NIJ Journal No. 255 • November 2006

by Catherine C. McNamee with Mary B. Murphy

About the Authors
Catherine C. McNamee is a Social Science Analyst at the National Institute of Justice. Mary B. Murphy is the Managing Editor of the NIJ Journal.

To most people, Charles Cullen was an experienced nurse attending to the elderly in hospitals and nursing homes. The perception of Cullen as a devoted caretaker came to an abrupt end in 2004, however, when he admitted that he intentionally administered fatal doses of medication to almost 40 patients in various institutions over a 16-year period. Because most of Cullen’s early victims were elderly and seriously ill, and because toxicology and other tests were not done to detect whether there had been wrongdoing, medical examiners did not classify the deaths as homicides.1 As a result, no criminal investigations were initiated for several years, which resulted in the loss of valuable forensic evidence.2

Cullen’s case is an extreme example of what happens when professionals fail to recognize the signs of elder abuse. Despite the wake-up call high-profile cases such as Cullen’s should provide, little is known about how to recognize, prevent, or prosecute incidences of elder abuse.

Early findings from NIJ-funded research projects on the elderly are beginning to build a body of knowledge that will help caretakers, medical personnel, and law enforcement officers to recognize abuse indicators—known as forensic markers—and isolate factors that place elderly individuals at risk.3

Why Are We Behind the Curve?

One reason that so little is known about elder abuse is that a “gold standard test” for abuse or neglect does not exist.4 Those working with elders who have been abused or neglected must rely on forensic markers. The problem with this approach is that caregivers, Adult Protective Services agencies, and doctors are often not trained to distinguish between injuries caused by mistreatment and those that are the result of accident, illness, or aging.

Compounding the difficulty in diagnosis is the fact that many elderly individuals suffer from diseases or conditions that produce symptoms mirroring those resulting from abuse. Because these symptoms may mask or mimic indicators of mistreatment, their presence does not send up a red flag for treating physicians or for medical examiners charged with determining manner of death. In addition, doctors caring for elders often fail to recognize how psychological conditions—such as depression and dementia—place an individual at greater risk of falling victim to elder abuse; such psychological conditions themselves are indicators that abuse may be taking place.

Even if a doctor suspects abuse, police officers are rarely trained to investigate elder abuse and thus may not know how to interview an older adult, work with a person who has dementia, collect forensic evidence, or recommend that criminal charges be brought when responding to reports of injuries at care facilities or in homes.

Successful prosecutions are further impeded by the absence of a sufficient number of qualified experts to testify to a reasonable medical certainty that the injuries were the result of abuse or neglect. Medical testimony is crucial in such cases because the victims are often too ill or incapacitated to provide a coherent explanation of how the injury occurred. And the absence of any standardized laws defining elder abuse further constrains the ability of police, medical professionals, and prosecutors to develop a systematic approach to amassing evidence to prosecute offenders. (See “Impediments to Pursuing Elder Justice.”)

Bruising: An Accident or a Consequence of Abuse?

In one NIJ-funded study, researchers are examining bruising, one of the most common indicators of abuse and neglect. Although there is a body of research on the site, pattern, and dating of bruising in children, research on the differentiation between accidental and intentionally inflicted bruising in the geriatric population simply does not exist.

By following a group of elderly individuals for a 16-month period, researcher Laura Mosqueda, M.D., of the University of California, Irvine, and her colleagues, documented the occurrence, progression, and resolution of accidentally inflicted bruising on elderly persons. Researchers found that accidental bruising occurred in predictable locations in older adults: 90 percent of all bruises were on the extremities; no accidental bruises were observed on the ears, neck, genitals, buttocks, or soles of the feet. Contrary to a popularly held belief that one can estimate the age of a bruise by its color, this research found that the color of a bruise at the time of its initial appearance is unpredictable. More bruising was observed on those individuals who were on medication known to have an impact on the blood clotting system and on those older adults with compromised functional ability.5

This ongoing research is contributing to a body of data that officials can use for comparison when they suspect that an elderly person with bruising has been abused. The data will also assist doctors and medical examiners in developing a set of forensic markers for use in elder abuse cases.

Study of Elder Deaths Yields Markers

NIJ-funded researchers are also examining data on the deaths of elderly residents in long-term care facilities to identify potential markers of abuse. Led by Erik Lindbloom, M.D., of the University of Missouri-Columbia, the study examined coroners’ reports of elderly nursing home residents in Arkansas over a 1-year period.6 Amassing data collected pursuant to an Arkansas law7 requiring nursing homes to report all deaths to local coroners, researchers studied the medical examiner’s investigative process to gather impressions about markers that might indicate mistreatment and identify barriers to accurate assessments of abuse.

Although a majority of the coroner investigations did not raise suspicions of mistreatment, researchers identified four categories of markers that often led to referral to the Arkansas Attorney General for further investigation:

1. Physical condition/quality of care. Specific markers include: documented but untreated injuries; undocumented injuries and fractures; multiple, untreated, and/or undocumented pressure sores; medical orders not followed; poor oral care, poor hygiene, and lack of cleanliness of residents; malnourished residents who have no documentation for low weight; bruising on nonambulatory residents; bruising in unusual locations; statements from family concerning adequacy of care; and observations about the level of care for residents with nonattentive family members.
2. Facility characteristics. Specific markers include: unchanged linens; strong odors (urine, feces); trash cans that have not been emptied; food issues (unclean cafeteria); and documented problems in the past.
3. Inconsistencies. Specific markers include: inconsistencies between the medical records, statements made by staff members, and/or observations of investigators; inconsistencies in statements among groups interviewed; and inconsistencies between the reported time of death and the condition of the body.
4. Staff behaviors. Specific markers include: staff members who follow an investigator too closely; lack of knowledge and/or concern about a resident; unintended or purposeful, verbal or nonverbal evasiveness; and a facility’s unwillingness to release medical records.

Attitudes Hinder Investigations

Lindbloom’s multidisciplinary research team also conducted focus group interviews with medical examiners, coroners, and geriatricians across the United States to assess the state of forensic investigation of nursing home deaths and to determine ways to identify how abuse and neglect leading to mistreatment deaths might be identified. Results from the focus groups revealed that many professionals believe that deaths due to mistreatment are rare, so forensic investigations would be of little value in improving quality of care. Some medical examiners and coroners felt that decedents’ families might resist such investigations, particularly if a family member’s complaint had not initiated the investigation. Researchers also identified a propensity for medical examiners and coroners to exhibit ageism—a belief that focusing on nursing home deaths was “a waste of their time and resources…because of the poor health status of most nursing home residents… [who] would die anyway.”8 These beliefs are major impediments to improvements in the forensic identification of elder deaths.

Role of the Medical Examiner

Carmel Bitondo Dyer, M.D., of the Baylor College of Medicine, is leading a team of researchers who are examining the deaths of elders who reside in the community to isolate risk factors and identify potential markers of abuse. Funding from NIJ enabled Dyer and her colleagues to conduct research at the Harris County Medical Examiner’s Office (HCMEO) in Texas. They are surveying the medical examiners to determine their practice in identifying forensic markers or risk factors in elder death cases and in reporting elder abuse as a cause of death. They are also viewing autopsies to observe and offer geriatric consultation in elder death cases.

By cross-referencing data from the Texas Department of Family and Protective Services–Adult Protective Services databank with the HCMEO database, Dyer’s team has discovered that since 1999, as many as 900 elder death cases (autopsies, external exams, and inquests) had previously been reported to Adult Protective Services. She and her colleagues at Baylor College of Medicine are currently conducting a pilot study by abstracting 30 cases from this dataset to determine if forensic markers were identified by the medical examiners or if elder abuse was suspected at autopsy. Dyer is also promoting the creation of a Geriatric Toxicology Registry to identify which drugs lead to death in elders.

Vulnerabilities of Victims Impede Detection of Abuse

Researchers are also examining how psychological conditions place elders at risk for abuse—in particular, sexual abuse. Ann Burgess, D.N.Sc., of Boston College, examined 20 nursing home residents who had been sexually assaulted and found that the presence of a preexisting cognitive deficit such as dementia not only impairs the ability of victims to communicate but potentially compounds the trauma of the sexual assault.9 The vulnerability of this population places them at unusually high risk for severe traumatic reactions to assault, researchers assessed, noting that 11 of the 20 victims died within 12 months of the assault.10 Many of the victims remained silent about the attack—the incidents came to light only after suspicious signs or evidence were noted by a staff or family member.11

The study highlighted the importance of training caregivers to identify the signs of assault-related trauma, particularly in those victims who are not likely to report the incident. Researchers noted a disturbing propensity of nursing home staff to diminish the gravity of assaults on residents. Responses ranging from cynical disbelief to perverse amusement were observed.

The study recommended that guidelines be established for conducting rape trauma examinations on elderly patients. In many cases, researchers noted, doctors were unable to perform the standard forensic rape examination because of the elderly resident’s physical resistance to the procedure or the examining physician’s inability to effectively communicate with the victim. As a result, patients were examined in only half the cases.

IMPEDIMENTS TO PURSUING ELDER JUSTICE In 2003, the National Research Council‘s Panel to Review Risk and Prevalence of Elder Abuse and Neglect estimated that between one and two million Americans aged 65 and older have been harmed by a caretaker in either an institutional or domestic setting.12 Statistics indicate that the problem only stands to grow as the population ages and life expectancy continues to rise.13 But the data show that the science, education, and clinical practice associated with elder abuse and neglect are 30 to 40 years behind those associated with other problems, such as child abuse and domestic violence.14 This gap in knowledge and practice places an increasingly large population of elders at risk and poses a huge hurdle for prosecutors in bringing elder abuse cases, notes Marie-Therese Connolly, Senior Trial Counsel and Coordinator of the Elder Justice and Nursing Home Initiative at the U.S. Department of Justice. And the potential for effective research studies is further diminished by a lack of reporting. The limited data show that only 16 percent of abuse incidents are reported to Adult Protective Services. The remaining incidents are likely hidden by caregivers in homes and institutions where the elderly reside.15

Moving Forward

Because victims of elder abuse often suffer from physical and mental disabilities, many cases must rely exclusively on forensic evidence. NIJ’s portfolio of research will help in the crucial task of identifying forensic markers that can be used to identify cases of abuse and prosecute offenders.

NCJ 215458

Notes

1. Quigley, T., “Suspicions of Cullen Arose in ’93,” The Express-Times, May 30, 2004.
2. On March 2, 2006, Cullen was sentenced in Somerset County Superior Court in New Jersey to 11 consecutive life sentences for 22 murders and the attempted murders of 3 others in New Jersey. He will be sentenced at a later date for 7 murders and 3 attempted murders in Pennsylvania. Source: CBS News, available at www.cbsnews.com/elements/2003/12/16/in_depth_us/
   whoswho588843_0_1_person.shtml. (Retrieved from the World Wide Web on March 9, 2006.)
3. Researchers have identified 14 potential markers of abuse or neglect. They include: abrasions, lacerations, bruising, fractures, restraints, decubiti (bedsores), weight loss, dehydration, medication use, burns, cognitive and mental health problems, hygiene, sexual abuse, and financial fraud and exploitation. Dyer, C.B., M.T. Connolly, and P. McFeeley, “The Clinical and Medical Forensics of Elder Abuse and Neglect,” Elder Mistreatment: Abuse, Neglect, and Exploitation in an Aging America, ed. R.J. Bonnie and R.B. Wallace, Washington, DC: National Academies Press, 2003: 344–360 (reporting findings of the Panel to Review Risk and Prevalence of Elder Abuse and Neglect).
4. Ibid., 343.
5. Mosqueda, L., K. Burnight, and S. Liao, Bruising in the Geriatric Population, final report submitted to the National Institute of Justice, Washington, DC: June 2006 (NCJ 214649), available at www.ncjrs.gov/pdffiles1/nij/grants/214649.pdf.
6. Lindbloom, E., J. Brandt, C. Hawes, C. Phillips, D. Zimmerman, J. Robinson, B. Bowers, and P. McFeeley, The Role of Forensic Science in Identification of Mistreatment Deaths in Long-Term Care Facilities, final report submitted to the National Institute of Justice, Washington, DC: April 2005 (NCJ 209334), available at www.ncjrs.gov/pdffiles1/nij/grants/209334.pdf.
7. P.L. 499, Arkansas Statutes [2005].
8. Ibid., 32.
9. Because older victims usually have fewer support systems and reserves—physical, psychological, and economic—the impact of abuse and neglect is magnified, and a single incident of mistreatment is more likely to trigger a downward spiral leading to loss of independence, a serious complicating illness, and even death. Burgess, A., and N. Hanrahan, Identifying Forensic Markers in Elder Sexual Abuse, final report submitted to the National Institute of Justice, Washington, DC: 2006 (forthcoming).
10. Ibid. Because more than half of the victims were aged 80 to 95 years at the time of the assault, it is impossible to determine if the death was a distal effect of the assault. Although it is not possible to determine whether in each case 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.
11. Reporting by victims accounts for very few instances of elder abuse cases. A study by Jones, J., J.D. Dougherty, D. Schelbie, and W. Cunningham, “Emergency Department Protocol for the Diagnosis and Evaluation of Geriatric Abuse,” Annals of Emergency Medicine 17 (1998): 1006–15, reported that 72 percent of elder abuse victims did not complain of the abuse at the time of presentation to an emergency center. Dyer et al., “Clinical and Medical Forensics,” Elder Mistreatment: 363.
12. Ibid., 9, citing Pillemer and Finkelhor (1998); Pavlik et al. (2001).
13. Ibid., 9–10. In 2003, 13 percent of the Nation’s population was over the age of 65. The figure is expected to rise to almost 20 percent over the next two decades. Burgess and Hanrahan, Forensic Markers in Elder Sexual Abuse.
14. Those who work in the field of elder abuse and neglect believe that the state of medical knowledge and forensic science regarding elder abuse and neglect is approximately equivalent to that of child abuse and neglect three decades ago and domestic violence 10 to 15 years ago. Dyer et al., “Clinical and Medical Forensics,” Elder Mistreatment: 339.
15. Gallanis, T.P., A. Dayton, and M. Wood, Elder Law: Readings, Cases, and Materials, Dayton, OH: Anderson Publishing Co., 2000: 287.