Normal Aging vs. Physical and Sexual Abuse

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Texas Elder Abuse and Mistreatment Institute
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Module 4DIFFERENTIATING NORMAL AGING FROM
SIGNS OF PHYSICAL AND SEXUAL ABUSE

• Kathleen R. Liscum, M.D.
• Baylor College of Medicine

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Pre-Test Questions

• Which of the following examination findings is
  most suggestive of abuse?
• a. Skin tears
• b. Hip fracture
• c. Ulnar surface arm lacerations
• d. Unexplained weight loss

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Pre-Test Questions

• 2. Elderly victims of sexual abuse often have
  significant cognitive impairment.
• a. True
• b. False

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Pre-Test Questions

• An elderly patient presents with a history of
  multiple falls and long bone fractures in the
  past 18 months. Which of the following would be
  most helpful in determining whether abuse or
  aging was the cause of her fractures?
• a. CT scan
• b. Bone scan
• c. Total body radiologic survey
• d. Bone density scan
•  

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Common Findings in Abuse

• General
• A gestalt raising the level of suspicion
• Observing patient interact with caregiver
• System by system
• Head to toe examination

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General Guidelines

• History
• Patients often present with somatic complaints.
• When asked directly, will deny abuse.
• Physical exam
• Important for patient to be completely undressed.
• Patient does not have physical aids.
• Observe caregiver/patient interactions.
• Physical exam inconsistent with story.

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Importance of Documentation

• Written documentation
• Measure size of injuries.
• Use body chart.
• Include patient quotes.
• Photography

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General Appearance

• Evidence of weight loss, anxiety
• Poor hygiene/patient odor
• Unkempt appearance
• Malnourishment
• Fear of examiner
• Signs of overmedication

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Head

• Traumatic alopecia
• Hematomas
• Poor oral hygiene

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Skin

• Lacerations
• Abrasions
• Bruises (especially of different ages)
• Hematomas
• Bites

• Burns
• Unusual locations and/or shapes
• Pressure ulcers
• Lice/scabies
• Welts

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Patterns of Bruising

• Bilateral on upper arms.Shaking
• Clustered on trunk..Repeated striking
• Shapes similar to objects..(Belt)
• Around wrists/ankles..Restraints
• Inside thighs or arms..Sexual
• Ulnar surfaces of forearms....Defensive

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Abrasions
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Bruises
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Bite Marks
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Wounds
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Manual strangulation
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Musculoskeletal

• Unusual fractures
• Evidence of multiple old fractures

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Neurological/Psychological Findings

• Cognitive impairment
• Depressed mood
• Flat or avoidant effect (avoiding eye contact)
• Anger
• Hunger for attention
• Unexplained changes in behavior

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GU/Rectal

• Perineal rash
• STDs
• Impaction
• Rectal/vaginal bleeding

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Sexual Abuse

• Victims frequently have significant cognitive
  impairment.
• Possible difficulty getting evidence due to
  delayed reporting.
• Medical exam may be difficult.

• Primary evidence
• Presence of semen
• Bruising of pelvis/perineum
• Secondary evidence
• Purulent vaginal discharge
• STDs
• Blood

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Sexual Abuse

• Reasons for Concern
• Anxious or agitated at times of bath/perineal
  care
• Demonstration of reenactment behaviors
• Fear of male staff/examiner

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Differentiating Between Signs of Physical Abuse
and Normal Aging

• The process for identifying abuse is not quick or
  easy.
• Evaluate physical findings in light of the
  psychosocial findings.
• Laboratory and radiology are helpful adjuncts.

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Laboratory Findings

• BUN/Cr dehydration
• Glucose diabetes
• PT/PTT/platelets coagulopathy
• LFTs alcohol abuse
• TFTs hyperthyroidism as reason for weight loss

• Albumin nutritional assessment
• Fractures
• Consider bone density study
• UA fever source?

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Abuse vs. Normal Aging
 
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Long-Term Consequences of Abuse

• Depression
• Anxiety
• Anorexia

• Sleep changes
• Regression
• Death

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Summary

• Abuse is often not easy to recognize.
• Keep the possibility in the differential.
• Carefully evaluate each patient
• Thorough history and physical
• Adjunct testing
• Psychosocial evaluation

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Post-Test Questions

• Which of the following examination findings is
  most suggestive of abuse?
• a. Skin tears
• b. Hip fracture
• c. Ulnar surface arm lacerations
• d. Unexplained weight loss

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Post-Test Questions

• 2. Elderly victims of sexual abuse often have
  significant cognitive impairment.
• a. True
• b. False

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Post-Test Questions

• An elderly patient presents with a history of
  multiple falls and long bone fractures in the
  past 18 months. Which of the following would be
  most helpful in determining whether abuse or
  aging was the cause of her fractures?
• a. CT scan
• b. Bone scan
• c. Total body radiologic survey
• d. Bone density scan
•  

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Texas Elder Abuse and Mistreatment Institute
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