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Panelists will present results from NIJ-funded studies on bruising and CT scanning and discuss the important role of forensic information and technology in effectively investigating violent crimes against the elderly.
Carrie Mulford, National Institute of Justice
Carrie Mulford: Our technology expert in the back is wearing purple today, so kudos to him. As I mentioned yesterday our elder abuse portfolio has been growing over the past four years. This is, I think, our fifth year we've put out a solicitation specifically for research on elder abuse. And this is an area where we feel like NIJ really shines, and we put a lot of our focus into the forensic marker aspect — in part because there isn't any other agency that really would pick this up.
Wow, how about that?
We have funded studies in forensics in such things as bruising — which you'll hear about today — decubitus ulcers, studies of dementia to see if people who have mild to moderate forms of dementia can serve as witnesses to traumatic events, and then you'll hear about a CT scan study today also.
Let me go ahead and introduce our speakers, then Ill turn it over to them. Our first speaker today is Aileen Wiglesworth and she is assistant clinical professor of family medicine at the University of California, Irvine, College of Medicine. Its a whole lot of — a long title there. Not your title but the university — title to get out. She's been a lead researcher on many of the studies that I've mentioned, actually — the dementia, forensic markers of elder abuse and coroner investigations of suspicious elder death and has had projects funded by both NIA [National Institute on Aging] and NIJ in this area.
And then you will hear from Barry Daly who's a professor of radiology and vice chair for research in the department of diagnostic radiology at the University of Maryland, School of Medicine, in Baltimore. And his research interests are in forensic radiology, and he's investigating the use of high resolution, 3-D computed tomography — and hell show you some pictures so you know what that is — and magnetic resonance imaging as techniques to either compliment or replace conventional autopsy in death investigations, and he's going to talk about that study when he comes up.
And then we are very lucky to be joined by — as she tells me today she goes by either Sharie or Cherie — so we had a little debate about which it was and she says her mom calls her one and her dad calls her the other — Hill. She is a detective currently assigned to the family crimes detail of the Anaheim Police Department in California, and we met her when we went out to California and she is a favorite of NIJ, so we always invite her. Also as I mentioned yesterday with our other discussant that anything we have where we need a law enforcement perspective we always invite Cherie. And she's a member of the elder abuse forensics abuse center in Orange County, California — so we are very happy to have her, and she will be commenting on the presentations.
With that, I turn it over to Aileen.
And if you could hold your questions until the end — unless they're clarification questions.
Aileen Wiglesworth, Assistant Clinical Professor of Family Medicine, University of California, Irvine
Aileen Wiglesworth: Good afternoon, can you all hear me? Do I have to be close? Well see.
Ill start out with a few pictures of some evidence of abuse. But what we were — I'm also involved with the forensic center. I'm a researcher with the same group that started the Elder Abuse Forensic Center in Orange County. And people would bring cases to the forensic center, and there would be bruising evidence — except that the prosecutor didn't feel like it would stand up in court because well, you know, elders, they bruise easily and they fall, and perpetrators, they remember things, and abused elders have memory problems. So we saw some potential for research, and NIJ agreed with us. This is actually our second bruising project that were doing now. The first study — the baseline study — is [on] what does bruising look like in the geriatric population. There wasn't much point in looking at bruising associated with physical abuse until we understood what normal, accidental bruising looked like; so Dr. Laura Mosqueda (who I work for), and Kerry Burnight did that study, and it was published in 2005 in the Journal of the American Geriatrics Society, and this is the follow-on study. In this study, we looked at bruising as a forensic marker of elder abuse. So we have the first study to do some comparison — so its about accidental versus inflicted bruising.
So Ill just revisit what some of the findings are from the first study. Well, we just wanted to describe common bruising patterns [for] people over age 65. We wanted to find bruises from the beginning and follow them until they resolved and look at size, timing, location on body — you'll see some of the things that we thought were important to measure. The main finding was that 90 percent of bruises were on the extremities. We did not find bruising on neck, ears, genitals or feet. You can see all the bruises on the arms and legs.
Other findings: People don't know how they get accidental bruises — I sure don't So only 24 percent of the people could say the cause of a bruise — and this was a bruise that occurred within 24 hours because we found them within 24 hours. They were more likely to recall getting the bruise if it occurred on the trunk. Color of a bruise is not a good indicator of age — this is an old myth. Since my predecessor started doing this study and we published it, the child abuse literature has published something similar. You really cant tell how old a bruise is based on its color. We did a lot of very systematic analysis of this, and it can basically be any color on any day.
Bruises resolved on average by day six, but there were some bruises that lasted up to six weeks — so that varies a great deal. Medications, which you hear a lot about being associated with bruising, did have an effect. People who were on medications that interfere with coagulation pathways — is the terminology — were more likely to have multiple bruises, but the duration of the bruise was not associated with the medication. And just to show you other things we investigated, we tried to think of anything that anybody might think would be associated with bruising and looked at it. Of these things, use of assisted devices, whether or not they were ambulatory, gait and balance, falls, etc., depression, dementia, handedness. The only thing that was associated either with bruising or with characteristics of bruises was activities of daily living which has to do with peoples disability or need for, help with bathing, transfers, dressing, toileting, feeding and continence.
So now lets look at the new study, and the objective here was to describe bruises associated with physical abuse and to compare it to see what we can learn from the comparison with those who had not been abused. So this is how we did it — we have a great relationship with Adult Protective Services in Orange County, and they do a fabulous job despite repeated budget cuts — so they helped us to recruit clients. They basically asked their clients if they were willing to be contacted by our research nurse, and then she would try to recruit and consent them. Those who were consented submitted to complete skin examination of their whole body, and then there was an interview with certain standard instruments. We couldn't assume that physical abuse had occurred just because they were APS clients who had been reported for physical abuse — even APS doesn't assume that without an investigation — but we couldn't assume that the APS standard of what is confirmed abuse was to research standards, so we assembled an expert panel, and Ill tell you more about that. This was tough to do, but we ended up with 67 older adults with confirmed physical abuse participating.
Our expert panel was four geriatricians with experience in elder abuse. Each case was presented to them, and here's what they knew: They knew the investigation findings from the APS worker. Our researcher collected data on a revised conflict tactic scale, which I've seen some researchers here use that for intimate partner violence; we modified that a little bit and used it for elder abuse, and we really like it. It asks very direct questions of the person who was abused: Were you hit? Were you kicked? Were you grabbed? So we used the physical assault questions, then something called the elder abuse instrument, which is a clinical interview to collect evidence of physical abuse. So those things were presented — and some of it in writing to the panel — and then the panel could ask questions of the APS worker and the research nurse. They couldn't ask about the bruising — we were very tough on them about that. They needed to be blind to bruising as evidence so that they could make an unbiased conclusion about that. They asked — for instance — what other evidence of physical abuse were there? Were there any other injures? Was the person in pain any place? Was there a police investigation? Actually there's a set of these questions on our Web site. Every decision was unanimous — if it wasn't unanimous, we decided we couldn't say it was abuse.
This is our — in of 67, [there were] more female than male, certainly more Caucasian. Twenty-five percent of the people were less than 24 on the MMSC, which is one way of saying they were cognitively impaired. A number needed assisted devices. Most of the perps were family members — almost 90 percent. And then if you look at elapsed time, that's sort of interesting too. We said were going to see anybody within six weeks because we don't want to miss any bruises — everybody we saw, we saw within 30 days. But the average length of time since the abuse — just because of how difficult it was to get out there and get involved in these cases — was 10 days. So I'm sure we missed some bruises that were already resolved — if you'll recall [some of] those bruises can resolve within a week.
It was a very tough recruitment situation. The APS workers approached over 400 of their clients reported for physical abuse, and either because they refused to even deal with APS or they ended up being committed to a facility where we couldn't go in and do research — what are some of the other reasons? If the subject was too agitated, we weren't going to approach them to be in research, and a lot of them are. So out of those, less than half of those are nurse approached. She got about half of them to take their clothes off and answer all these questions — and these are traumatized people. We really understand that this is hard to do. And then the expert panel found that 67 of the 80 were physical abuse victims.
So the study design is similar except that we just saw the people one time instead over this length of time — and felt lucky to see them then. We looked at all those same variables — we didn't look at depression; we decided that probably didn't have anything to do with bruising. We did not find the association with ADLs and coagulation pathways, but we did find that those using assisted devices for mobility were more likely to have bruises. Now were not sure if using assisted devices was a result of chronic abuse or acute abuse — this is a cross-sectional study.
So what proportion had bruises? Well 72 percent of these people reported to APS even though some of them probably, their bruises had resolved — had bruises. When we sent this in for publication, someone pointed out if you've got bruises, you're more likely to be reported so I don't know if this is all abuse, but it certainly seems to be the evidence that's most prevalent in terms of physical evidence of abuse.
And where were the bruises? Well 70 percent roughly were on the extremities. If you remember in the other study it was 90-10 so here's 70-30 — so more on the trunk and head. But we can break these down a little more because we have another category. Before we had accidental bruises that they remembered or unknown bruises they couldn't remember well. More than half of the bruises they told us were inflicted. So when we break down those inflicted bruises, you have an even larger proportion on the trunk and head.
Now, well get into the comparison, and its a little unfortunate the groups don't really compare all that well. You know when you start thinking about it, its hard to know — people who aren't abused and people who are abused don't compare that well; they have different characteristics. But its really more of an artifact of the way the research is done. We need to be able to find people every day for up to six weeks and so in the initial study, we had people in assisted living and in nursing homes, and so they're more frail. As you'll see the no physical abuse group is older; they are on more meds, more likely to be bed bound; their balance was worse if they weren't bed bound. Whereas APS by its nature, serves people in the community, and so these are community dwelling, but look at how they're different in terms of they needed assisted devices and they fell more. Well again, I think maybe those are more about being abused than they are about real differences. They matched on all the other variables. And the other real difference that I need to mention — just in terms of full disclosure, obviously — is that the no physical abuse [group], they were seen many times, and we only saw the physical abuse victims once.
So given those differences — I still think these are real differences, in terms of abused elders with bruises remember how they got at least one of them — 90 percent of them remember how they got at least one bruise. Whereas not abused, its less than a quarter of them. So one of the big findings from this study is ask them. Abused elders have larger bruises, so this shows bruises smaller than a centimeter. All abused elders had at least one bruise that was larger than that. And the majority of them had at least one bruise that was over five centimeters, which is a couple inches. Whereas a third of the accidentally bruised elders, their largest bruise was less than a centimeter in only 7 percent — so bruises from abuse appear to be larger.
And where are they located? Well, they can be anywhere. I don't want anyone to think, Oh, bruises from abuse have to be [in] certain locations — they can be anywhere. But there is a statistically significant difference in them appearing on the head and neck, the posterior torso, and the lateral and anterior arms. And you know, you cant really say on the feet — but there were bruises on the feet, and there were not in our abused sample. So looking some more at locations of bruises — I don't have a pointer — but the lateral and anterior aspect — so this is the diagram, its like this. This is anterior; this is lateral, and if you look at the right on arm on the left side, there are a bunch of bruises along that lateral aspect. The anterior is here; so if you think about looking at someone — the lateral surface faces forward if you're facing a perpetrator — and this ought to be somewhat protected. Its protected more from accidental bruises; most accidental bruises are on these posterior surfaces — you're bumping into things. So it looks like there might be something going on there.
I'm probably going way too fast — I wonder what I have forgotten to tell you.
Suspicious bruises are large, or they certainly can be. They can be anywhere, but note especially if they are in those places, and the main thing I would say is that you should ask. And we talk a lot to geriatricians, physicians and try to get them to do this. Anyone who is a mandated reporter — this kind of evidence is certainly enough to make you suspicious and report. And certainly if you talk to them and they tell you — you need to report. Were hoping it will also encourage police and prosecutors to pursue these cases.
The data seems pretty simple, but it can get a little complicated in the explanation so I think it probably does take an expert witness to bring judges and juries along with what's going on with it. Then I wanted to mention what I've talked about so far. Were about to get published, but were continuing to do some analysis. We had a multidisciplinary advisory board — and there was a police investigator and a district attorney and an emergency room doctor — and we asked them before we went out, how to change our analysis to help them. And they said ask the people to tell you the story of the abuse, and so we did. So we have stories when they told them — and not all of them did — to the research nurse. We also have this revised conflict tactic scale data about: Were you grabbed? Were you punched? Were you kicked? — those kinds of questions. So what were looking at doing is saying — its a small in, its a small data set, so I'm kind of interested in opinions on whether this is worth doing. If we can associate the bruise location with a story, and it already looks interesting in terms of the bruises on the head — 8 out of 10 of those people with bruises on the head say they were punched or hit — and then if we look at the story, we can find more detail on the story. Those lateral and anterior arm bruises — 18 out of 23 of people with those bruises say they were grabbed.
And you know, I got onto this I was presenting some of this preliminary data, and there was a retired occupational therapist, and I was telling her about these arm bruises, and she said, If you're handling someone roughly when you're transferring them, that's where they get bruises. So I went back and looked at this data. So looking at breaking it down a little bit, you know, you talk about the upper and lower arm — again, small in — but 5 out of 7 of those bruises on the lateral right arm, those people were punched, and we have that specific story that they were punched on that right arm. The left arm, the interior bruises here, if you think about a right-handed perpetrator grabbing the person, they would grab them and make bruises in that part of the arm.
So, I think we've got another article here, and Id be interested in if people think this is useful. I think I heard from our advisory board that it would be useful to show that the bruising evidence is consistent with the victims story as opposed the perpetrators story. So if the perpetrator said, Oh, that bruise; that's from falling; the victim says — I didn't mention, but we had data from even the people who had cognitive impairment were able to tell us — Yeah, that's an inflicted bruise — they can often tell you a story, too. If you have their story consistent with where the bruise occurs and the perpetrators is not, maybe that'll help put some of these cases along — I hope so.
So, that's what I've got. Our collaborators: Orange County Adult Protective Services; Dr. Schneider from USC came up and helped us with our led panel along with three physicians from UCI, and then our Elder Abuse Forensic Center has just been great in terms of giving us ideas and supporting us. Laura Mosqueda is the PI on this grant, and there is our team, and there is our Web site; so thanks.
Barry Daly, Professor of Radiology and Vice Chair for Research, Department of Diagnostic Radiology, University of Maryland School of Medicine
Barry Daly: Thank you very much, and good afternoon. This is an unusual audience for me to actually address, and it is probably a somewhat unusual topic for many of the people in the audience, although some of you have actually, probably, had a CT scan at some stage and have some idea of what its like — or some family member who's had one. But what were going to talk about today clearly is the use of whole-body CT imaging in postmortem detection of elder abuse and neglect.
Id like to say a little bit about the background of our center and how this came about and just give you a little bit of perspective on this. We've had a collaboration running — a forensic imaging initiative running between my department and the office of the chief medical examiner for the state of Maryland since 2006 — only a couple of years, but this has been quite a successful collaboration and Ill give you a little bit of background about it. There are quite a number of people in my own department who actually contribute to this process, and perhaps the group Id recognize most are actually the bottom line there — the CT technologists and MRI technologists who actually are the ones that physically scan the decedents bodies, wrapped in body bags. And this has actually been something we've just had wonderful cooperation with from our colleagues in CT technologies, in particular, as they've done most of it. Then on the other side of the street, literally, we have the office of the chief medical examiner for the state of Maryland, and he and a number of his M.D.s and other colleagues have helped and the group who have been especially helpful are the forensic investigators who actually are legally charged with care of the body at all times.
To give you a little bit of background about where all this started, whole-body computed tomography, or CT as we call it for short — the use of imaging and what we sometimes refer to as virtual autopsy — you may hear this expression — was initially developed in the first half of this decade at the University of Berne in Switzerland as a collaboration of forensic pathologists, medical examiners and radiologists — to try and introduce advanced imaging into routine forensic medicine practice. As the scanners that we've got have become more powerful and we now have the ability to do more 3-D imaging of the whole body — the applications that have been used in the living body of course — we can now scan the heart in just a couple of seconds, we can scan the brain in a couple of seconds, we can do a lot of things we were never able to do before, but it certainly struck a number of people that really there was probably a huge role for imaging in the forensic medicine setting.
In this country there have been some research initiatives. One started off at the Armed Forces Institute of Pathology here in D.C. and also at Dover Air Force Base in Delaware where CT scans have been performed on all of the military casualties who have returned from Iraq and Afghanistan in the last five years, and a large amount of data has been accumulated both to determine the cause of death, and also to try to determine whether it might be possible to actually avoid major casualties in the future by, for example, determining whether body armor is inadequate or looking at the results of explosives like IEDs — how does it actually kill people? Because there is information we can get from 3-D imaging of the body, that's actually kind of tough to get from a conventional autopsy.
There have been a couple of civilian initiatives — our own one at the University of Maryland and other small initiatives both at the University of Pennsylvania and with the University of Michigan — but in fact were actually relatively behind the curve because most of the countries in the list at the bottom there have been doing this for a number of years, particularly in places such as Japan, because in Buddhist culture, doing an autopsy on the body after death is considered a very inappropriate thing to do unless its absolutely mandated in a suspected criminal case. But other countries are actually way ahead — and we can actually see an image there of a body in a body bag actually on a CT scanner which — the scanner is essentially the same for someone who's still alive.
Just to give you a couple of examples of what we've been trying to answer with respect to different problems is that can CT or MR imaging either augment or completely replace the autopsy, and this is one such example — blunt accidental trauma — this is the victim of a high-speed MVA — it was actually somebody who got hit by a train, and you can see that they have massive skull injuries. We can see lots of fractures; over here we can see multiple fractures. Within the brain itself we can actually see that there is a large amount of gas and there's actually — sorry I'm going a little fast — there's actually even some blood, and down in the corner that's what a normal brain should look like day one after death, so you can actually appreciate there's a big difference because there's a lot of swollen traumatic effect upon that brain which is certainly consistent with the sudden death that occurred.
Just a couple of other examples --its another case with multiple skull fractures and you can see what the arrows are actually pointing out all of the different fractures that are actually present. The colored view over on your right is actually what we sometimes refer to as a virtual dissection view, because this is essentially what the skull base looks like if the pathologist — I'm sorry it keeps jumping ahead — if the pathologist actually took the top off the skull and actually removed the brain and looked inside, this is exactly what he would see — so this is sometimes referred to as a virtual dissection view.
Here's a third case: the victim of a high speed MVA — got hit by a truck — and multiple severe injuries are present. We can see lots of fractures in the pelvis. I can just point out a couple here — and I don't think I'm going to actually bother you trying to use the scroll, but if we actually look at this image of the lower limb, I think you don't need to be a physician, you don't need to be a radiologist to appreciate the number of fractures that are actually present here, so this really was a severely traumatized body. There is actually trauma inside the brain, there's trauma in the image showing you the chest over on the left as well, and its probably not surprising that the driver was dead at the scene. So this is an example of where really imaging can really replace an autopsy because frankly, I think we could ask the questions — do you really need more information regarding what caused death? And I think the answer is certainly not in the setting of accidental death, although were not here to discuss that today.
The office of the chief medical examiner in Maryland covers the entire state, and its actually on the University of Maryland Medical Campus, and we were exceptionally lucky in that sense that we have a one-state system. Many other jurisdictions around the country, as we all know, are very fragmented and may be much smaller and we are exceptionally lucky in that respect, which tells me we are actually a good center to actually do research because of the economy's scale. There clearly are logistical challenges when actually scanning decedents in a medical center, which is what we've had to do because we don't actually have a CT scanner in the medical examiners office yet — that's coming — but we do actually scan the bodies usually in the early hours of the morning when the scanners are quiet and in an area that doesn't have access to the general public, so that's actually a very practical thing for us to do. But we've really got to be careful to make sure that we never — we have a rule that the deceased must always wait for the living and we have to be careful about that. But we've had tremendous support from our hospital and our department administration because they have essentially allowed us to do all this initial research at no cost because they've considered it as being public service and have, for that reason, been agreeable to doing it — and as I've said, we've had tremendous cooperation and interest with our technologists and with the chief medical examiners and staff who are responsible for selecting all the cases and a lot of the other work involved, and the investigators who take care of the bodies when they are actually being brought to the University hospital from the medical examiners office and back again.
Just to give you a brief overview of all the things that we do, this is the list of potential indications — its pretty long, and well just move on from there to this slide, which actually points out in green all of the things that we've been doing at Maryland including blunt trauma — especially either accidental or non-accidental penetrating trauma, particularly ballistics, which of course is 99 percent of the time, is of course non-accidental. I'm trying to identify the unidentified bodies which are occasionally found. We are also very interested in suspected non-accidental injury in children. We do not do any suicide cases, but we've certainly done drowning cases, we've done burns cases, we've done unknown causes of death and, of course, we have now got a project working — a research project on suspected elder abuse.
Just to very briefly talk about one area — that of course might interest this audience — and that is the setting of doing research into suspected non-accidental injury in young children. We are particularly interested in looking for the injuries that may occur as a result of shaking of the young child, so were looking for evidence of brain hemorrhage, retinal hemorrhage, bone fractures, soft tissue injuries and, indeed, internal organ injuries — all of which may be manifestations of abuse. And we found that MRI is the best test to actually do for these young children, and we have a very high resolution research scanner for MRI — this is a very very powerful one — and we can actually see one such example showing a sagittal view of the brain in a young child who was actually — the question of non-accidental injury was raised, but this actually turned out to be a sudden infant death syndrome, as we found an entirely normal body without any evidence of abuse in this case.
Unfortunately, we do see cases that are abused, and this is actually a CT scan showing a possible optic nerve hemorrhage in a suspected pediatric non-accidental injury death. So this is a CT scan just showing the two eyes and the pink arrow is actually showing a thickened optic nerve and that's a concern for hemorrhage. But CT is not great for showing us hemorrhage, and one of the things wed really like to know is: Can we detect this optic nerve hemorrhage before we actually have a child in the medical examiners office? We would really prefer to see and identify these injuries when the child is still alive, and hopefully, maybe, an intervention may be possible. Unfortunately, this is actually a child who subsequently died of their injuries; and what were actually now doing is actually high resolution — what we call a high-resolution — a micro MRI scanner — were actually looking for evidence of retinal and optic nerve hemorrhage and suspected pediatric non-accidental injury. If you actually look at the image in the far corner — on the right side — the yellow arrows are actually pointing to a dark area along the optic nerve and that's actually hemorrhage along the optic nerve and one of the things we want to be able to see is what's the best way to detect it? How can we find it? Can we actually find it before anyone else can find it? Because if hemorrhage starts inside the brain and we can actually identify it in the optic nerves, that may be very, very helpful. And this actually, unfortunately, is research that is being done on the extracted eyes of dead children, who unfortunately have been the victims of fatal abuse, but this is just another aspect of the research we do.
However, after all of that preamble, I would like to talk about the matter in hand, which is the project were doing, which is investigating the utility of whole-body CT imaging in postmortem detection of elder abuse and neglect, and we are comparing it to and addressing the potential substitution for standard autopsy, and this is just an update on this project — which is still very much works in progress — but I'm very pleased to at least have an opportunity to share some information with the audience on this.
Our initial work consisted of the development of an optimum whole-body CT scan protocol technique for evaluating these potentially abused elder decedents based upon our centers prior accrued experience in scanning deceased victims of blunt and penetrating trauma — and indeed in pediatric abuse. So very roughly, how things go if we follow the arrows — I'm not trying to teach you the physics of CT scanning other than to point out that we start off in the top corner with a decedent in a body bag in the CT scanner, and they will actually travel through the CT scanner, and images will be generated from 365 degrees — lets see if we can actually use our pointer. We take images of the body from 360 degrees — from every angle — and of course, all that information subsequently goes into a powerful computer which allows us to generate images of the body in virtually all planes. We have the axial, or transverse, image over on your left and then the coronal or frontal view is the next one which we can generate. And then we can generate sagittal views — this is actually a view obviously of the neck — and then we can actually extract certain tissues. For example, we can extract the bones — this is actually extracting all the ribs. We can actually see there is evidence of a clear fracture of the humorous in the upper arm on the right side — we can actually see that right there. So this is just a very quick overview of how this scanning actually works without going into any detail.
Now I was told there might be one or two lawyers in the audience, so I thought I better put a fine print slide in — just joking. This is our protocol which you don't really need to know about, but just to tell you we scan the entire body in thin section --in 1 millimeter intervals, which actually generates at least a couple of thousand images from each scan, and we use 3-D imaging in every case to actually optimize the different views that we take of each part of the body.
To date, we have actually scanned and actually got conventional autopsy data on 37 out of an approved cohort of 80 decedents — so were not quite at the half way mark, unfortunately. This unfortunately has been a project that has taken longer to generate data from than we would like. We use 2-D and 3-D images in each case, and all studies are interpreted by two radiologists individually and by consensus. The CT and autopsy findings have been determined blindly without knowledge of the other study in each case.
As I stated, we haven't actually got to the halfway point. We are planning — because this project has taken longer than we had hoped — that once we do get to 40, that we will actually analyze and hopefully publish at least half of the cohort and then continue on the accrue more cases to finally reach a total of 80 — which we will be able to do over time, but its taking longer than we would really like.
Why would this delay — well case accrual has certainly been slower than anticipated, and the projected volume of cases, which I'm afraid I have to blame the medical examiner and colleagues for telling me we would have no difficulty accumulating 80 cases in two years — but that, unfortunately, has not turned out to be the case because I think they are actually applying criteria relatively carefully. And then one of the other questions we have, of course, is whether those cases of abuse that we know are out there are actually even being referred to our medical examiners or not. We had, unfortunately, some delay in CT interpretations due to a serious family health reason for one of our trained radiologists, and we have to actually get this new person retrained, which has delayed things more recently.
Why the slow case accrual? There may be other reasons, such as the known cyclical variations in the incidence of this crime or perhaps, as I said, more careful application of inclusion criteria. What we have done though — with NIJ approval — is to expand this study to include suspected cases of abuse of decedents who are less than 65 years of age but greater than 18 years, who are residents in long term care facilities in whom abuse has been alleged. So we actually have recently accumulated several cases that fit into that age range, although the vast majority are in the over-65 age range and certainly fit into the elder category.
Just to actually look at some preliminary results — some of this information is very preliminary — but we've only had an opportunity to actually correlate the conventional autopsy and CT imaging findings in 20 of our 37 cases so far. No findings suspicious for elder abuse have been identified reliantly on either test so far, and all deaths have been determined by the medical examiner as natural. The medical examiners in our medical examiners office work by consensus. They actually have rounds where a minimum of 10 of them will do rounds on all of the cases of the day — both in the morning and then after autopsy, and other investigations have taken place including scanning — and will make their determination as by consensus. And so far, none of these cases have actually been identified as definite cases of elder abuse. The major causes of death that have been identified — and some of these overlap because more than one cause of death occurred — include cardiac most often, pulmonary embolism, chest infections frequently, head injuries and neurologic events such as stroke and one accidental medication overdose.
Some of the things that we've seen on scanning that are actually — have been of note — have been the presence of multiple acute rib fractures which have been seen in 10 out of the 37 cases. All of them were bilateral, and upper anterior locations of the chest and all have been associated with attempted cardio pulmonary resuscitation — and this is actually something we can talk about a little bit more in a minute. There were a couple of cases where we saw long-standing rib fractures, but we didn't see any case where we saw what would be a typical suspicious mixture of both recent and old fractures in the setting of somebody who had been abused over a period of time. Osteoporotic compression fractures were noted on the spine — were noted on eight cases, and these were actually again very frequent events which occur in the elderly — which of course do not really correlate well with abuse as we know it.
This is an example of a case where there were multiple fractures which were associated with an attempted resuscitation, and in fact there was actually some bleeding identified with in the chest, which we've marked with the pink arrow demonstrating some bleeding occurring within the chest. When we looked at the ribs in detail we were able to identify multiple fractures both on a 3-D image over on your left and the 2-D image over on your right. And those rib fractures are very, very commonly seen in osteoporotic elderly patients. I have personal experience with this — when, as a medical intern, I was responsible for actually breaking multiple ribs in an elderly gentlemen who actually had a cardiac arrest on the floor. But the response of my senior colleague when I told him — because I felt very guilty about it — was in an elderly person and you're doing resuscitation, sometimes you have to break eggs to make omelets. Now the fact that this unfortunate patient made an excellent recovery and walked out of the hospital two weeks later, did make me feel somewhat better, but I can always remember that feeling that — oh my God — but elderly osteoporotic bones do unfortunately fracture very easily when you attempt to resuscitate patients; that's well-known. So this is something that were going to see more of in this particular patient population.
There were some discordant findings however. There was one case of a neck fracture and dislocation that was not seen on autopsy, which was seen on CT, and one case of a grade 4 decubitus ulceration not seen at autopsy. There were two cases of grade 1 to 2 decubitus ulceration not seen at CT — which is perhaps not surprising, because CT is not very good at finding the superficial ulcers; and one case of neck fracture which was not seen at CT, but was called at autopsy but even in going back at it, it just looks like severe degenerative disease to us, so were really not quite sure what we missed.
Here's one case which was a fracture dislocation through the C4 and C5 vertebral body with the yellow arrows pointing out both the lateral and frontal view. What was initially surprising to me was that this was actually overlooked at autopsy, but when we actually talked to the medical examiners about it, they said, well the reason is there was severe riga mortis in this particular case, and when rigor is present, the neck examination may be very difficult because everything's very, very stiff — and the reality is that the dissection of the spine is very difficult as part of the autopsy. They don't routinely do it unless they have an index of suspicion on the basis of either their clinical examination or other information they may have regarding the case. It can take absolutely hours to dissect through the spine — to actually find these fractures, and if they had been suspicious and found a lot of mobility in the neck, they would have definitely done a dissection, but they didn't, so this is actually something where again the CT scan may show things that the autopsy doesn't, and that's actually been our experience also — or elsewhere if you will, not just in elder abuse.
This is a case of discordant findings where a C5 vertical fracture — which is outlined in yellow — was seen in autopsy only. We still think it looks like degenerative disease, and this was a patient who actually died of a subarachnoid hemorrhage from a fall. The pink arrows are showing small areas of bleeding on the view of the CT scan, on the view of the head which we see there.
There were discordant findings — as I mentioned — with respect to decubitus ulcers. This was described as a stage 2 decubitus ulcer by autopsy, but we can clearly see that there is actually some very deep ulceration present. The yellow arrows are outlining that, and the pink arrow is actually outlining chronic bone involvement, which, again, CT is very good at finding — but that can actually be difficult for the medical examiner to determine, and this is why we can detect the osteomyelitis infective changes more easily than the conventional autopsy can.
And finally, just to show that sometimes we actually do identify a clear cause of natural death, this was a case of cardiac tamponade where an acute leak of blood actually occurs from the heart into the surrounding sack, very typically occurs in the setting of acute myocardial infarction and blood loss, and the yellow arrows are just showing the large amount of hemorrhage which developed around the heart.
So finally, allow me to summarize what I've done, in addition to the overview of what our program does — is to give you some kind of an overview of this study to date, although I would again stress that its very much works in progress. We had very limited hard data so far, I'm afraid.
However, we are pleased to note that this is something that you can practically do — and other centers could do also — because there are the logistical challenges in transporting, scanning and forming conventional autopsy — all within that sort of 24-hour period in which the medical examiners really have to work with because they just have to be able to come to conclusions as a result of what's going on and move on, but clearly we need to make sure they have the best information available as possible. Our study accrual is clearly less than 50 percent still, and slower than projected, but were hoping to just keep working at it until we get where we need to go — and in addition, the adult cases less than 65 years of age may actually help.
Finally, this is going to be the new medical examiners office for the state of Maryland, which will actually be open in the spring of 2010 — its on the university campus again. Its going to be the first U.S. medical examiners office to be equipped with a CT scanner because we actually can justify it both in of terms of what were doing and in terms of research, but even more importantly, we can even actually make a good economic argument for having a scanner because of the fact that it will replace — hopefully — a lot of the conventional autopsy work that's currently taking place. And finally, I do thank you for your attention, and hopefully if we have questions we can deal with them later. Thank you.
Cherie Hill, Detective, Anaheim Police Department
Cherie Hill: How's everybody doing? You guys awake?
You know, it was interesting because, like Carrie said, I went to an NIJ conference last February, and I was sitting in a room full of, with a lot of you statisticians, researchers, and I sat there as the only law enforcement, and I had no clue what anybody was talking about. I was completely lost, and I had to turn around to the researcher next to me and say, What the heck are they talking about? I cant understand the language they're using — Kerry Burnight. And she explained to me — and what I discovered as time went on — was that in fact we all do speak the same language because statisticians and researchers look for facts, right? My friend Aileen over there likes to say that — well you said it the other day; you said you were a nerd, right? You know what? I'm a knuckle-dragging street cop is what I am. But the fact is we all speak the same language, right? And were looking for facts, and when I'm putting together cases I'm looking for facts. So the role of law enforcement when were looking at cases of elder abuse is were going to investigate these cases of elder abuse with or without the testimony of the victim. I like to go into elder abuse cases thinking that my persons deceased. That might not sound right, but the fact of the matter is a lot of them are on medication, a lot of them cant speak for themselves — they have cognitive disabilities.
The other role that I have is I have to gather the evidence, and that's where Dr. Wiglesworth and Dr. Daly can help me gather evidence. I have to look at the body. I cant rely on that elder person to be able to talk to me. So I'm going to look at their body to figure out what kind of evidence I can get from them, as well as their surroundings and caretakers stories. And then I'm going to go ahead and present my case to try and get a prosecutor to file on that case.
Just to give you a little bit more background ... In the state of California, 368A is considered our elder abuse code. And what the legislature in California decided was that crimes against elders deserve special protection — not unlike the special protection provided for minor children. And why is that? Its because as the legislature declared that elders might be confused; they're on various medications. They might be mentally or physically impaired or incompetent, and they cant protect themselves. They might not be able to understand or report criminal conduct, and they are less able to testify. Again, that's why I have to go back to these studies of these absolutely brilliant researchers to help me out, put my cases together, because I cant rely on that elder victim to help me, to speak to me, to tell me their story, to tell me what happened to them.
When I first became a patrol officer, I had a field training officer that told me there's three rules I needed to follow — and I took this to heart. The first rule was if you see a gun just shoot first — kill the guy. The second was everybody lies, and it doesn't matter who they are — they might be a victim, they might be a witness, they might be a suspect — every single person that I encounter in the street is going to lie to me. And the third one is just go out there and have fun.
So I took this to heart when I went and became a detective. Prior to me going upstairs we did not have a detective that was devoted to working elder abuse cases. We didn't know a lot about elder abuse. So low and behold, I volunteer and I get my very first elder abuse case, and its the (undistinguishable) case. Now mind you, I had no clue about studies. I didn't know what bruising studies were; I didn't know any of this. So I get a 54-year-old who has advanced Parkinson's disease, and she has an orbital fracture, which is around her eye; its all fractured. And she has severe bruising on her face, and I interview her, and she tells me, I fell. OK, I'm looking at her, and I'm thinking, You know what? She's a liar. I know she didn't fall, but I cant prove anything. And you know what? Since everybody lies, she doesn't want to be a victim. So, oh well, right? Oh, and by the way, she had a very controlling boyfriend. But I kept pushing her, and she kept saying, I fell. So what did I do? So I thought, Well my victim doesn't want to be a victim, so I'm going to walk away from it, and I did. I interviewed — instead of going out in person and interviewing the boyfriend because I didn't have anything to corroborate what my instinct was that she was lying. So I interview the boyfriend on the phone and he's like, Oh, she fell. And then I didn't go out to the house. You know she's telling me she has this padded carpeting, but I thought, Well still, she doesn't want to be a victim so I'm not going to do anything. Because I didn't know to go back and treat her as if she was a homicide victim, and I also didn't have the bruising study — I didn't have it. If I had had that bruising study when I first became a detective, I certainly would have handled that case a lot differently. I would have gotten out into the field; I would have pushed her; I would have brought him in because I would have had that evidence — with the doctors and the diagrams — that I could have presented to the suspect and said, Hey, you're lying. And I would have presented it to her as well. And as a matter of fact, I would have gone back to the doctor as well — which is what I do now; so I would have handled it a lot differently.
So what did I learn when I started meeting with the doctors from UCI and the researchers? I learned that bruises on the face, the neck, the torso, the groin and then at that point — this is the original bruising study — the thighs and feet — that those are really indicative of abuse. So I could have used that definitely in the handling that particular case. This is actually a case from UCI that the sheriffs worked on; this case where this guy was kicked by the suspect.
Something that Aileen discussed in her study was the color of bruises. OK, well what's my number two rule everybody? Everybody lies, right? Everybody lies. So whether its a victim in domestic violence or a victim in elder abuse, if the person said to me, I was hit today, and they had a yellow bruise, I would go to my prosecutor, sit down with him — and I clearly remember doing this — and Id have the case with me, and Id said, Look at this picture; its a yellow bruise. And they're telling me that he beat her up today. LLPOF — liar, liar, pants on fire.
Because people don't get yellow bruises the first day they're hit — but I was wrong. I was absolutely wrong. And now I have this study that shows that you know what? People can have bruises different colors on the very first day. So its certainly changed the way that I handle my cases, and its definitely changed the way I present my information to prosecutors. And through this process of learning about this study, I've been able to actually educate several prosecutors within my city as well as within the county.
I thought this was so amazing to me, to have this data to backup — that I could present this data actually to suspects and say — hey, that LLPOF thing — Look, this injury was inflicted. And the other thing that I thought was interesting in the study was that basically 90 percent of abused elders remember the cause of at least one bruise. That is phenomenal because what do elders have? Remember, we talked about the fact that the legislature recognizes on medication, they might not have that cognitive ability, they might not remember, they might not be able to speak for themselves. But in numerous cases, they will remember the cause of the abuse — and I've had several cases that I've got prosecutions on because the person could tell me exactly who did the abuse. I had one elderly lady that she kept repeating the fact that — despite her dementia — that her grandson kicked her with a pair of boots in her back; and so we got a guilty on that one.
Here's a little example of one of my cases that Dr. Mosqueda came out on, and I call it football or wrestling. A 74-year-old woman with dementia; she has a 23-year-old grandson, and they all reside in the same home so there's a position of trust between them. They get in a fight over the remote control because, believe it or not, granny liked to watch wrestling and the grandson wanted to watch football. And basically what happens is they start wrestling, and he grabs onto her arm and pushes her around, and she suffers bruising and laceration to her wrists and face. And her story was — that day — was that he grabbed me.
And then next day when all seven of her family members came with her we arrested him, by the way, at the scene but when her family members came in with her to the front counter of our police department, her story had changed, and it was, A cereal box fell on my arm. Well I wasn't buying that, so I convinced her son to bring her in and get a medical — a freebie, right? — a free medical exam by our lovely Dr. Mosqueda, who by now has the results of the bruising study. So Dr. Mosqueda comes in, and she looks at the bruise — and if you guys see the bruise and based on Aileen's study, you can tell that's not an accidental bruise — I mean its circular, it goes all the way around her arm, and then there's that laceration on it as well, and you can see the bump on it. So despite the fact that she had dementia, she kept telling Dr. Mosqueda, He grabbed me. OK, the cereal box fell on me, but he grabbed me. Well I was raking, but he grabbed me. So do you see and like Carrie was talking about the dementia study — that's going to be absolutely brilliant for us because people do remember even if they have dementia; they do remember, and they can always go back to how they received that particular injury. The story around it might change, but they remember how they got that injury. So based on the interview, based on Dr. Mosqueda wrote a report for me saying that this was abuse and not accidental. That grandson who had all the family members come in and trying to lie to get him out, he plead guilty to elder abuse, so we got a conviction on that.
Basically in law enforcement, in elder abuse, they can be really tough cases. We have the obvious cases and that's not in elder abuse. Obviously this guy was in a struggle. How do I know that? Well there's blood all over the place, and he's got items thrown all over. He's a big robust guy so he was in a fight for his life, and unfortunately he lost. But then we get cases like this with the elder on the right-hand side. And this was another one of my very first cases and really hard to determine what this guy died of. That's again where forensic exams and CT can come in handy and help me out in my case. If you think about it on a traditional autopsy, were not going to filet somebody — we don't slice open every little bit of them and skin them like a deer, right? So if this guy has fractures somewhere, chances are its going to get missed so that's where I think that Dr. Daly's study will come in handy.
On the forensic exam, were going to see are they any unexplained injuries? Are there fractures? And I could use the information that we get in CT scans to either corroborate or contradict a caretaker or a suspects story. I love to do stuff like that — trip them up.
What I like to do is I like to compare — because again this research is fairly recent — I like to compare how elder abuse is a lot like child abuse. And so I'm going to talk about this case of Alexis. This is a true story; it happened about two months ago. A 4-month-old found by mother with difficulty breathing. He presents with multiple bruises over his entire body his foot, his legs, his arms. Mother states he was playing with a friend. I don't know about any of you, but when my kid was 4 months old, she was not out playing with friends. So right away something's like, oh, what was that? LLPOF liar. So basically the emergency doctors as well as the doctors at Chalk hospital in Orange County ordered a CT scan, and what they found — and this is Dr. Murray from UCI — determined the 4-month-old had a left acute sub — how do you say that doctor? Subarachnoid?
Barry Daly: Subarachnoid, yes.
Hill: Thank you — hematoma, an older subdural hematoma, right distil femur metaphyseal lesion. So there's old and new injuries, right? And then the doctor writes — based on that CT scan the history by the mother does not explain all of the injuries. The injuries are consistent with abusive head trauma and nonaccidental trauma. So what we did was we took that information from the CT scan and went back to the mother who surprisingly enough decided that maybe it was time to confess and confessed to pinching, beating, shaking her child and punching the kid in the face as well. He had this little thing that keeps your, this thing that keeps your — attached, your lip — that was ripped off as well.
So how do I think this is going to relate to elders? Well, elders atrophy — their muscles atrophy. They become frail; they get thin — not all, but some of them — were talking bed ridden and they have lack of muscle mass. Now remember, earlier we talked about how the law says they cant protect themselves because they might be confused and less able to understand or report criminal conduct. So basically what I'm thinking is that maybe if they get hurt or beat over a period of time and I do have cases where this has happened — they cant report it. I had a lady that had a broken hip — she couldn't report it; she did not report it. She was suffering, but she didn't report it.
So the CT scan can give a range of time for the injury — it can point to a cause of death when the victim cannot testify. And talking to prosecutors, the prosecutors can then argue the presence of old and new injuries such as fractures, bleeds, internal lacerations from blunt trauma that these were not an accident but show a pattern of abuse and neglect over a period of time. And I talked about elders being frail, if there's of evidence of shaken baby — like shaken baby, like shaken elder — that's acceleration and deceleration that occurs with violent shaking — how's an older person going to get that if they're nonambulatory, if they cant walk? How are they going to get one of those? They're not going to have subdural hematoma if they cant walk and there's no history of them falling. So I can take this information back — I can confront the suspects.
I have a case right now where the woman has bruising all over her face. She has a bruise on her neck, a bruise on her cheek, a bruise underneath her eye and when I interviewed the suspects the two caretakers — they said, Well you know — by the way she's not ambulatory — she must have rubbed her face on the sheet. OK, I'm not buying that story — call me stupid, I don't know, but I'm not buying it. But there's no witnesses, and she has Alzheimer's; she cant tell me what happened. So basically I have Dr. Mosqueda right now looking at those records. What I'm going to do is once I get her evaluation on that report, I'm going to go ahead and take that information back, and I'm going to give the two suspects a polygraph exam. Then I'm going to let them tell me their story. Then I'm going to go after them for neglect, if I cant get abuse. So these studies are really important for law enforcement.
And to conclude, this is actually the gentleman that I showed you earlier. This is why the research is so important in law enforcement. Again, this was actually my second case after the (undistinguishable) case. And this is one of those things that kind of haunts me a little bit because we couldn't get a prosecution on this, and I know this man suffered. Evidently he had sepsis, but they didn't know where it came from, but perhaps with the CT scans we can figure out how deep it was into his bone. The coroner that did this exam did not look. I just want to thank you doctors both for all your research. Thank you NIJ because it really has real-life application for what I do out in the field. It has really helped me get prosecutions; its changed the way I look at law enforcement and the way I handle everything. Thank you.
Question and Answer Session
Carrie Mulford: Thank you to all of you. Let me open the floor for questions. Anybody?
I actually have a question for you, Dr. Daly. I know that we talked about this on the phone a little bit. There's possibility for application to use the CT scans earlier, so can you talk a little bit about how that could happen — be used in either the investigation when you suspect there might be elder abuse. Did I get that right?
Barry Daly: Are you referring to elder abuse in the living?
Mulford: Yes, in the living.
Daly: You're quite correct because much of what we would expect to see in a decedent is what we would also expect to see in somebody who is still alive, although clearly it may be a question of degree, because if we find evidence — were always looking for things like the subdural hematomas, which we saw a very good example of described — were looking for things like that and especially if you see something you cant explain why has this occurred. We then are going to be working more with the gerontologist. I don't believe that we see perhaps as much of that as we might. Perhaps we haven't really been using imaging as much as we might, but we actually have a consultant who actually works with us on this project, and one of the things we've looked at is starting to address whether there are other applications that we should be pushing out as we work through this project. Should we be using certain things like CT in elder cases? There is certainly potential, and I'm sure it does happen — that's something we don't see so much in the forensic setting as we see in gerontology perhaps.
Mulford: I'm visualizing several studies. OK. Now we've got three questions — one, two, three.
[Audience Member 1]: Dr. Daly, maybe it didn't surprise you that the autopsy missed a stage four decubitus but it did surprise me. I can understand not being able to detect bone involvement, but not what lead to that. Did it surprise you, and if so, how is that an autopsy could miss that?
Daly: And that is something I cant honestly explain because I've got that data, but we haven't actually gone back. We've correlated the data and said, Hey, this doesn't fit, but we haven't actually gone back to the specific case and addressed it with the medical examiner who was involved — who was one of a team of 15 different medical examiners — so I am afraid I honestly don't have a good answer for you. In the case that occurred — and I'm sorry I didn't actually include the image; perhaps I should have — what we did notice was that the actual external opening seemed quite small, but there was clearly (undecipherable) and there was bone involvement, so sometimes we will see infection that's more of what wed call a sinus track, which is not like a big, open decubitus ulcer, but more of the narrower, deeper process. And it may not occur always as a result of direct pressure; there may be other things going on, such as it might even occur in the setting of infection occurring in the bone and tracking out, and then you end up with kind of the same effect. You wouldn't necessarily see a really big, ugly looking decubitus ulcer going all the way down to the bone, which is what we think of the typical decubitus ulcer as being.
Mulford: I've been asked to repeat the question so that the recorder can pick them up, and that question was can you explain why the stage four decubitus ulcer may not have been detected by the autopsy?
Right there, right.
[Audience Member 2]: I was just curious about the prosecution piece of this. Once you identify your other bruising, does that help you with the prosecutions cases? How is the D.A.'s office ...
Cherie Hill: Its helping 100 percent.
Mulford: Can you repeat the question?
Hill: Basically the questions was has the bruising study helped the D.A.'s office determine if they're going to prosecute or not. Absolutely. I'm really fortunate ... In the city of Anaheim, we actually have our own prosecutors that handle all of our misdemeanor cases, so I take my misdemeanors to them, which a lot of the bruising wouldn't have significant felony filing quality to take to the D.A., which would be separate injuries. But its completely changed the way — in the past four years — that our prosecution has handled these cases, yes. What we've done is I've taken the studies to them, and I've given them copies of the study. And I've taken them to training and educated them about here's what's indicative of abuse. And then we've been blessed enough to have geriatricians from UCI come in and actually look at the victims or look at pictures that we've taken out in the field. And then they'll write a determination based on medical records — as well as the bruising — if they feel that this was indicative of abuse, so that's helped. I would say that since I've been upstairs in detectives the past four years, we've had like 100-percent increase in getting cases filed, and in all but one we got a guilty plea. Its just phenomenal what this study has done for us.
[Audience Member 3]: How many other agencies — are there a lot of agencies in the nation that know about this study? And how is that who knows about this study, because I find it fascinating.
Hill: You know what --
Mulford: The question was how many agencies know about this study? How well known is it? The bruising study.
Hill: And well have to let both Dr. Wiglesworth and myself answer this question. As far as my knowledge, we've put on a lot of training through posts in California, so we try to get other agencies to come in and then educate them about this. And I know a lot of the physicians are going out training. Its been in journals as well — but you're right we need a better way of disseminating the information.
Aileen Wiglesworth: The first study was published in the "Journal of the American Geriatrics Society", and the second study's going to be published in the same place. We probably do need to learn more about publishing to law enforcement, but we do also — well, we have the Web site, the Center on Elder Abuse, and we put our research results there; we speak at conferences. And yes, we are struggling with how do we get this out more? We've talked about do we — are we going to distribute fact sheets? If you all have any thoughts or suggestions on that. I know that Dr. Mosqueda does a lot more traveling than I do, and she does speak about it whenever she's got a likely audience, and people have heard of us, sometimes just because of that. But the world of elder abuse research and prosecution is not that — its not as big as it needs to be.
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