Original Article
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Injury Patterns and Causal Mechanisms of Bruising in Physical Elder Abuse Carolyn E. Ziminski, RN, BSN1, Aileen Wiglesworth, PhD2, Raciela Austin, RN2, Linda R. Phillips, RN, PhD1, and Laura Mosqueda, MD1 ABSTRACT The recognition of injury patterns can aid forensic nurses to identify victims of elder abuse. This study examined the mechanism of injury of bruises endured by physical elder abuse victims. A sample of 67 elders aged 65 years and older who reported to Adult Protective Services for physical elder abuse was included in the analysis. A research nurse conducted assessments and documented the presence and characteristics of all bruises. Data regarding the abusive incident were collected through victim descriptions and the Revised Conflicts Tactic Scales (CTS2) physical assault scale. The most common bruising locations were the lateral/anterior arms (n = 23, 34.3%), head and neck (n = 10, 14.9%), and posterior torso (n = 7, 10.4%). Victims’ odds of having head and neck bruises were greater when reporting being choked (OR = 7.71, 95% CI [1.29, 45.90], p = 0.039), punched (OR = 13.53, 95% CI [2.55, 71.80], p = 0.001), and beaten up (OR = 5.60, 95% CI [3.26, 74.45], p = 0.001). The odds of having lateral/anterior arm bruises were eight times greater when the victim reported being grabbed (OR = 8.43, 95% CI [2.67, 26.65], p G 0.001). The findings suggest similarities between injuries experienced in elder abuse and those in intimate partner violence. Findings highlight injury patterns that elder abuse victims sustain and can be informative for forensic nurses. KEY WORDS: elder abuse; forensic markers; injury patterns; intimate partner violence; mechanism of injury
E
lder abuse can lead to injuries, the need to be placed on mechanical ventilation, hospital admission, and even death (Dong et al., 2009; Friedman, Avila, Tanouye, & Joseph, 2011; Lachs et al., 1997). The National Elder Abuse Incidence Study conducted in 1996 Author Affiliations: 1School of Nursing, University of California, Los Angeles, and 2Program in Geriatrics, School of Medicine, University of California, Irvine. This project was funded by Grant 2005-IJ-CX-0048 from the Department of Justice, Office of Justice Programs, and by the John A. Hartford Foundation’s Building Academic Geriatric Nursing Capacity Award Program. The authors have disclosed that they have no financial relationships related to this article. Correspondence: Carolyn Ziminski, RN, BSN, School of Nursing, University of California, Los Angeles, Factor Building Room 5-133A, 700 Tiverton Avenue, Los Angeles, CA 90095. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s web site (www.journalforensicnursing.com). Received July 30, 2012; accepted for publication October 28, 2012. Copyright * 2013 International Association of Forensic Nurses DOI: 10.1097/JFN.0b013e31827d51d0
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estimated that half a million older adults were victims of elder abuse and only 16% of the cases were reported to Adult Protective Services (APS; National Center on Elder Abuse, 1998). However, it is commonly believed that elder abuse estimates are only capturing the ‘‘tip of the iceberg’’ (National Center on Elder Abuse, 1998), and since 1996, the number of victims has surely increased with the growth of the older adult population. Healthcare practitioners have both legal and ethical responsibilities to ensure their patients’ safety and report incidences of assault, but fulfilling those responsibilities requires advancement of knowledge of clinical forensic medicine patterns and characteristics pertaining to elder abuse. Forensic nurses are essential in assessing and intervening in elder abuse. Linking the study of elder abuse to clinical forensic medicine is a recent, but essential, step in advancing knowledge about elder abuse. In 2000, the Elder Justice Roundtable concluded that application of forensic science was needed to aid in the prosecution of elder abuse cases (National Institute of Justice, 2000). However, before cases can be prosecuted, forensic markers need to be established as standards for assessment and diagnosis, in order to aid practitioners in detecting and reporting elder abuse (Dyer, Connolly, & McFeeley, 2003). Clearly delineated forensic Volume 9 & Number 2 & April-June 2013
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Original Article markers for elder abuse are very important because of the difficulty in distinguishing symptoms of abuse from chronic or geriatric syndromes (Dyer et al., 2003). Bruising patterns and locations may be used by forensic nurses to identify physical abuse and as evidence in the prosecution of elder physical abuse cases (Dyer et al., 2003). However, limited research supports the argument that a particular bruising pattern is an indicator of abuse. Identification of common abuse-related injuries and common mechanisms of injury in abuse and establishing a link between the two aid in the development of forensic markers. The mechanism of injury provides the clinician with an understanding of what the victim experienced, including injury severity and locations (Sheridan & Nash, 2007). To date, one study has examined traumatic injuries experienced in severe physical abuse by older adults seen in emergency department trauma centers (Friedman et al., 2011). Although it has limited forensic use, the study showed that, as compared with a control group, abused individuals were significantly more likely to experience penetrating injuries and to be admitted to an intensive care unit and placed on a ventilator. The injuries most commonly experienced by the victims of abuse included open wounds (56.1%), internal injuries (24.4%), and fractures (22%), most commonly incurring to the head (61%) and torso (31.7%; Friedman et al., 2011).
Mechanism of Injury in Intimate Partner Violence Elder abuse is an act committed by a person in a trusted relationship with the elder, most often a family member (National Center on Elder Abuse., 1998). Similarities between elder abuse and intimate partner violence (IPV) have been suggested because they both involve reasonably independent people who live with physically stronger people who victimize them (Pillemer, 2005). The IPV literature regarding injuries is fairly well advanced and pertinent to the study of elder abuse but rarely applied to elder abuse. The IPV field has identified patterns in injury locations and types sustained by victims. The head, neck, and face are the most common sites of injury (CDC, 2005; Fanslow, Norton, & Spinola, 1998; Le, Dierks, Ueeck, Homer, & Potter, 2001; Muelleman, Lenaghan, & Pakieser, 1996; Sheridan & Nash, 2007). These locations have been used in the literature as predictive variables in detecting IPV (Halpern, Susarla, & Dodson, 2005; Perciaccante, Carey, Susarla, & Dodson, 2010). Bruises or contusions are common injuries sustained by victims of IPV (Fanslow et al., 1998; Le et al., 2001). Other injuries include lacerations and musculoskeletal injuries (CDC, 2005; Fanslow et al., 1998; Le et al., 2001). Mechanisms of injury reported in IPV include being punched, pushed, kicked, slapped, choked, or hit with Journal of Forensic Nursing
an object, with more than one type frequently occurring (Muelleman et al., 1996). Strangulation has also been identified as a common mechanism of injury in IPV. Wilbur and colleagues (2001) conducted a survey of IPV victims recruited from women’s shelters who survived a strangulation attempt and found 68% had experienced previous strangulation attempts. Victims reported being strangled an average of 5.3 times along with the co-occurrence of other types of abuse (88%), most frequently verbal abuse (68%). The average length of relationships before the first strangulation was 5.2 years, and the average length of abuse before the initial strangulation was 3.1 years, suggesting that strangulation occurs late in the relationship and late in the trajectory of abuse (Wilbur et al., 2001).
Bruising in the Older Adults Bruising is caused by a force being applied to an area resulting in blood vessels under the intact skin leaking into the surrounding tissue (McDonough, 2006). A bruise can be caused by a fall or minimal blunt force trauma and can be accidental or intentional. Bruising is recognized as a sign of physical elder abuse (Dyer et al., 2003; Pearsall, 2005; Wiglesworth et al., 2009). However, in a comprehensive review of the literature on bruising in the elderly population, only two studies were identified. One study documented the occurrence, progression, and characteristics of accidentally acquired bruises in elders aged 65 years and older (Mosqueda, Burnight, & Liao, 2005). Subjects were recruited from three community-based settings and two skilled nursing facilities. One hundred one seniors were examined daily at home for a maximum of 6 weeks to document the presence or absence of bruising. One hundred eight bruises were found (Mosqueda et al., 2005). Of those, 89% were on the extremities, with 76% on the dorsal aspect of the arms. No bruises were found on the neck, ears, genitalia, buttocks, or soles of feet. The authors noted that the color of a bruise was not a good indicator of its age. The bruises resolved in 4Y41 days (11.7 T 7.1). People on medications known to affect coagulation pathways and people with compromised function were more likely to have multiple bruises (Mosqueda et al., 2005). The second bruising study investigated the characteristics of bruises sustained by physically abused older adults (Wiglesworth et al., 2009). Findings were compared with the results of the aforementioned study of accidental bruises. Recruited subjects were APS clients. Physical abuse was confirmed for 67 participants. Forty-eight (72%) of the 67 participants had bruises for a total of 155 bruises. Of these, participants reported 89 (57.4%) were inflicted, 40 (25.8%) were of unknown causes, and 26 (16.8%) were accidental. Locations of the inflicted bruises included the extremities (57.3%) and the trunk/head (42.7%). As www.journalforensicnursing.com
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Original Article compared with the study about accidental bruises, this study found that medications that interfere with coagulation pathways were not associated with the presence of multiple bruises and participants needing assistance with activities of daily living (ADL) did not present with multiple bruises, but findings suggested that participants who used assistive devices for mobility were more likely to have bruising. From a forensic perspective, what is known about the characteristics of bruises inflicted on older adults is limited to their size and location on the body, establishing that they are distinct from bruises sustained accidentally (Wiglesworth et al., 2009). Research has not yet examined if certain mechanisms of injuries produce bruises on certain body locations. The objective of this study was to describe the mechanisms of injury associated with characteristics of the bruises in a sample of elders who experienced physical elder abuse. The study was designed to address three specific research questions: 1. What are the common bruise locations in a sample of physically abused elders? 2. What are the common mechanisms of injury in a sample of physically abuse elders? 3. What mechanisms of injury are related to bruises found in physical elder abuse?
h Methods
The findings reported in this article result from a secondary analysis of data from the Wiglesworth and colleagues (2009) study described previously. The study protocol was approved by the institutional review board at the University of California, Irvine. Consent to participate in the study was obtained from the subject, or if the potential study subject appeared to lack decision-making capacity, consent was obtained from an authorized surrogate. Decisionmaking capacity was determined by the research nurse through the use of the MacArthur Competence Assessment Tool for Clinical Research (Appelbaum & Grisso, 2001).
Study Population This study took place in Orange County, California, and was completed between July 2006 and May 2008. All subjects invited to participate in the study had been referred to APS for possible physical abuse. Study inclusion criteria were (a) adults aged 65 years and older, (b) had a physically abusive incident occurring in the previous six weeks, and (c) that the perpetrator was in a position of trust (not a stranger). Because the APS referrals were for alleged physical abuse, not confirmed physical abuse, verification of physical abuse was needed to achieve the study’s goal of examining bruising associated with abuse. Therefore, upon consenting to participate in the study, participants’ status of physical abuse was externally confirmed by the LEAD panel (Longitudinal, Experts, All Data), consisting of four board-certified geriatricians with a combined 37 years of experience in the 86
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field of elder abuse. The LEAD panel made their decisions based on data presented by the research nurse as well as evidence from the investigation file presented by the APS case worker, which included information on the elder’s injuries, events leading to the altercation, and need for medical care afterwards. Information about bruising was withheld from the panel to ensure the independence of the analyses for bruising associated with abuse. This allowed the researchers to objectively examine the potential use of bruises as a forensic marker of elder abuse because the bruising status had no influence in the confirmation of physical abuse. The operational definition of physical abuse and sample questions asked by the panel are available at: http://www .centeronelderabuse.org/. All members of the LEAD panel had to be in agreement to designate a case as physical abuse. Of 407 APS clients with allegations of possible elder physical abuse, 67 participants were confirmed as having been victims of elder physical abuse (see Supplemental Digital Content 1, http://links.lww.com/JFN/A6). Of these 67 participants, 48 individuals had bruises. There were 155 total bruises among the 48 individuals with bruising. Of the 93 APS clients who refused to participate after speaking to the research nurse, demographic data are available on 78 people. The 78 with available data were not significantly different from the participants in the study in age (76.9 T 7.5 years) or gender (51 women).
Protection of Human Rights Several measures were taken to ensure that the rights of the participants were maintained. First, there was a memorandum of understanding in place with APS explaining the terms of collaboration and protecting the rights of the participants. When an APS social worker received a report of alleged physical abuse, the social worker asked the client for permission for a research nurse to contact them. After speaking with the research nurse, the APS clients who agreed to participate and who met study inclusion criteria were consented. The consent form detailed the maintenance of confidentiality including assigning of participant code numbers to research files, maintaining research records in locked offices, and leaving names and identities out of research reports. Participants were also informed that no personally identifiable information would be disclosed without a separate consent, except as required by law. To comply with the legally mandated reporting requirements, if the researchers suspected that additional types of abuse were occurring other than what was originally reported, the researchers made an additional report to the assigned APS social worker. Lastly, the participants’ identities were not revealed during the LEAD panel assessment. The researchers complied with all privacy and confidentiality requirements of the National Institute of Justice. Volume 9 & Number 2 & April-June 2013
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Original Article Data Collection Study assessments were performed in the subject’s home, relative’s home, or inpatient setting. The research nurse collected the following data: demographics, number of falls (past week, month, 6 months, and 12 months), medical history/diagnoses, and medications (prescription and overthe-counter drugs; see Table 1). Results of functional, mobility, gait, and balance assessments are reported elsewhere (Wiglesworth et al., 2009). Twelve physical assault questions from the Revised Conflict Tactics Scale (CTS2) were used to collect evidence of the abuse (Straus, Hamby, BoneyMcCoy, & Sugarman, 1996). A thorough head-to-toe skin examination was performed to assess the presence of injuries or bruises associated with the alleged incident. The location, size (length and width), and causation (whether accidental or inflicted) of bruises, as well as time elapsed since the day of the incident, were recorded. The subject or surrogate was asked to describe the abusive incident and how it related to the injuries sustained, generating qualitative data. The same research nurse completed all of the data collection.
TABLE 1. Descriptive Characteristics of Sample Total sample of abused Characteristic elderly, N = 67 Inflicted bruises, n (%)
48 (71.6)
Female, n (%)
48 (71.6)
White, n (%)
63 (94)
Number of prescription medications, mean T SD
5.14 T 4.16
Number of over the counter medications, mean T SD
0.91 T 2.01
Needs assistance with activities of daily living, n (%)
28 (41.7)
Unable to maintain self on instrumental activities of daily living, n (%)
17 (25.4)
Mini-Mental State Examination score, mean T SD Bedbound, n (%)
26.91 T 5.49 1 (1.5)
Tinetti gait score, mean T SD
10.49 T 8.38
Tinetti balance score, mean T SD
12.06 T 8.53
Fell one or more times in previous month, n (%)
26 (38.8)
Fell one or more times in previous year, n (%)
35 (52.2)
Journal of Forensic Nursing
h Analysis
Data were collected on 67 confirmed cases of physical elder abuse. Forty-eight victims had bruises. The objective was to analyze characteristics of bruises, and a single elder could have had more than one bruise, so all documented bruises were used in the analysis. The number of bruises sustained ranged from 0 to 9 (mean = 2.3, SD = T2.3). The CTS2 items were used to represent the mechanism of injury. Frequency data were used to describe the common bruise locations and mechanisms of injury. Fisher’s exact test of independence and odds ratios were calculated comparing mechanisms of injury with bruise locations.
h Results
The victims’ ages ranged from 65 to 95 years (76.7 T 8.2 years). There were more female victims (48, 71.6%) than male victims (19, 28.4%). The mean score on the Mini-Mental State Examination was 26.91 T 5.49. Four of the 67 participants required a surrogate to respond to the assessment battery including the CTS2 questions, and three of these had bruises. Alleged perpetrators included spouses (n = 6, 9.4%), sons (n = 17, 26.6%), daughters (n = 17, 26.6%), and other relatives (n = 18, 28.1%). If reported, the gender of the alleged perpetrators was evenly divided between men (n = 31, 47%) and women (n = 31, 47%). The most common bruising locations were the lateral/ anterior arms (n = 23, 34.3%), head and neck (n = 10, 14.9%), and posterior torso (n = 7, 10.4%). The three most frequently endorsed items on the CTS2 were ‘‘a family member or other adult I know pushed or shoved me’’ (n = 34, 50.7%), ‘‘a family member or other adult I know grabbed me’’ (n = 23, 34.3%), and ‘‘a family member or other adult I know punched or hit me with something that could hurt’’ (n = 21, 31.3%). Five items from the CTS2 were significantly associated with bruise locations (see Table 2). Persons who endorsed ‘‘a family member or other adult I know choked me’’ on the CTS2 were significantly more likely to have bruises on the lumbar region (p = 0.007, n = 2/6), head and neck (p = 0.039, n = 3/6), and left anterior upper arm (p = 0.004, n = 3/6) than persons with bruises who were not choked. Persons who endorsed ‘‘punched or hit me’’ on the CTS2 were significantly more likely to have bruises on the head and neck (p = 0.001, n = 8/21) and right lateral upper arm (p = 0.027, n = 5/21) than persons with bruises who did not report being punched. Persons who endorsed ‘‘grabbed me’’ on the CTS2 were significantly more likely to have lateral/ anterior arm bruises (p e 0.001, n = 15/23), including the left anterior upper arm (p = 0.003, n = 5/23) and the left anterior lower arm (p = 0.016, n = 5/23), than persons with bruises who did not report being grabbed. Persons who endorsed ‘‘a family member or other adult I know beat me up’’ on the CTS2 www.journalforensicnursing.com
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Original Article TABLE 2. Incidence of Bruise by Location Predicted by CTS2 Item Bruise Fisher’s exact Sample size, CTS2 location test (p) n (%)
cipants endorsed ‘‘choked me’’ on the CTS2. The six (9%) victims who experienced strangulation also reported ‘‘punched in the last year’’ (50%) and ‘‘beat up in the last year’’ (83.3%).
Choked recently
The odds of having lateral and/or anterior arm bruises were eight times greater when the victim endorsed ‘‘grabbed me’’ on the CTS2 (OR = 8.438, 95% CI [2.671, 26.655], p e 0.001). Descriptive stories of victims regarding the incidents of bruising suggested that lateral/anterior arm bruises were the result of being grabbed during physical altercations and not the result of the caregiver being rough during caregiving tasks. The victims in this sample described either having their arms ‘‘grabbed and twisted’’ or being ‘‘grabbed and dragged.’’ These events evolved as part of an altercation with the alleged perpetrator. For example, a victim asked her daughter to follow up on Supplemental Security Income (SSI) paperwork. The daughter proceeded to grab the victim’s arm and twist it, resulting in left lower lateral arm bruising. She then shoved the SSI paperwork in the victim’s mouth. In a different incident, a victim was walking across the room and blocked the view of the television. The son-inlaw yelled, ‘‘I’ll show you how to move, I’ll put you in your place’’ and grabbed the victim by her upper arms, dragged her into the bedroom, and pushed her down onto the bed. The victim sustained bruising on the left anterior upper arm. In two of the incidents in which the bruises were attributed to being grabbed, the attacks escalated to the victim being strangled.
Punched recently
Grabbed recently
Lumbar
0.007
2/6 (33.3)
Head and neck
0.039
3/6 (50)
Left anterior upper arm
0.004
3/6 (50)
Head and neck
0.001
8/21 (38)
Right lateral upper arm
0.027
5/21 (23.8)
Left anterior upper arm
0.003
5/23 (21.74)
Left anterior lower arm
0.016
5/23 (21.74)
Lateral/ anterior arm
G0.001
15/23 (65.2)
Beat recently
Head and neck
0.001
6/11 (54.5)
Slammed recently
Lumbar region
0.005
2/5 (40)
were significantly more likely to have bruising on the head and neck (p = 0.001, n = 6/11) than persons with bruises who did not report this. Lastly, persons who endorsed ‘‘a family member or other adult I know slammed me against a wall’’ on the CTS2 were significantly more likely to have bruises on the lumbar region (p = 0.005, n = 2/5) than persons with bruises who did not report being slammed. Because head and neck and lateral/anterior arm bruises are characteristic of inflicted rather than accidental bruises, further analyses were conducted to describe the events that resulted in these injuries.
Head and Neck Ten (14.9%) elders sustained head and neck bruises. Victims who sustained head and neck bruises had an 8 times greater odds of endorsing ‘‘choked me’’ on the CTS2 (OR = 7.714, 95% CI [1.296, 45.905], p = 0.039), a 14 times greater odds of endorsing ‘‘punched me’’ on the CTS2 (OR = 13.538, 95% CI [2.553, 71.807], p = 0.001), and a 6 times greater odds of endorsing ‘‘beat me up’’ on the CTS2 (OR = 5.600, 95% CI [3.269, 74.456], p = 0.001). Having head and neck bruises was significantly associated with male gender of the perpetrator (p = 0.006). Furthermore, six (9%) study parti88
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Lateral/Anterior Arm
h Discussion
The results of this study offer insights into the injurious processes of violence occurring in elder abuse. Findings that the CTS2 items are associated with bruise locations are useful because they suggest mechanisms that cause the bruising of elder abuse victims. They highlight injury patterns that victims sustain and can be informative for forensic nurses assessing older adults. In addition, lateral and/or anterior arm bruises were found to be the result of physical altercations, not acts occurring during caregiving tasks, and this fact compels forensic nurses to be aware of the possibility of abuse during their assessments. Previous research has found that bruises sustained in elder abuse are distinguishable from bruises attained accidentally (Wiglesworth et al., 2009). Consistent with previous findings, this study found that bruising in elder abuse victims was associated with injury to the lateral right arm and to the head/neck (Wiglesworth et al., 2009). This study expanded that knowledge on abusive bruises by finding certain mechanisms of injury are more likely to cause bruises in particular locations. There were similarities between the current findings and IPV literature. Research has found that women who present to the ED as victims of IPVare likely to have injuries Volume 9 & Number 2 & April-June 2013
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Original Article to the face, head, and neck, committed by a male perpetrator (CDC, 2005; Fanslow et al., 1998; Le et al., 2001; Muelleman et al., 1996; Sheridan & Nash, 2007). In this sample, 9 of the 10 cases with head and neck bruises involved male perpetrators. It has also been reported in IPV that, in the midst of violent attacks, perpetrators apologize while attacking victims (Shields, Corey, Weakley-Jones, & Stewart, 2010). In a descriptive report from this study, an elderly female subject stated that her son said, ‘‘I’m sorry Mom I have to do this’’ and started punching her in the face. In IPV, strangulation is common in later stages of abuse (Wilbur et al., 2001), results in a myriad of clinical symptoms (Shields et al., 2010; Smith, Mills, & Taliaferro, 2001; Wilbur et al., 2001), and can lead to homicide (Shields et al., 2010). The victims in this sample who experienced strangulation had bruises in an array of areas and reported a history of being ‘‘punched’’ (50%) and ‘‘beat up’’ (83.3%) over the last year. If strangulation is in fact indicative of progressive stages of violence culminating in homicide, these findings are strong support for a heightened sensitivity to the importance of recognizing patterns of escalation. Recent findings on homicide in elderly victims by caregivers suggest that widowed White non-Hispanic women aged 80 years and older are more likely to be victims of homicide (Karch & Nunn, 2011). The Karch and Nunn study found homicide by firearm (35.3%) and intentional neglect (25%) as most common; nonetheless, homicide by hanging/strangulation/suffocation was experienced by 7.4% of victims (Karch & Nunn, 2011). Further research is needed to examine the specificity and sensitivity of these proposed markers in elder abuse populations. Research is also needed in examining the link between other injuries sustained during assaults, bruising, and the mechanism of injuries. The findings on strangulation suggest a need for larger studies examining the occurrence and circumstances of strangulation in elder abuse and its relationship to homicide.
Limitations This study has limitations. The sample size is small and limits the findings to what can be learned from this specific set of abuse incidents. Accordingly, the confidence intervals for the calculated odds ratios are large; however, other IPV studies linking characteristics to injuries have found similarly wide confidence intervals (Fanslow et al., 1998; Halpern et al., 2005; Petridou et al., 2002). The sample consisted entirely of persons referred to APS for physical abuse who agreed to participate in the study. Estimates suggested for every one case reported to the authorities, another five go unreported (National Center on Elder Abuse, 1998). The APS sample may reflect victims experiencing more acute situations of abuse so they are noticed by the system, or they may reflect Journal of Forensic Nursing
victims experiencing less acute situations who have better resources who can contact the system. Some of these limitations are offset by the use of the LEAD panel, which externally confirmed cases of abuse, a strength of the sampling method.
for Clinical Forensic h Implications Nursing Practice Recognition of common injuries, circumstances surrounding elder abuse, and forensic markers of elder abuse will aid forensic nurses, healthcare practitioners, and investigating agencies to identify and assist elder abuse victims. In the context of clinical forensic nursing, it will also aid the legal system in prosecution and substantiation of elder abuse cases. Excluding elder abuse cases from the legal system denies this population the same protection and rights afforded to younger victims of violence (Heisler, 2000), reinforcing the need to develop forensic knowledge for elder abuse. Early detection of abuse can protect the individual from future injury and even death. Prompt assistance for elder abuse victims is needed to protect them from further physical and psychological effects of violence. Forensic nurses treat the immediate effects of violence and are uniquely positioned to intervene with local investigation agencies to ensure patient safety. This study suggests bruising to the lateral/anterior arms and to the head/ neck is characteristic of physical elder abuse. Therefore, forensic nurses should pay particular attention to bruising in these areas when conducting abuse assessments. In addition, the findings suggest bruising to the arms is a result of conflict and not of ‘‘rough’’ caregiving (i.e., transferring someone by the arms); therefore, forensic nurses need to be open minded to the possibility of elder abuse occurring in caregiving situations. This reinforces the recommendation that every older adult with a bruise be questioned about the possibility of elder abuse (Pearsall, 2011). In addition, it is important to note that caregivers often blame intentional bruises on the occurrence of a fall. An analysis of cognitively impaired older adults in the emergency department found a reported history of a fall was significantly related to internal injuries, bruises on the breast, and upper dislocations (Ziminski, Phillips, & Woods, 2012). Although these injuries are possible outcomes of a fall, they are unusual for a ground level fall and should raise the level of suspicion of elder abuse. Every healthcare provider caring for an older adult after a fall needs to obtain a detailed subjective history and be aware of the possibility of a false story (Pearsall, 2011). Moreover, although falls are a legitimate reason older adults seek emergency care, not all falls are accidental because older adults can be pushed, tripped, and dropped. This study found that bruising to the anterior/lateral www.journalforensicnursing.com
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Original Article arm and to the head and neck is not consistent with a falllike mechanism of injury. Elders, even those with a cognitive impairment, can often relate how an injury occurred (Wiglesworth et al., 2009), but they have to be asked. In this study, 13 of 18 participants with bruises and MMSE scores indicating mild to moderate impairment reported that their bruises were inflicted during an abusive event. Therefore, every older adult needs to be screened for elder abuse. Forensic nurses can be champions for elder abuse assessment through educating other healthcare professionals on the need for elder abuse screenings. Although the U.S. Preventive Services Task Force has concluded that there is insufficient evidence to assess the benefits and harms of screening all older adults for abuse and neglect (USPSTF, 2012), forensic nurses must remember that they are legally mandated reporters. Although mandatory reporting is controversial, victims of elder abuse may not have the necessary support and resources to be able to make a free choice about self-reporting (Moskowitz, 1998). With that, it is important for all healthcare providers to actively discuss elder abuse with their patients and their families. Two tools forensic nurses can use to identify victims of elder abuse include the Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST; Neale, Hwalek, Scott, Sengstock, & Stahl, 1991) and the Elder Assessment Instrument (EAI; Fulmer, Paveza, Abraham, & Fairchild, 2000). The H-S/EAST is a nine-item tool, with the elder as respondent, and is used to assess physical, psychological, and financial abuse in a clinical setting (Neale et al., 1991). The EAI is a 35-item tool used to guide assessment abuse, neglect, exploitation, and abandonment through Likert-type scales, complete with areas for comments (Fulmer et al., 2000). The EAI does not provide a scoring or interpretation system, rather it provides a summary of clinical interpretations. The EAI has been used in a busy clinical setting including the emergency department (Fulmer et al., 2000). Furthermore, the American Medical Association also has published guidelines on the diagnosis and treatment of elder abuse, which forensic nurses may find valuable in practice (Aravanis et al., 1993).
h Acknowledgments Copyright Permissions: The CTS2 (copyright (c) 2003 by Western Psychological Services) was adapted for use in specific scholarly application by the University of California, Irvine, Program in Geriatrics, under limited-use license from the publisher, Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, CA 90025-1251, USA. All rights reserved. ([email protected]). The authors are grateful to Adult Protective Services of Orange County, California, for making it possible to recruit the participants for the original study and to the participants for telling us their stories. 90
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h References
Appelbaum, P. S., & Grisso, T. (2001). MacArthur competence assessment tool for clinical research (MacCAT-CR). Sarasota, FL: Professional Resource Press. Aravanis, S. C., Adelman, R. D., Breckman, R., Fulmer, T. T., Holder, E., Lachs, M., I Sanders, A. B. (1993). Diagnostic and treatment guidelines on elder abuse and neglect. Archives of family medicine, 2(4), 371Y388. doi: 10.1001/ archfami.2.4.371 CDC. (2005). Intimate partner violence injuriesVOklahoma, 2002. Morbidity and Mortality Weekly Report, 54(41), 1041Y1045. Dong, X., Simon, M., Fulmer, T., Beck, T., Hebert, L., Dyer, C., I Evans, D. (2009). Elder self-neglect and abuse and mortality risk in a community-dwelling population. Journal of the American Medical Association, 302(5), 517Y526. doi: 10.1001/jama .2009.1109 Dyer, C., Connolly, M. T., & McFeeley, P. (2003). The clinical and medical forensics of elder abuse and neglect. In National Research Council (U.S.) panel to review risk and prevalence of elder abuse and neglect, R. J. Bonnie & R. B. Wallace (Eds.), Elder mistreatment: Abuse, neglect, and exploitation in an aging America. Washington, DC: National Academies Press. Fanslow, J. L., Norton, R. N., & Spinola, C. G. (1998). Indicators of assault-related injuries among women presenting to the emergency department. Annals of Emergency Medicine, 32(3), 341Y348. doi: 10.106/S0196064498700113 Friedman, L. S., Avila, S., Tanouye, K., & Joseph, K. (2011). A case-control study of severe physical abuse of older adults. Journal of the American Geriatrics Society, 59(3), 417Y422. doi: 10.1111/j.1532-5415.2010.03313.x Fulmer, T., Paveza, G., Abraham, I., & Fairchild, S. (2000). Elder neglect assessment in the emergency department. Journal of Emergency Nursing: JEN : Official Publication of the Emergency Department Nurses Association, 26(5), 436Y443. doi: 10.1067/ men.2000.110621 Halpern, L. R., Susarla, S. M., & Dodson, T. B. (2005). Injury location and screening questionnaires as markers for intimate partner violence. Journal of Oral and Maxillofacial Surgery, 63(9), 1255Y1261. doi: 10.1016/j.joms.2005.05.295 Heisler, C. J. (2000). Elder abuse and the criminal justice system: New awareness, new responses. Generations, 24, 52Y58. Karch, D., & Nunn, K. C. (2011). Characteristics of elderly and other vulnerable adult victims of homicide by a caregiver: National Violent Death Reporting SystemV17 US States, 2003Y2007. Journal of Interpersonal Violence, 26(1), 137Y157. doi: 10.1177/0886260510362890 Lachs, M. S., Williams, C. S., OBrien, S., Hurst, L., Kossack, A., Siegal, A., & Tinetti, M. E. (1997). ED use by older victims of family violence. Annals of Emergency Medicine, 30(4), 448Y454. doi: 10.1016/S0196-0644(97)70003-9 Le, B. T., Dierks, E. J., Ueeck, B. A., Homer, L. D., & Potter, B. F. (2001). Maxillofacial injuries associated with domestic violence. Journal of Oral and Maxillofacial Surgery, 59(11), 1277Y1283. doi: 10.1053/joms.2001.27490 McDonough, E. T. (2006). Death investigation. In R. M. Hammer, B. Moynihan, & E. M. Pagliaro (Eds.), Forensic nursing : A handbook for practice. Sudbury, MA: Jones and Bartlett. Moskowitz, S. (1998). Saving granny from the wolf: Elder abuse and neglectVThe legal framework. Connecticut Law Review, 31, 77Y204. Mosqueda, L., Burnight, K., & Liao, S. (2005). The life cycle of bruises in older adults. Journal of the American Geriatrics Society, 53(8), 1339Y1343. doi: 10.1111/j.1532-5415.2005.53406.x Volume 9 & Number 2 & April-June 2013
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Original Article Muelleman, R. L., Lenaghan, P. A., & Pakieser, R. A. (1996). Battered women: Injury locations and types. Annals of Emergency Medicine, 28(5), 486Y492. doi: 10.1016/S0196-0644(96)70110-5 National Institute of Justice. (2000). Elder justice: Medical forensic issues concerning abuse and neglect. Summary of a Roundtable. Washington, DC. Neale, A. V., Hwalek, M. A., Scott, R. O., Sengstock, M. C., & Stahl, C. (1991). Validation of the Hwalek-Sengstock Elde Abuse Screening Test. Journal of Applied Gerontology, 10(4), 406Y418. doi: 10.1177/073346489101000403 Pearsall, C. (2005). Forensic biomarkers of elder abuse: What clinicians need to know. Journal of Forensic Nursing, 1(4), 182Y186. doi: 10.1111/j.1939-3938.2005.tb00043.x Pearsall, C. (2011). Elder maltreatment: Forensic biomarkers. In v. A. Lynch & J. B. Duval (Eds.), Forensic nursing science (2 ed.) (pp. 355Y369). St. Louis: Elsevier Mosby. Perciaccante, V. J., Carey, J. W., Susarla, S. M., & Dodson, T. B. (2010). Markers for intimate partner violence in the emergency department setting. Journal of Oral and Maxillofacial Surgery, 68(6), 1219Y1224. doi: 10.1016/j.joms.2010.02.010 Petridou, E., Browne, A., Lichter, E., Dedoukou, X., Alexe, D., & Dessypris, N. (2002). What distinguishes unintentional injuries from injuries due to intimate partner violence: A study in Greek ambulatory care settings. Injury Prevention, 8(3), 197Y201. doi:10.1136/ip.8.3.197 Pillemer, K. (2005). Elder abuse is caused by the deviance and dependence of abusive caregivers. In: D. R. Loseke, R. J. Gelles, & M. M. Cavanaugh (Eds.), Current Controversies on Family Violence (2nd ed.). Thousand Oaks, CA: SAGE. Sheridan, D. J., & Nash, K. R. (2007). Acute injury patterns of intimate partner violence victims. Trauma Violence & Abuse, 8(3), 281Y289. doi: 10.1177/1524838007303504 Shields, L. B. E., Corey, T. S., Weakley-Jones, B., & Stewart, D. (2010). Living victims of strangulation: A 10-year review of cases in a metropolitan community. American Journal of
Forensic Medicine & Pathology, 31(4), 320. doi: 10.1097/ PAF.0b013e3181d3dc02 Smith, D. J., Mills, T., & Taliaferro, E. H. (2001). Frequency and relationship of reported symptomology in victims of intimate partner violence: The effect of multiple strangulation attacks. Journal of Emergency Medicine, 21(3), 323Y329. doi: 10.1016/S0736-4679(01)00402-4 Straus, M. A., Hamby, S. L., Boney-McCoy, S., & Sugarman, D. B. (1996). The Revised Conflict Tactics Scales (CTS2): Development and preliminary psychometric data. Journal of Family Issues, 17(3), 283Y316. doi: 10.1177/019251396017003001 Tatara, T., Kuzmeskus, L., Duckhorn, E, Bivens, L., Thomas, C., Gertig, J. I Croos, J. (1998). The national elder abuse incidence study. U.S. Administration on Aging, National Center on Elder Abuse. Retrieved from http://aoa.gov/AoARoot/ AoA_Programs/Elder_Rights/Elder_Abuse/docs/ABuseReport_ Full.pdf. USPSTF. (2012). Screening for intimate partner violence and abuse of elderly and vulnerable adults: Draft recommendation statement. (12-05167-EF-2). Retrieved from http://www.uspreventive services taskforce.org/uspstf12/ipvelder/draftrecipvelder.htm Wiglesworth, A., Austin, R., Corona, M., Schneider, D., Liao, S., Gibbs, L., & Mosqueda, L. (2009). Bruising as a marker of physical elder abuse. Journal of the American Geriatrics Society, 57(7), 1191Y1196. doi: 10.1111/j.1532-5415.2009 .02330.x Wilbur, L., Higley, M., Hatfield, J., Surprenant, Z., Taliaferro, E., Smith, D. J., & Paolo, A. (2001). Survey results of women who have been strangled while in an abusive relationship. Journal of Emergency Medicine, 21(3), 297Y302. doi: 10.1016/ S0736-4679(01)00398-5 Ziminski, C. E., Phillips, L. R., & Woods, D. L. (2012). Raising the index of suspicion for elder abuse: Cognitive impairment, falls, and injury patterns in the emergency department. Geriatric Nursing, 33(2), 105Y112. doi: 10.1016/j.gerinurse.2011.12.003
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Injury Patterns and Causal Mechanisms of Bruising in Physical Elder Abuse Carolyn E. Ziminski, RN, BSN1, Aileen Wiglesworth, PhD2, Raciela Austin, RN2, Linda R. Phillips, RN, PhD1, and Laura Mosqueda, MD1 ABSTRACT The recognition of injury patterns can aid forensic nurses to identify victims of elder abuse. This study examined the mechanism of injury of bruises endured by physical elder abuse victims. A sample of 67 elders aged 65 years and older who reported to Adult Protective Services for physical elder abuse was included in the analysis. A research nurse conducted assessments and documented the presence and characteristics of all bruises. Data regarding the abusive incident were collected through victim descriptions and the Revised Conflicts Tactic Scales (CTS2) physical assault scale. The most common bruising locations were the lateral/anterior arms (n = 23, 34.3%), head and neck (n = 10, 14.9%), and posterior torso (n = 7, 10.4%). Victims’ odds of having head and neck bruises were greater when reporting being choked (OR = 7.71, 95% CI [1.29, 45.90], p = 0.039), punched (OR = 13.53, 95% CI [2.55, 71.80], p = 0.001), and beaten up (OR = 5.60, 95% CI [3.26, 74.45], p = 0.001). The odds of having lateral/anterior arm bruises were eight times greater when the victim reported being grabbed (OR = 8.43, 95% CI [2.67, 26.65], p G 0.001). The findings suggest similarities between injuries experienced in elder abuse and those in intimate partner violence. Findings highlight injury patterns that elder abuse victims sustain and can be informative for forensic nurses. KEY WORDS: elder abuse; forensic markers; injury patterns; intimate partner violence; mechanism of injury
E
lder abuse can lead to injuries, the need to be placed on mechanical ventilation, hospital admission, and even death (Dong et al., 2009; Friedman, Avila, Tanouye, & Joseph, 2011; Lachs et al., 1997). The National Elder Abuse Incidence Study conducted in 1996 Author Affiliations: 1School of Nursing, University of California, Los Angeles, and 2Program in Geriatrics, School of Medicine, University of California, Irvine. This project was funded by Grant 2005-IJ-CX-0048 from the Department of Justice, Office of Justice Programs, and by the John A. Hartford Foundation’s Building Academic Geriatric Nursing Capacity Award Program. The authors have disclosed that they have no financial relationships related to this article. Correspondence: Carolyn Ziminski, RN, BSN, School of Nursing, University of California, Los Angeles, Factor Building Room 5-133A, 700 Tiverton Avenue, Los Angeles, CA 90095. E-mail: [email protected]. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s web site (www.journalforensicnursing.com). Received July 30, 2012; accepted for publication October 28, 2012. Copyright * 2013 International Association of Forensic Nurses DOI: 10.1097/JFN.0b013e31827d51d0
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estimated that half a million older adults were victims of elder abuse and only 16% of the cases were reported to Adult Protective Services (APS; National Center on Elder Abuse, 1998). However, it is commonly believed that elder abuse estimates are only capturing the ‘‘tip of the iceberg’’ (National Center on Elder Abuse, 1998), and since 1996, the number of victims has surely increased with the growth of the older adult population. Healthcare practitioners have both legal and ethical responsibilities to ensure their patients’ safety and report incidences of assault, but fulfilling those responsibilities requires advancement of knowledge of clinical forensic medicine patterns and characteristics pertaining to elder abuse. Forensic nurses are essential in assessing and intervening in elder abuse. Linking the study of elder abuse to clinical forensic medicine is a recent, but essential, step in advancing knowledge about elder abuse. In 2000, the Elder Justice Roundtable concluded that application of forensic science was needed to aid in the prosecution of elder abuse cases (National Institute of Justice, 2000). However, before cases can be prosecuted, forensic markers need to be established as standards for assessment and diagnosis, in order to aid practitioners in detecting and reporting elder abuse (Dyer, Connolly, & McFeeley, 2003). Clearly delineated forensic Volume 9 & Number 2 & April-June 2013
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Original Article markers for elder abuse are very important because of the difficulty in distinguishing symptoms of abuse from chronic or geriatric syndromes (Dyer et al., 2003). Bruising patterns and locations may be used by forensic nurses to identify physical abuse and as evidence in the prosecution of elder physical abuse cases (Dyer et al., 2003). However, limited research supports the argument that a particular bruising pattern is an indicator of abuse. Identification of common abuse-related injuries and common mechanisms of injury in abuse and establishing a link between the two aid in the development of forensic markers. The mechanism of injury provides the clinician with an understanding of what the victim experienced, including injury severity and locations (Sheridan & Nash, 2007). To date, one study has examined traumatic injuries experienced in severe physical abuse by older adults seen in emergency department trauma centers (Friedman et al., 2011). Although it has limited forensic use, the study showed that, as compared with a control group, abused individuals were significantly more likely to experience penetrating injuries and to be admitted to an intensive care unit and placed on a ventilator. The injuries most commonly experienced by the victims of abuse included open wounds (56.1%), internal injuries (24.4%), and fractures (22%), most commonly incurring to the head (61%) and torso (31.7%; Friedman et al., 2011).
Mechanism of Injury in Intimate Partner Violence Elder abuse is an act committed by a person in a trusted relationship with the elder, most often a family member (National Center on Elder Abuse., 1998). Similarities between elder abuse and intimate partner violence (IPV) have been suggested because they both involve reasonably independent people who live with physically stronger people who victimize them (Pillemer, 2005). The IPV literature regarding injuries is fairly well advanced and pertinent to the study of elder abuse but rarely applied to elder abuse. The IPV field has identified patterns in injury locations and types sustained by victims. The head, neck, and face are the most common sites of injury (CDC, 2005; Fanslow, Norton, & Spinola, 1998; Le, Dierks, Ueeck, Homer, & Potter, 2001; Muelleman, Lenaghan, & Pakieser, 1996; Sheridan & Nash, 2007). These locations have been used in the literature as predictive variables in detecting IPV (Halpern, Susarla, & Dodson, 2005; Perciaccante, Carey, Susarla, & Dodson, 2010). Bruises or contusions are common injuries sustained by victims of IPV (Fanslow et al., 1998; Le et al., 2001). Other injuries include lacerations and musculoskeletal injuries (CDC, 2005; Fanslow et al., 1998; Le et al., 2001). Mechanisms of injury reported in IPV include being punched, pushed, kicked, slapped, choked, or hit with Journal of Forensic Nursing
an object, with more than one type frequently occurring (Muelleman et al., 1996). Strangulation has also been identified as a common mechanism of injury in IPV. Wilbur and colleagues (2001) conducted a survey of IPV victims recruited from women’s shelters who survived a strangulation attempt and found 68% had experienced previous strangulation attempts. Victims reported being strangled an average of 5.3 times along with the co-occurrence of other types of abuse (88%), most frequently verbal abuse (68%). The average length of relationships before the first strangulation was 5.2 years, and the average length of abuse before the initial strangulation was 3.1 years, suggesting that strangulation occurs late in the relationship and late in the trajectory of abuse (Wilbur et al., 2001).
Bruising in the Older Adults Bruising is caused by a force being applied to an area resulting in blood vessels under the intact skin leaking into the surrounding tissue (McDonough, 2006). A bruise can be caused by a fall or minimal blunt force trauma and can be accidental or intentional. Bruising is recognized as a sign of physical elder abuse (Dyer et al., 2003; Pearsall, 2005; Wiglesworth et al., 2009). However, in a comprehensive review of the literature on bruising in the elderly population, only two studies were identified. One study documented the occurrence, progression, and characteristics of accidentally acquired bruises in elders aged 65 years and older (Mosqueda, Burnight, & Liao, 2005). Subjects were recruited from three community-based settings and two skilled nursing facilities. One hundred one seniors were examined daily at home for a maximum of 6 weeks to document the presence or absence of bruising. One hundred eight bruises were found (Mosqueda et al., 2005). Of those, 89% were on the extremities, with 76% on the dorsal aspect of the arms. No bruises were found on the neck, ears, genitalia, buttocks, or soles of feet. The authors noted that the color of a bruise was not a good indicator of its age. The bruises resolved in 4Y41 days (11.7 T 7.1). People on medications known to affect coagulation pathways and people with compromised function were more likely to have multiple bruises (Mosqueda et al., 2005). The second bruising study investigated the characteristics of bruises sustained by physically abused older adults (Wiglesworth et al., 2009). Findings were compared with the results of the aforementioned study of accidental bruises. Recruited subjects were APS clients. Physical abuse was confirmed for 67 participants. Forty-eight (72%) of the 67 participants had bruises for a total of 155 bruises. Of these, participants reported 89 (57.4%) were inflicted, 40 (25.8%) were of unknown causes, and 26 (16.8%) were accidental. Locations of the inflicted bruises included the extremities (57.3%) and the trunk/head (42.7%). As www.journalforensicnursing.com
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Original Article compared with the study about accidental bruises, this study found that medications that interfere with coagulation pathways were not associated with the presence of multiple bruises and participants needing assistance with activities of daily living (ADL) did not present with multiple bruises, but findings suggested that participants who used assistive devices for mobility were more likely to have bruising. From a forensic perspective, what is known about the characteristics of bruises inflicted on older adults is limited to their size and location on the body, establishing that they are distinct from bruises sustained accidentally (Wiglesworth et al., 2009). Research has not yet examined if certain mechanisms of injuries produce bruises on certain body locations. The objective of this study was to describe the mechanisms of injury associated with characteristics of the bruises in a sample of elders who experienced physical elder abuse. The study was designed to address three specific research questions: 1. What are the common bruise locations in a sample of physically abused elders? 2. What are the common mechanisms of injury in a sample of physically abuse elders? 3. What mechanisms of injury are related to bruises found in physical elder abuse?
h Methods
The findings reported in this article result from a secondary analysis of data from the Wiglesworth and colleagues (2009) study described previously. The study protocol was approved by the institutional review board at the University of California, Irvine. Consent to participate in the study was obtained from the subject, or if the potential study subject appeared to lack decision-making capacity, consent was obtained from an authorized surrogate. Decisionmaking capacity was determined by the research nurse through the use of the MacArthur Competence Assessment Tool for Clinical Research (Appelbaum & Grisso, 2001).
Study Population This study took place in Orange County, California, and was completed between July 2006 and May 2008. All subjects invited to participate in the study had been referred to APS for possible physical abuse. Study inclusion criteria were (a) adults aged 65 years and older, (b) had a physically abusive incident occurring in the previous six weeks, and (c) that the perpetrator was in a position of trust (not a stranger). Because the APS referrals were for alleged physical abuse, not confirmed physical abuse, verification of physical abuse was needed to achieve the study’s goal of examining bruising associated with abuse. Therefore, upon consenting to participate in the study, participants’ status of physical abuse was externally confirmed by the LEAD panel (Longitudinal, Experts, All Data), consisting of four board-certified geriatricians with a combined 37 years of experience in the 86
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field of elder abuse. The LEAD panel made their decisions based on data presented by the research nurse as well as evidence from the investigation file presented by the APS case worker, which included information on the elder’s injuries, events leading to the altercation, and need for medical care afterwards. Information about bruising was withheld from the panel to ensure the independence of the analyses for bruising associated with abuse. This allowed the researchers to objectively examine the potential use of bruises as a forensic marker of elder abuse because the bruising status had no influence in the confirmation of physical abuse. The operational definition of physical abuse and sample questions asked by the panel are available at: http://www .centeronelderabuse.org/. All members of the LEAD panel had to be in agreement to designate a case as physical abuse. Of 407 APS clients with allegations of possible elder physical abuse, 67 participants were confirmed as having been victims of elder physical abuse (see Supplemental Digital Content 1, http://links.lww.com/JFN/A6). Of these 67 participants, 48 individuals had bruises. There were 155 total bruises among the 48 individuals with bruising. Of the 93 APS clients who refused to participate after speaking to the research nurse, demographic data are available on 78 people. The 78 with available data were not significantly different from the participants in the study in age (76.9 T 7.5 years) or gender (51 women).
Protection of Human Rights Several measures were taken to ensure that the rights of the participants were maintained. First, there was a memorandum of understanding in place with APS explaining the terms of collaboration and protecting the rights of the participants. When an APS social worker received a report of alleged physical abuse, the social worker asked the client for permission for a research nurse to contact them. After speaking with the research nurse, the APS clients who agreed to participate and who met study inclusion criteria were consented. The consent form detailed the maintenance of confidentiality including assigning of participant code numbers to research files, maintaining research records in locked offices, and leaving names and identities out of research reports. Participants were also informed that no personally identifiable information would be disclosed without a separate consent, except as required by law. To comply with the legally mandated reporting requirements, if the researchers suspected that additional types of abuse were occurring other than what was originally reported, the researchers made an additional report to the assigned APS social worker. Lastly, the participants’ identities were not revealed during the LEAD panel assessment. The researchers complied with all privacy and confidentiality requirements of the National Institute of Justice. Volume 9 & Number 2 & April-June 2013
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Original Article Data Collection Study assessments were performed in the subject’s home, relative’s home, or inpatient setting. The research nurse collected the following data: demographics, number of falls (past week, month, 6 months, and 12 months), medical history/diagnoses, and medications (prescription and overthe-counter drugs; see Table 1). Results of functional, mobility, gait, and balance assessments are reported elsewhere (Wiglesworth et al., 2009). Twelve physical assault questions from the Revised Conflict Tactics Scale (CTS2) were used to collect evidence of the abuse (Straus, Hamby, BoneyMcCoy, & Sugarman, 1996). A thorough head-to-toe skin examination was performed to assess the presence of injuries or bruises associated with the alleged incident. The location, size (length and width), and causation (whether accidental or inflicted) of bruises, as well as time elapsed since the day of the incident, were recorded. The subject or surrogate was asked to describe the abusive incident and how it related to the injuries sustained, generating qualitative data. The same research nurse completed all of the data collection.
TABLE 1. Descriptive Characteristics of Sample Total sample of abused Characteristic elderly, N = 67 Inflicted bruises, n (%)
48 (71.6)
Female, n (%)
48 (71.6)
White, n (%)
63 (94)
Number of prescription medications, mean T SD
5.14 T 4.16
Number of over the counter medications, mean T SD
0.91 T 2.01
Needs assistance with activities of daily living, n (%)
28 (41.7)
Unable to maintain self on instrumental activities of daily living, n (%)
17 (25.4)
Mini-Mental State Examination score, mean T SD Bedbound, n (%)
26.91 T 5.49 1 (1.5)
Tinetti gait score, mean T SD
10.49 T 8.38
Tinetti balance score, mean T SD
12.06 T 8.53
Fell one or more times in previous month, n (%)
26 (38.8)
Fell one or more times in previous year, n (%)
35 (52.2)
Journal of Forensic Nursing
h Analysis
Data were collected on 67 confirmed cases of physical elder abuse. Forty-eight victims had bruises. The objective was to analyze characteristics of bruises, and a single elder could have had more than one bruise, so all documented bruises were used in the analysis. The number of bruises sustained ranged from 0 to 9 (mean = 2.3, SD = T2.3). The CTS2 items were used to represent the mechanism of injury. Frequency data were used to describe the common bruise locations and mechanisms of injury. Fisher’s exact test of independence and odds ratios were calculated comparing mechanisms of injury with bruise locations.
h Results
The victims’ ages ranged from 65 to 95 years (76.7 T 8.2 years). There were more female victims (48, 71.6%) than male victims (19, 28.4%). The mean score on the Mini-Mental State Examination was 26.91 T 5.49. Four of the 67 participants required a surrogate to respond to the assessment battery including the CTS2 questions, and three of these had bruises. Alleged perpetrators included spouses (n = 6, 9.4%), sons (n = 17, 26.6%), daughters (n = 17, 26.6%), and other relatives (n = 18, 28.1%). If reported, the gender of the alleged perpetrators was evenly divided between men (n = 31, 47%) and women (n = 31, 47%). The most common bruising locations were the lateral/ anterior arms (n = 23, 34.3%), head and neck (n = 10, 14.9%), and posterior torso (n = 7, 10.4%). The three most frequently endorsed items on the CTS2 were ‘‘a family member or other adult I know pushed or shoved me’’ (n = 34, 50.7%), ‘‘a family member or other adult I know grabbed me’’ (n = 23, 34.3%), and ‘‘a family member or other adult I know punched or hit me with something that could hurt’’ (n = 21, 31.3%). Five items from the CTS2 were significantly associated with bruise locations (see Table 2). Persons who endorsed ‘‘a family member or other adult I know choked me’’ on the CTS2 were significantly more likely to have bruises on the lumbar region (p = 0.007, n = 2/6), head and neck (p = 0.039, n = 3/6), and left anterior upper arm (p = 0.004, n = 3/6) than persons with bruises who were not choked. Persons who endorsed ‘‘punched or hit me’’ on the CTS2 were significantly more likely to have bruises on the head and neck (p = 0.001, n = 8/21) and right lateral upper arm (p = 0.027, n = 5/21) than persons with bruises who did not report being punched. Persons who endorsed ‘‘grabbed me’’ on the CTS2 were significantly more likely to have lateral/ anterior arm bruises (p e 0.001, n = 15/23), including the left anterior upper arm (p = 0.003, n = 5/23) and the left anterior lower arm (p = 0.016, n = 5/23), than persons with bruises who did not report being grabbed. Persons who endorsed ‘‘a family member or other adult I know beat me up’’ on the CTS2 www.journalforensicnursing.com
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Original Article TABLE 2. Incidence of Bruise by Location Predicted by CTS2 Item Bruise Fisher’s exact Sample size, CTS2 location test (p) n (%)
cipants endorsed ‘‘choked me’’ on the CTS2. The six (9%) victims who experienced strangulation also reported ‘‘punched in the last year’’ (50%) and ‘‘beat up in the last year’’ (83.3%).
Choked recently
The odds of having lateral and/or anterior arm bruises were eight times greater when the victim endorsed ‘‘grabbed me’’ on the CTS2 (OR = 8.438, 95% CI [2.671, 26.655], p e 0.001). Descriptive stories of victims regarding the incidents of bruising suggested that lateral/anterior arm bruises were the result of being grabbed during physical altercations and not the result of the caregiver being rough during caregiving tasks. The victims in this sample described either having their arms ‘‘grabbed and twisted’’ or being ‘‘grabbed and dragged.’’ These events evolved as part of an altercation with the alleged perpetrator. For example, a victim asked her daughter to follow up on Supplemental Security Income (SSI) paperwork. The daughter proceeded to grab the victim’s arm and twist it, resulting in left lower lateral arm bruising. She then shoved the SSI paperwork in the victim’s mouth. In a different incident, a victim was walking across the room and blocked the view of the television. The son-inlaw yelled, ‘‘I’ll show you how to move, I’ll put you in your place’’ and grabbed the victim by her upper arms, dragged her into the bedroom, and pushed her down onto the bed. The victim sustained bruising on the left anterior upper arm. In two of the incidents in which the bruises were attributed to being grabbed, the attacks escalated to the victim being strangled.
Punched recently
Grabbed recently
Lumbar
0.007
2/6 (33.3)
Head and neck
0.039
3/6 (50)
Left anterior upper arm
0.004
3/6 (50)
Head and neck
0.001
8/21 (38)
Right lateral upper arm
0.027
5/21 (23.8)
Left anterior upper arm
0.003
5/23 (21.74)
Left anterior lower arm
0.016
5/23 (21.74)
Lateral/ anterior arm
G0.001
15/23 (65.2)
Beat recently
Head and neck
0.001
6/11 (54.5)
Slammed recently
Lumbar region
0.005
2/5 (40)
were significantly more likely to have bruising on the head and neck (p = 0.001, n = 6/11) than persons with bruises who did not report this. Lastly, persons who endorsed ‘‘a family member or other adult I know slammed me against a wall’’ on the CTS2 were significantly more likely to have bruises on the lumbar region (p = 0.005, n = 2/5) than persons with bruises who did not report being slammed. Because head and neck and lateral/anterior arm bruises are characteristic of inflicted rather than accidental bruises, further analyses were conducted to describe the events that resulted in these injuries.
Head and Neck Ten (14.9%) elders sustained head and neck bruises. Victims who sustained head and neck bruises had an 8 times greater odds of endorsing ‘‘choked me’’ on the CTS2 (OR = 7.714, 95% CI [1.296, 45.905], p = 0.039), a 14 times greater odds of endorsing ‘‘punched me’’ on the CTS2 (OR = 13.538, 95% CI [2.553, 71.807], p = 0.001), and a 6 times greater odds of endorsing ‘‘beat me up’’ on the CTS2 (OR = 5.600, 95% CI [3.269, 74.456], p = 0.001). Having head and neck bruises was significantly associated with male gender of the perpetrator (p = 0.006). Furthermore, six (9%) study parti88
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Lateral/Anterior Arm
h Discussion
The results of this study offer insights into the injurious processes of violence occurring in elder abuse. Findings that the CTS2 items are associated with bruise locations are useful because they suggest mechanisms that cause the bruising of elder abuse victims. They highlight injury patterns that victims sustain and can be informative for forensic nurses assessing older adults. In addition, lateral and/or anterior arm bruises were found to be the result of physical altercations, not acts occurring during caregiving tasks, and this fact compels forensic nurses to be aware of the possibility of abuse during their assessments. Previous research has found that bruises sustained in elder abuse are distinguishable from bruises attained accidentally (Wiglesworth et al., 2009). Consistent with previous findings, this study found that bruising in elder abuse victims was associated with injury to the lateral right arm and to the head/neck (Wiglesworth et al., 2009). This study expanded that knowledge on abusive bruises by finding certain mechanisms of injury are more likely to cause bruises in particular locations. There were similarities between the current findings and IPV literature. Research has found that women who present to the ED as victims of IPVare likely to have injuries Volume 9 & Number 2 & April-June 2013
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Original Article to the face, head, and neck, committed by a male perpetrator (CDC, 2005; Fanslow et al., 1998; Le et al., 2001; Muelleman et al., 1996; Sheridan & Nash, 2007). In this sample, 9 of the 10 cases with head and neck bruises involved male perpetrators. It has also been reported in IPV that, in the midst of violent attacks, perpetrators apologize while attacking victims (Shields, Corey, Weakley-Jones, & Stewart, 2010). In a descriptive report from this study, an elderly female subject stated that her son said, ‘‘I’m sorry Mom I have to do this’’ and started punching her in the face. In IPV, strangulation is common in later stages of abuse (Wilbur et al., 2001), results in a myriad of clinical symptoms (Shields et al., 2010; Smith, Mills, & Taliaferro, 2001; Wilbur et al., 2001), and can lead to homicide (Shields et al., 2010). The victims in this sample who experienced strangulation had bruises in an array of areas and reported a history of being ‘‘punched’’ (50%) and ‘‘beat up’’ (83.3%) over the last year. If strangulation is in fact indicative of progressive stages of violence culminating in homicide, these findings are strong support for a heightened sensitivity to the importance of recognizing patterns of escalation. Recent findings on homicide in elderly victims by caregivers suggest that widowed White non-Hispanic women aged 80 years and older are more likely to be victims of homicide (Karch & Nunn, 2011). The Karch and Nunn study found homicide by firearm (35.3%) and intentional neglect (25%) as most common; nonetheless, homicide by hanging/strangulation/suffocation was experienced by 7.4% of victims (Karch & Nunn, 2011). Further research is needed to examine the specificity and sensitivity of these proposed markers in elder abuse populations. Research is also needed in examining the link between other injuries sustained during assaults, bruising, and the mechanism of injuries. The findings on strangulation suggest a need for larger studies examining the occurrence and circumstances of strangulation in elder abuse and its relationship to homicide.
Limitations This study has limitations. The sample size is small and limits the findings to what can be learned from this specific set of abuse incidents. Accordingly, the confidence intervals for the calculated odds ratios are large; however, other IPV studies linking characteristics to injuries have found similarly wide confidence intervals (Fanslow et al., 1998; Halpern et al., 2005; Petridou et al., 2002). The sample consisted entirely of persons referred to APS for physical abuse who agreed to participate in the study. Estimates suggested for every one case reported to the authorities, another five go unreported (National Center on Elder Abuse, 1998). The APS sample may reflect victims experiencing more acute situations of abuse so they are noticed by the system, or they may reflect Journal of Forensic Nursing
victims experiencing less acute situations who have better resources who can contact the system. Some of these limitations are offset by the use of the LEAD panel, which externally confirmed cases of abuse, a strength of the sampling method.
for Clinical Forensic h Implications Nursing Practice Recognition of common injuries, circumstances surrounding elder abuse, and forensic markers of elder abuse will aid forensic nurses, healthcare practitioners, and investigating agencies to identify and assist elder abuse victims. In the context of clinical forensic nursing, it will also aid the legal system in prosecution and substantiation of elder abuse cases. Excluding elder abuse cases from the legal system denies this population the same protection and rights afforded to younger victims of violence (Heisler, 2000), reinforcing the need to develop forensic knowledge for elder abuse. Early detection of abuse can protect the individual from future injury and even death. Prompt assistance for elder abuse victims is needed to protect them from further physical and psychological effects of violence. Forensic nurses treat the immediate effects of violence and are uniquely positioned to intervene with local investigation agencies to ensure patient safety. This study suggests bruising to the lateral/anterior arms and to the head/ neck is characteristic of physical elder abuse. Therefore, forensic nurses should pay particular attention to bruising in these areas when conducting abuse assessments. In addition, the findings suggest bruising to the arms is a result of conflict and not of ‘‘rough’’ caregiving (i.e., transferring someone by the arms); therefore, forensic nurses need to be open minded to the possibility of elder abuse occurring in caregiving situations. This reinforces the recommendation that every older adult with a bruise be questioned about the possibility of elder abuse (Pearsall, 2011). In addition, it is important to note that caregivers often blame intentional bruises on the occurrence of a fall. An analysis of cognitively impaired older adults in the emergency department found a reported history of a fall was significantly related to internal injuries, bruises on the breast, and upper dislocations (Ziminski, Phillips, & Woods, 2012). Although these injuries are possible outcomes of a fall, they are unusual for a ground level fall and should raise the level of suspicion of elder abuse. Every healthcare provider caring for an older adult after a fall needs to obtain a detailed subjective history and be aware of the possibility of a false story (Pearsall, 2011). Moreover, although falls are a legitimate reason older adults seek emergency care, not all falls are accidental because older adults can be pushed, tripped, and dropped. This study found that bruising to the anterior/lateral www.journalforensicnursing.com
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Original Article arm and to the head and neck is not consistent with a falllike mechanism of injury. Elders, even those with a cognitive impairment, can often relate how an injury occurred (Wiglesworth et al., 2009), but they have to be asked. In this study, 13 of 18 participants with bruises and MMSE scores indicating mild to moderate impairment reported that their bruises were inflicted during an abusive event. Therefore, every older adult needs to be screened for elder abuse. Forensic nurses can be champions for elder abuse assessment through educating other healthcare professionals on the need for elder abuse screenings. Although the U.S. Preventive Services Task Force has concluded that there is insufficient evidence to assess the benefits and harms of screening all older adults for abuse and neglect (USPSTF, 2012), forensic nurses must remember that they are legally mandated reporters. Although mandatory reporting is controversial, victims of elder abuse may not have the necessary support and resources to be able to make a free choice about self-reporting (Moskowitz, 1998). With that, it is important for all healthcare providers to actively discuss elder abuse with their patients and their families. Two tools forensic nurses can use to identify victims of elder abuse include the Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST; Neale, Hwalek, Scott, Sengstock, & Stahl, 1991) and the Elder Assessment Instrument (EAI; Fulmer, Paveza, Abraham, & Fairchild, 2000). The H-S/EAST is a nine-item tool, with the elder as respondent, and is used to assess physical, psychological, and financial abuse in a clinical setting (Neale et al., 1991). The EAI is a 35-item tool used to guide assessment abuse, neglect, exploitation, and abandonment through Likert-type scales, complete with areas for comments (Fulmer et al., 2000). The EAI does not provide a scoring or interpretation system, rather it provides a summary of clinical interpretations. The EAI has been used in a busy clinical setting including the emergency department (Fulmer et al., 2000). Furthermore, the American Medical Association also has published guidelines on the diagnosis and treatment of elder abuse, which forensic nurses may find valuable in practice (Aravanis et al., 1993).
h Acknowledgments Copyright Permissions: The CTS2 (copyright (c) 2003 by Western Psychological Services) was adapted for use in specific scholarly application by the University of California, Irvine, Program in Geriatrics, under limited-use license from the publisher, Western Psychological Services, 12031 Wilshire Boulevard, Los Angeles, CA 90025-1251, USA. All rights reserved. ([email protected]). The authors are grateful to Adult Protective Services of Orange County, California, for making it possible to recruit the participants for the original study and to the participants for telling us their stories. 90
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h References
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