Ivan Dieb Miziara1* and Carmen Silvia Molleis Galego Miziara2
1Associate Professor, Head of Department of Legal Medicine, Ethics and Social Medicine-Faculty of Medicine, University of São Paulo, Brazil
2Auxiliary Professor, Discipline of Legal Medicine, ABC Faculty of Medicine, Santo André, Brazil
*Corresponding author:Ivan Dieb Miziara, Associate Professor, Head of Department of Legal Medicine, Ethics and Social Medicine-Faculty of Medicine, University of São Paulo, Brazil
Submission: September 21, 2021 Published: October 06, 2021
ISSN 2578-0093Volume7 Issue2
Many authors point out that Elder Abuse (EA) is recognized as a significant issue affecting older adults by researchers, clinicians, and policymakers in the U.S., such as the Centers for Disease Control and Prevention . Besides, with the global growth of the elderly population, specific issues related to this group require a detailed discussion about its signs and symptoms. Among these issues is violence, which plays an essential role because it is associated with distress and increased mortality . Therefore, it is a serious public health, and Legal Medicine plays a fundamental role in diagnosing such cases of abuse. Abuse is defined as the violation of an individual’s human and civil rights. The following six types of abuse have been described: physical, sexual, psychological, financial or material, neglect or act of omission, and discriminatory [2,3].
The Centers for Disease Control and Prevention  also defines elder abuse as an intentional act or failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult. Because of this, the medico-legal examination is of crucial importance in detecting and diagnosing abuse against the elderly in any of its forms (physical, sexual, etc.)
This paper aims to outline some of the most common physical examination findings among elderly victims of physical, sexual aggression, or negligence, whose incidence has been increasing during these Covid-19 pandemic times .
The physical sign most evident is the formation of bruises by blunt action. These bruises have a peculiar aspect and should not be confused with spots resulting from vascular fragility and the more sensitive skin of the elderly. They usually appear in some preferred places on the body, with different sizes and shapes, often mimicking the shape of the blunt instrument used in the aggression. The presence of bruises greater than five cm in length on the lateral arm or right shoulder, neck, head, thoracolumbar region, buttocks, and soles of the feet are not often observed in accidental injuries and should be considered to result from an act of violence . Therefore, it is crucial to examine the soles of the feet of the victim. Many attackers believe that this type of wound will go unnoticed. However, suppose the victim cannot support himself on the soles of his feet or has an exaggerated and inexplicable difficulty walking. In that case, this should be another warning sign for the coroner or any other health professional.
Multiple wounds in different stages of cicatrization; many bruises at various stages of evolution (purple, brown, green, yellow, and finally brownish yellow); injuries in the shape of any instrument; marks of containment on the wrists, ankles, and heels; traumatic alopecia, edema of the scalp, and fractured teeth or burns are other warning signs. Burns caused by cigarette coals are ubiquitous and have characteristic shapes. In general, they are multiple, circular, measuring between 1 and 1.5 centimeters, with raised, reddish edges and a whitish or fibrin-covered bottom (the most recent). The older ones have a similar shape but brownish color and are commonly covered by hematic crust.
Complimentary exams are mandatory. Recent and old bone fractures should be investigated through radiological examinations. Laterorrinia and facial edema should call attention to nasal and jaw fractures. Deformities of long bones, such as the humerus and femur, should also be evaluated, as they may be a sign of neglect in treatment. However, to avoid a misinterpretation of the bruises found, it is necessary to exclude a possible blood clotting disorder. So, it is crucial to perform a coagulogram. Likewise, bone densitometry must be requested, as the lesions found in the bones may be the result of bone porosity and not aggression. Otherwise, radiological images showed that misaligned fractures in different stages of consolidation could also be signs of physical attack . On the other hand, innocent bruises frequently occur on the extremities . However, recognizing this abuse is difficult due to physiological aging but should always be considered, particularly when the clinical history contradicts the findings of physical or laboratory examinations.
Violence by negligence
The violence perpetrated through negligence principally occurs in a domestic environment, which also makes diagnosis difficult. In many instances, the victim does not report the violence because they do not understand it as a form of violence or are afraid to say their close relatives as the perpetrators. It is essential to point out that deaths, injuries, and trauma from traffic accidents and falls could also suggest negligent acts committed by the authorities or people involved with the accessibility of the elderly individual . Physicians and coroners should expect the presence of pressure sores, localized areas of tissue damage or necrosis in the elderly, especially in those individuals who spend most of their time bedridden, but this type of lesions can be avoided with simple care, and therefore the presence of these lesions might be an indicator of inadequate care .
Pressure ulcers in older adults living in institutions such as nursing homes can indicate negligence on caregivers, especially if on examination these lesions do not show signs of being treated (e.g., creams, dressings, signs of recent surgical debridement, etc.) In addition, neglect can be manifested by the absence of simple care (such as the constant movement of the elderly in bed) and by carelessness with daily medications in people with diabetes. Suppose the older adult comes for examination with dirty clothes, without minimum bodily care, or inadequate clothes (too many clothes in the summer and few in the winter). In that case, it is also an alarm signal for neglect of care. Worse, the Covid-19 pandemic leveraged instances of violence against the elderly through negligence. As a result, there has been a marked increase in reports of elder abuse, including those related to poor hygiene conditions .
Sexual violence: a challenging diagnosis
In general, libidinous acts of various types tend to leave no trace. However, an accurate examination must be performed, taking into account the complaints reported by the elderly. Some signs may corroborate the story written by the victim. It is necessary to pay attention to some critical factors: the skin of the anogenital region of the elderly is much more fragile; vaginal lubrication in the case of older women is minimal or nonexistent. In this way, forced coitus will leave visible marks, which will be more visible the less time elapsed between the exam and the violence suffered. Abrasions or bruises on the vaginal opening or anus are common in these situations. Although they are not in themselves signs of certainty of sexual violence, they should be considered highly suggestive. Besides, it is mandatory to collect vaginal and anal swabs to search for sperm. Thus, in addition to proving the violence, we can also identify the aggressor.
Signs suggestive of sexual violence injuries include itching, anal or vaginal bleeding, pain, sexually transmitted diseases, and spotting or bleeding in the underwear . Physicians, including coroners, should pay attention to these lesions, as there are many types of sexual abuse against the elderly, and the diagnosis is difficult.
Under-notification might partially reflect the clinical manifestations of abuse are often mistaken with the embodiments of diseases inherent to aging (bruises, etc.) . Another explanation for the low rate of abuse notification against the elderly is that the elderly are silent victims. In these Covid-19 pandemic times, the medical examiner (and clinicians in general) must look for signs of all forms of violence against the elderly to avoid underreporting these cases.
© 2021 Ivan Dieb Miziara. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and build upon your work non-commercially.