a pattern of the distribution of injury in physical elder abuse is emerging that would present radiologists with a starting point in determining imaging correlates. Our analysis found that the largest numbers of physical injuries were located in the upper extremity (43.98%). Pointers to physical abuse in this location include contusions and abrasions to the axilla and inner aspects of the arms that do not commonly arise from accidental trauma [21]. Mechanisms of injury could include grasping by the abuser, use of restraints, or as a result of attempted self-defence by the victim [23]. Bruising on the lateral aspect of the arm has also been reported as occurring more commonly in physically abused elders [20].
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Injuries to the posterior torso and the lower extremity, inner thigh, or dorsal or plantar aspect of the foot have also been suggested as indicators of physical elder abuse because these areas are less likely to be the point of impact in accidental injury [11,19]. Certain patterns of physical injury in elder abuse may lend themselves particularly well to identification by specific disciplines. The studies that reported most injuries that occurred in the upper extremity also noted that most of these injuries were of a mild nature [13]. Patterns of injury that occurred with this localization and severity would probably be more noticeable to clinicians in primary care, and appropriate intervention by a family physician at this point could prevent significant morbidity or mortality. However, in the autopsy series and case-control study of severe trauma [15,17], most of the injuries were to the brain, head, and neck; patterns that would be most useful in emergency department and forensic practice. Reports of injury distribution in intimate partner (domestic) violence rarely occur in the extremities as is the case in physical elder abuse, instead mostly localized to the head, neck, and face [24,25]. Although the distribution of injuries that commonly occur in physical elder abuse have been outlined, there is no convincing evidence as yet that distinguishes them from those that occurred accidentally, and, therefore, risk factors that relate to the victim, potential perpetrator, and circumstances remain crucial to accurate detection of this entity. Risk factors that relate to the victim, perpetrator, and circumstances have been well documented in the literature and provide important context in the clinical setting. Dementia and depression are documented risk factors for elder abuse, and physical abuse in particular appears to occur more frequently in the elderly with dementia, possibly due to disruptive and aggressive patient behavior that provokes retaliation [11,26]. The concept of transgenerational violence, in which abused children later abuse their parents, which perpetuates a cycle of violence, is considered a major factor in physical elder abuse [27]. Physical elder abuse appears to occur more commonly in the evenings and on weekends due to increased social interaction and increased alcohol intake by the perpetrators during this time [13]. Social isolation of the victim, except for contact with the caregiver, increases the risk of elder abuse in general. Although elderly women were thought to be the most common victims of abuse, some large surveys have reported no sex differences [10]. Characteristics of perpetrators include ongoing mental illness, alcohol and/or drug abuse, financial and/or emotional dependence on the victim, and depression [28]. Screening tools such as the elder abuse index and elder abuse suspicion index that incorporate physical findings and social factors have been developed and validated for use in the community and in busy clinics or emergency departments to assist in detection of elder abuse [29,30]. However, because it relates to radiologic and pathologic findings, more work is warranted to determine whether there are definite distinguishing factors between accidental and abuse-related injury to the head, neck, torso, or upper and lower extremities in the elderly.
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K. Murphy et al. / Canadian Association of Radiologists Journal 64 (2013) 10e14
A key limitation of this review is its dependence on level 3 to 5 evidence, that is, from 2 case-control studies, 2 cross-sectional studies, 4 case series, and 1 case report. However, it is hoped that this review will provide some basis for more robust scientific work in this relatively understudied area. The data were acquired from reports from 6 countries; however, most of the reports were small case series, case reports, or cross-sectional surveys, and, it, therefore, would be premature to draw conclusions on regional variability in patterns of physical elder abuse. It should be noted that articles varied in their references for onset of old age. Although this has not been clearly defined, the World Health Organization uses the age of 60 years as the reference [1]. However some researchers took 65 years to be the minimum age of persons considered as elderly [16,17,27]. This may have influenced the prevalence of abuse. The coexistence of different types of abuse has been reported, although not to the extent that might have been anticipated. Two articles reported neglect in 2 of 17 and 4 of 14 of physically abused elders [16,17], and one reported emotional and financial abuse having occurred in 5 and 3 of 14 patients, respectively [17]. In conclusion, two-thirds of injuries that occurred in elder abuse were to the upper extremity and maxillofacial region. Validation of the specificity of these findings to physical elder abuse is required before the radiologist can confidently raise the suspicion in practice. Therefore, the social context in which the injuries take place remains crucial to accurate identification of abuse. Acknowledgements A similar paper accepted for presentation at the annual meeting of the Radiological Society of North America (RSNA) 2012. The authors thank Panos Lambiris, University Health Network (UHN) Library Toronto, for assistance with the literature search. References [1] Krug EG, Dahlberg LL, Mercy JA, et al., editors. World Report on Violence and Health; Chapter 5: Abuse of the elderly. Geneva: WHO Press. Available at: http://www.who.int/violence_injury_prevention/ violence/world_report/en/introduction.pdf; 2002. Accessed January 21, 2012. [2] Family Violence in Canada: A Statistical Profile. 2009; Section 3: Police Reported Violence Against Seniors. Available at: http://www. statcan.gc.ca/pub/85-224-x/85-224-x2010000-eng.pdf. Accessed January 18, 2012. [3] WHO Toronto Declaration on Elder Abuse 2002. Available at: http:// www.who.int/ageing/projects/elder_abuse/alc_toronto_declaration_ en.pdf. Accessed December 18, 2011. [4] Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual and financial abuse and potential neglect in the United States: The National Elder Mistreatment Study. Am J Pub Health 2010;100:292e7. [5] Sinha M. Family Violence in Canada: A Statistical Profile, 2010; p. 6. Available at: http://www.statcan.gc.ca/pub/85-002-x/2012001/article/ 11643-eng.pdf. Accessed July 24, 2012.
[6] Sethi D, Wood S, Mitis F, et al, eds. European Report on Preventing Elder Maltreatment, 2011. WHO Regional Office for Europe Publication. Available at: http://www.euro.who.int/__data/assets/pdf_file/ 0010/144676/e95110.pdf. Accessed July 24, 2012. [7] Turcotte M, Schellenberg G. A Portrait of Seniors in Canada. Statistics Canada, Social and Aboriginal Division. Available at: www.statcan.gc. ca/pub/89-519-x/89-519-x2006001-eng.pdf; 2006. Accessed January 30, 2012. [8] Lachs MS, Williams CS, O’Brien SMS, et al. The mortality of elder mistreatment. JAMA 1998;280:428e32. [9] Rosenblatt DE, Cho K, Durance PW. Reporting mistreatment of older adults: the role of physicians. J Am Geriatr Soc 1996;44:65e70. [10] Lachs MS, Pillemer K. Elder abuse. Lancet 2004;364:1263e72. [11] Burston GR. Letter: Granny-battering. Br Med J 1975;3:592. [12] Anetzberger GJ, Dyer CB, Barth J, et al. A case series of abused or neglected elders treated by an interdisciplinary geriatric team. J Elder Abuse Negl 1999;10:131e9. [13] Abath Mde B, Leal MC, Melo Filho DA, Marques AP. Physical abuse of older people reported at the Institute of Forensic Medicine in Recife, Pernambuco State, Brazil. Cad Saude Publica 2010;26:1797e806. [14] Gaioli CCLO, Rodrigues RAP. Occurrence of domestic elder abuse. Rev Latino-am Enfermagem 2008;16:465e70. [15] Friedman LS, Avila S, Tanouye K, et al. A case control study of severe physical abuse of older adults. J Am Geriatr Soc 2011;59:417e22. [16] Cham GWM, Seow E. The pattern of elder abuse presenting in an emergency department. Singapore Med J 2000;41:571e4. [17] Akaza K, Bunai Y, Tsujinaka M, et al. Elder abuse and neglect: social problems revealed from 15 autopsy cases. Leg Med (Tokyo) 2003;5: 7e14. [18] Nagurney JT, Borczuk P, Thomas SH. Elderly patients with closed head trauma after a fall: mechanisms and outcomes. J Emerg Med 1998;16: 709e13. [19] Yamamoto K, Matsusue Y, Murakami K, et al. Maxillofacial fractures in older patients. J Oral Maxillofac Surg 2011;69:2204e10. [20] Wiglesworth A, Raciela A, Corona M, et al. Bruising as a marker of elder physical abuse. J Am Geriatr Soc 2009;5:1191e6. [21] Caffey J. Multiple fractures in the long bones of infants suffering from chronic subdural hematomas. Am J Roentgenol Radium Ther 1946;56: 163e73. [22] Caffey J. Some traumatic lesions in growing bones other than fractures and dislocations: clinical and radiological features. Br J Radiol 1957; 30:225e38. [23] Croce D, Croce Junior D. Manual de medicina legal [in Portuguese]. S~ao Paulo, Brazil: Saraiva; 2004. [24] Petridou E, Browne A, Lichter E, et al. What distinguishes unintentional injuries from injuries due to intimate partner violence: a study in Greek ambulatory care settings. Inj Prev 2002;8:197e201. [25] Wu V, Huff H, Bhandari M. Pattern of physical injury associated with intimate partner violence in women presenting to the emergency department: a systematic review and meta-analysis. Trauma Violence Abuse 2010;11:71e82. [26] Dyer CB, Pavlik VN, Murphy KP, et al. The high prevalence of depression and dementia in elder abuse. J Am Geriatr Soc 2000;48:205e8. [27] Collins KA. Elder maltreatment: a review. Arch Pathol Lab Med 2006; 130:1290e6. [28] Kleinschmidt KC. Elder abuse: a review. Ann Emerg Med 1997;30: 463e72. [29] Fulmer T. Screening for mistreatment of older adults. Am J Nurs 2008; 108:52e9. [30] Fulmer T, Strauss S, Russell SL, et al. Screening for elder mistreatment in dental and medical clinics. Gerodontology 2012;29: 96e105. [31] Stavrianos C, Dietrich EM, Zouloumis L, et al. Elder abuse: two cases. Res J Med Sci 2010;4:357e61. [32] Paranitharan P, Pollanen MS. The interaction of injury and disease in the elderly: a case of fatal elder abuse. J Forensic Leg Med 2009;16: 346e9.