Physical violence or abuse is an act that is carried out with the intent of causing physical pain or injury such as hitting, grabbing, slapping, pushing, or other bodily injury and that may result in sprains, bruises, abrasions, skeletal fractures, burns, and other wounds (Lachs & Pillemer, 1995). Some researchers also include sexual abuse within their definitions of physical abuse (Kleinschmidt, 1997).

Psychological or emotional abuse is commonly listed as a category of mistreatment (Lachs & Pillemer, 1995). This includes verbal or nonverbal insults, humiliation, or infantilization (Kleinschmidt, 1997) and is often defined as an act carried out with the intention of causing emotional pain or injury. Psychological abuse often accompanies physical abuse (Lachs & Pillemer, 1995).

Material exploitation or the misappropriation of money or property is the third category identified in the literature. This would include the theft of social security or pension checks, coercion in financial matters, and threats to enforce the signing or changing of legal documents such as wills or deeds (Lachs & Pillemer, 1995). Some researchers restrict this definition to only illegal or improper use of only specific government benefits, and often this form of elder mistreatment is not addressed in studies on elder abuse (Kleinschmidt, 1997). It is estimated that only 1 in 25 cases of financial exploitation is reported, which suggests that annually there may be as many as 5 million financial abuse victims (National Center on Elder Abuse, 2005).

Neglect is often defined as the failure of a designated caregiver to meet the needs of an elder who depends on that individual’s care. Neglect may be further divided into intentional neglect, where there is a deliberate failure in caregiving responsibilities with the intent to harm or punish an elder, or unintentional, which may be the result of ignorance or incapability to provide care (Lachs & Pillemer, 1995). Intent is a difficult concept to prove. This presents a problem in the literature, as intent-based definitions may technically not exist because intent may not be proved (Kleinschmidt, 1997). Some researchers consider abandonment a form of neglect (Kleinschmidt, 1997). Much of the controversy that surrounds the conceptual definition of elder abuse focuses on the issue of neglect. Cases of neglect raise difficult questions regarding who the responsible caregiver is, what the specific responsibilities are to the neglected individual, and whether this neglect was intentional or unintentional (Lachs & Pillemer, 1995).

The area of self-neglect is occasionally discussed in elder abuse research as a category of elder abuse. This is often defined as an act being conducted by an elder that threatens that individual’s health or safety as in an individual who has difficulty performing activities of daily living and refuses assistance despite resulting problems (Kleinschmidt, 1997).

Sexual abuse is defined as nonconsensual intimate contact. Elderly are at particular risk for sexual maltreatment as they may be too weak to resist assaults or they may be unable to recognize or report the abuse because of cognitive deficiencies (Kleinschmidt, 1997).

The National Aging Resource Center on Elder Abuse (NARCEA) has suggested that states use a separate category called “all other types.” This would include violation of rights, medical abuse, and abandonment (Kleinschmidt, 1997).

An argument exists that in our attempt to subdivide elder abuse into categories to assign blame, we are ignoring the needs of the victims themselves and that emphasis and resources should be directed to improving functions and quality of life. In response to this argument, many researchers choose to avoid the terms abuse and neglect and instead refer to the problem as the mistreatment of the elderly or the inadequate care of the elderly, which includes both the acts of omission and commission (Lachs & Pillemer, 1995).

Healthcare or legal professionals are often not witnesses to elder abuse. Therefore, the legal system relies on other reporters and evidence to identify the existence of abuse. Most extreme and heinous cases of mistreatment can be easily identified as abuse, for example, gunshot wounds, knife wounds, bite marks, and rope burns. The majority of cases, however, are not as clear cut because they may mimic or be mistaken for physiological and psychological changes that occur with age (Dyer, Connolly, & McFeeley, 2003), as elders respond differently from younger individuals in their response to injury (Centers for Disease Control and Prevention, 2001). In addition, elders recover at a slower rate from even minor injuries because of the age effect on the body’s ability to respond to injury and the disruption of physiological balance (Brown, Streubert, & Burgess, 2004). A research gap exists in the literature, as there is a paucity of primary research data regarding forensic markers of elder abuse (Dyer et al., 2003). The use of forensic markers may help evaluate elder abuse (Pearsall, 2005). Forensic markers include abrasions, lacerations, bruising, fractures, restraints, decutiti, weight loss, dehydration, burns, cognitive and mental health problems, hygiene issues, burns, and sexual abuse (Bonnie & Wallace, 2003). A discussion regarding potential forensic markers in each of the categories of elder abuse follows (Pearsall, 2005).

Numerous forensic markers have been identified through research that may signal the occurrence of elder physical abuse and maltreatment. These may include bruises, abrasions, lacerations, and fractures.

Blunt force trauma with associated rupture of small blood vessels under the skin without breaking the skin, results in the superficial discoloration of the skin commonly known as a bruise (Dyer et al., 2003) or a contusion (Brown, Streubert, & Burgess 2004). Blood escapes into the surrounding tissues and can track through fascial planes, resulting in bruising apart from the site of injury. Generally, with age, the blood vessels become easier to rupture (Dix, 2000). A bruise can become noticeable hours or days after an initial trauma. Eyelids, neck, and scrotum are very susceptible to enduring a bruise. In the elderly, bruises occur more frequently and resolve more slowly than in a younger person and can last for months rather then weeks (Dyer et al., 2003). Elder skin is fragile because with age it becomes thin, loose, and transparent with a decreased vascularity and atrophy. In addition, elders bruise under less force than do younger individuals (Brown et al., 2004). There is currently no way to determine exactly the amount of force needed to produce a bruise (Dix, 2000).

A classic study that was inspired by a case of child abuse looked at the question of the aging of a bruise (Langlois & Gresham, 1991). The goal was to determine whether it was possible to establish the age of a bruise by its appearance. Photographs were obtained of bruises using high-definition color film from three sources: patients presenting to the emergency department, inpatients, and staff. Only bruises where case and age were known were used. Photographs were obtained in sequence from the time of appearance to resolution whenever possible. These were then assessed for the presence of particular colors, and data were collected. A total of 369 photographs were obtained from 89 subjects with an age range of 10 to 100 years spanning a five-month period of time. The main colors that were noted were blue, red, yellow, and purple/black. Frequency of occurrence of each color was determined within each time interval for the two age groups and for the two age groups combined. Red was found to be commonly present in all age groups, whereas purple/black was less commonly seen. Yellow was found not to be present in bruises within the first two time intervals (0 to 6 hours and 7 to 18 hours), whereas it was observed with increasing frequency in the 157- to 288-hour time frame. The appearance of a yellow coloration was found to be highly significant, as a yellow bruise was very likely to be more than 18 hours old. Elders (individuals over the age of 65), showed a slower development of yellow color. Bilirubin, which is the result of hemoglobin metabolism, has been attributed to the yellow coloration in a bruise. Red, blue, and purple/black appeared anytime from within one hour of bruising to resolution of up to 21 days (Langlois & Gresham, 1991). The issue of whether a bruise on an elderly victim can be accurately aged by appearance remains controversial. This issue is currently under investigation. An accurate description of observed bruising should include the location, shape, and color of the bruise using appropriate terminology (Brown et al., 2004).

Bruises alone do not necessarily indicate abuse; however, they do necessitate further assessment. The size, shape, and appearance of all bruises, patterns of injury, injuries in unusual locations, and burns must be carefully and thoroughly documented including as much objective information as possible. Photographs of the injuries are helpful, and any suspicious injuries require further investigation (Humphries Lynch, 1997).

The pattern of bruising may suggest the cause of the injury, as a bruise can possess the shape of knuckles or fingers and parallel discoloration marks can demonstrate injury from a linear cylindrical object (Dyer et al., 2003). Brown et al. stressed the importance of a comprehensive assessment of the entire body of an elderly assault victim for bruising. The neck, arms, and legs may manifest fingertip bruising from restraint. The face, breast, chest, abdomen, and extremities may manifest bruises from punches and may resemble the shape of a fist with a central clear area, which is created when the punch trauma forces capillary blood away from the targeted location (Brown et al., 2004).

One study sought to develop a scoring system for bruise patterns as a tool for identifying abuse in children (Dunstan, Guildea, Kontos, Kemp, & Sibert, 2002). The aim was to determine whether abused and nonabused children differed in the extent and pattern of bruising and whether existing differences were sufficient to develop a score to assist in the diagnosis. The total length of bruising in 12 areas of the body (anterior chest and abdomen, back, buttocks, left and right arms, left and right face, left and right ears, other areas of the head, and neck) was determined in 133 physically abused and 189 control children ages 1 to 14. Abuse cases were identified via a child protection database, whereas the bruising patterns of control children were obtained from presentation to an ambulatory outpatient consultation for reasons other than abuse. Bruises were measured, and details of bruises were recorded together with the maximum dimension of each bruise and whether or not each bruise had a specific shape. Differences were noted between cases and controls in the total length of bruises. A scoring system was developed using logistic regression analysis using total duration of bruising. The authors concluded that a scoring system can provide a measure that discriminates between abused and nonabused children. However, it is noted that this score should not replace the complex analysis of abuse that includes a thorough history and physical examination (Dunstan et al., 2002). A review of the literature did not produce similar data regarding elder maltreatment.

Falls are the most common cause of injury in an adult and are often associated with bruising (Dyer et al., 2003). Falls have numerous causes such as decreased vision, accidents, and chronic medical conditions and are not always preventable. However, abusive or neglectful caregivers can accredit intentional bruises to an accidental fall. Falls alone are not indicative of elder abuse, as 30% of community-dwelling elderly and 50% of nursing home residents fall, and most elders who experience falls will have one to three falls annually (Dyer et al., 2003). However, complaints associated with a history of a fall require further questioning, assessment, and awareness on the part of the healthcare professional in terms of the potential for elder maltreatment.

Abrasions are exposed skin caused by friction, whereas lacerations are noted to be tears of the skin resulting from blunt trauma (Dix, 2000). Skin thickness, elasticity, and tensile strength decreases with age, and abrasions can result even from minor trauma. Abrasions may occur if an elder victim is pulled or dragged across a surface (Brown et al., 2004). Abrasions are vital for diagnostic purposes, because they retain the pattern of the causative agent better than any other form of injury, making careful documentation essential in identification of the mode of injury. Skin tears are a common form of lacerations in the elderly and can present on the forearms and occasionally on the lower extremities when the epidermis separates from the underlying connective tissue resulting in a skin flap (Dyer et al., 2003). The forensic nurse must be aware that an elder’s skin will often tear, causing a laceration if the victim is punched, pulled, or restrained (Pearsall, 2005).

Fractures are often the by-product of trauma and include a severing, splintering, or compression of the bone. The hip and distal wrist are the most common sites of fracture. Bones become thinner and less dense with age, exposing the elder to an increased risk for fractures. In addition, conditions such as osteoporosis, chronic steroid use, cancer, osteomalacia, Paget’s disease, poor nutrition, alcoholism, and age-related sex hormone deficiencies debilitate the bone and escalate the risk for fracture. In addition, elders heal at a much slower rate, and little or no data are available on the fracture resolution rate in the elderly population. Forensic nurses must conduct a detailed history and a comprehensive examination, as well as a complete assessment of medical records, to determine if a fracture should raise the suspicion of an abusive situation. Fractures of the the head, spine, and trunk are more indicative of abuse injuries than are fractures of the limbs, sprains, or musculoskeletal injuries. However, extremity fractures may occur in the struggle of an attacker to restrain an extremity during an attack, and arm fractures may be the result of an attempt to break a fall or by raising the arms as a means of protection against an attacker’s assault. Rib and thoracic cage fractures may occur when force is exerted to the chest wall when a victim is forced to the ground and sustains blows from the perpetrator’s arms, legs, or by other means of assault (Brown et al., 2004). In addition, fractures that exhibit a rotational component and spiral fractures of large bones absent of history of gross injury may also be indicators of abuse (Dyer et al., 2003).

Most physical abuse is accompanied by a psychological component, or psychological abuse may occur alone and may be difficult to recognize unless examples of verbal threats, insults, or humiliation are observed (Humphries Lynch, 1997). Subtle signs such as depression, change in behavior, fear, anxiety, or withdrawal, under careful assessment, may reveal that the elder is experiencing intimidation and maltreatment from the perpetrator (Wieland, 2000). Assessment or psychological maltreatment presents as a challenge, because the forensic nurse needs to search for concealed indicators in the dynamics presented by the elder and the caregiver (Pearsall, 2005). The importance of early identification is key because a forensic nurse can intervene early when signs of psychological abuse are subtle. In doing so, it may be possible to not only halt the abusive psychological behavior but also prevent the escalation to physical mistreatment (Humphries Lynch, 1997).

The inappropriate use of an elderly individual’s resources for personal gain is termed financial exploitation. This category includes credit card and telemarketing fraud, predatory lending, and theft or extortion, and it is accompanied by psychological abuse. These activities are often targeted at vulnerable elders who have cognitive impairment and are thus more vulnerable to trusting caregivers, relatives, and acquaintances. Financial exploitation is often unrecognized despite the devastating emotional and financial losses experienced by the elder. Up to one half of all categories of elder maltreatment in the United States is attributed to financial abuse. In the United States, an annual conservative estimate of elder maltreatment in individuals 65 years old and over is 3% to 4%. When financial abuse is included as an option in calculation of those figures, the prevalence rate may be closer to 12% (Tueth, 2000).

Financial abuse can present in three common situations (Tueth, 2000):

Financial abuse can be devastating to the victim and is often traced to family members, trusted friends, and caregivers. It is likely to occur with the tacit acknowledgment and consent of the elder person. The manifestations of financial abuse generally are not immediately evident and discoverable (Bonnie & Wallace, 2003).

Potential clinical indicators of financial abuse include observable changes in behavior related to the abuser and the elder, excessive interest in an elder’s personal assets, demonstration of excessive control, controlling phone use, unusual degree of fear exhibited by the elder, unexplained bank account withdrawals, and credit card activities (Tueth, 2000). A coercion to change a will or transfer assets abruptly and without forethought may also be a warning sign (Wieland, 2000).

Dehydration is a potential forensic biomarker for neglect. Dehydration is caused by intentional fluid withholding or if inadequate water intake persists for a long period of time. A lack of staff or family support may also lead to dehydration. Decreased fluid intake or excessive water loss can cause an inadequate level of body fluid, which results in dehydration. The elderly are much more prone to dehydration. Often elderly have decreased body fluid reserves, impaired thirst drives, and the central nervous system fluid regulation may be compromised. Medical illness is the most common cause of dehydration; however, indicators of dehydration can be used as forensic markers for abuse or neglect when fluid withholding or neglect of care is identified during a comprehensive examination (Dyer et al., 2003).

Malnutrition is often used as a forensic marker for neglect. Malnutrition refers to an inadequate health status resulting from a diminished intake of necessary nutrients. An age-related decrease in smell and taste may contribute to a decrease in appetite. In addition, illness, poor dentition, mental status changes, malabsorption syndromes, cancer, and other disorders can lead to malnutrition. Potential adverse effects of pharmacological agents, such as mental impairment and appetite suppression, can also contribute to malnutrition. The loss of 40% of body weight can cause death. The most frequent cause of malnutrition due to neglect in the institutional setting is often attributed to an inadequate staffing to assist individuals who require eating assistance. In addition, improper feeding techniques may contribute to choking, aspiration, pneumonia, or death (Dyer et al., 2003).

Use and abuse of medications may be forensic markers for abuse and neglect, as abusive or neglectful caregivers may withhold required medications, consume the prescriptions themselves, or overdose an elder (Dyer et al., 2003). Careful assessment of medication and treatment regimens, prescription renewal history, as well as appropriate laboratory medication levels may be helpful in ensuring that therapeutic medication levels are maintained (Pearsall, 2005).