Bruising in the Geriatric Population
Documenting normal bruising patterns in this population is the first step toward differentiating accidental from suspicious bruising. An NIJ-funded study found that:
- Accidental bruises occur in a predictable pattern.
- Most accidental large bruises are on the extremities.
- The initial color and appearance of bruises changes over time and is less predictable than previously thought.
- Individuals who are on medications known to make bruising more severe and those with compromised functional ability are more likely to have multiple bruises. 
The second step in differentiating accidental from suspicious bruising is to document bruises in elderly individuals who are confirmed victims of elder mistreatment. A follow-up study funded by NIJ found that:
- Sixty percent of examined bruises were inflicted, 14 percent were accidental and 26 percent were of unknown causes. Most participants from the study of non-abused elders (71 percent) could not identify the cause of any of their bruises.
- A majority of abused elders (56 percent) had a large bruise (>5 cm), which is much higher than the percent of non-abused elders from the previous study with a large bruise (7 percent).
- Abused older adults were more likely than non-abused elders to have bruises on the head, neck or torso. 
Determining Abuse as a Cause of Elder Death
NIJ funded research examining the decision-making processes medical examiners and coroners use when investigating suspicious deaths.
One study found that medical examiners can rarely differentiate symptoms of illness from signs of abuse in elderly decedents. As a result, signs of abuse commonly recognized in younger decedents are missed in elders, and abuse is rarely seen as a cause of death. These findings call for additional research on both the decision-making practices of medical examiners and the forensic markers of elder mistreatment. They also highlight the need for medical examiners to receive additional training on this issue.
Another study documented practices that 46 of the 58 California coroner/medical examiner (CME) agencies use to decide whether to investigate an elder's death. This study confirmed that CME offices do not assume jurisdiction over many elder deaths that experts in the field of elder mistreatment thought should be investigated because of signs of potential abuse or neglect.
In a subsequent phase of the project, the researchers worked with a Multidisciplinary Advisory Board to develop the Elder Suspicious Death Field Screen (ESDFS) and conducted a pilot study in three California CME agencies. Researchers expected to receive several thousand ESDFS forms during the six-month pilot study. Two of the agencies discontinued use of the ESDFS during the study, however, and in the end, only 115 ESDFS forms were completed. An expert panel reviewed 55 of the completed forms. The panel believed that two-thirds of the cases they reviewed should have received a higher level of investigation then was undertaken. In particular, the expert panel agreed that in many of the "waived" cases, someone should have viewed the entire body. Post-pilot-test interviews revealed that agencies' resistance to using the ESDFS was related to: (1) high workload and burnout; (2) a lack of integration between the ESDFS and current automated systems or redundancy with current screening items; and (3) investigators who saw no benefit to using the ESDFS.
In a separate study, researchers examined implementation of the Arkansas law giving county medical examiners the authority to investigate deaths occurring in long-term care facilities (LCF). They conducted focus group interviews with medical examiners, coroners and geriatricians from 27 states to determine their involvement in investigations into the deaths of LCF residents. Although the researchers' findings suggest that the Arkansas law had a positive impact on attention to elder mistreatment and the quality of care of LCF residents in Pulaski county, whether care has improved state-wide is not clear because of differences in implementation.
The second phase of this study concluded in 2007. The resulting data indicate that the Arkansas Long-Term Care Reporting law, which mandated that all deaths that occur in nursing homes in Arkansas be investigated officially, has not made a difference in quality of care in the state. The project also revealed additional factors associated with higher level of mistreatment suspicion, including family dissatisfaction with care; minority race; tube feeding; the presence of a severe pressure sore or recent ostomy.
Potential Markers for Elder Mistreatment
Researchers in Arkansas identified specific characteristics within four categories of markers that investigators can look for to determine whether elder mistreatment is occurring or has occurred. 
The table below shows specific characteristics identified by researchers in Arkansas within four categories of markers that investigators can look for to determine whether elder mistreatment is occurring or has occurred.
|Potential Markers to Identify Elder Mistreatment|
|Physical Condition and Quality of Care
Better Tools to Assess Psychological and Financial Abuse
NIJ-funded researchers have developed and tested two measurement tools that give the field better ways to assess financial and psychological abuse of elders: 
- Older Adults Psychological Abuse Measure, which has 31 items.
- Older Adults Financial Exploitation Measure, which has 30 items.
The researchers used concept mapping  to develop measurements of abuse. They tested the tools on 226 clients of adult protective services with substantiated cases of abuse.
Adult Protective Services in six sites in Illinois are using the two new measures along with assessment tools to measure physical and sexual abuse and neglect. They are doing so as part of an NIJ-funded followup project designed to pilot test a prototype for an electronic Elder Abuse Decision Support System — a computer-based application of the developed measures to help practitioners identify abuse.
[note 1] Mosqueda, L., K. Burnight, and S. Liao. Bruising in the Geriatric Population (pdf, 22 pages). Final report to the National Institute of Justice, June 2006, NCJ 214649.
[note 2] Wiglesworth A., R. Austin, M. Corona, and L. Mosqueda. Bruising as a Forensic Marker of Physical Elder Abuse (pdf, 27 pages) . Final Report to the National Institute of Justice, February 2009, NCJ 226457.
[note 3] Dyer, C.B., L. Sanchez, L. Kim, J. Burnett, S. Mitchell, B. Reilley, S. Pickens, and M. Mehta. Factors That Impact the Determination by Medical Examiners of Elder Mistreatment as a Cause of Death in Older People. Final report to the Office for Victims of Crime, July 2008, NCJ 223288.
[note 4] Mosqueda, L., and A. Wiglesworth. Coroner Investigations of Suspicious Elder Deaths. Final report to the National Institute of Justice, October 2012, NCJ 239923.
[note 5], [note 8] A brief description of the Arkansas law and how it came about can be found in Lindbloom, E., J. Brandt, C. Hawes, C. Phillips, D. Zimmerman, J. Robinson, B. Bowers, and P. McFeeley. Role of Forensic Science in Identification of Mistreatment Deaths in Long-Term Care Facilities. Final report submitted to the National Institute of Justice, January 2005, NCJ 209334.
[note 6], [note 9] Lindbloom, E., R. Kruse, J. Brand, M. Malcolm, A. Hough, Jr., D. Zimmerman, and J. Robinson. Mandatory Reporting of Nursing Home Deaths: Markers for Mistreatment, Effect on Care Quality, and Generalizability Final Report. Final report submitted to the National Institute of Justice, March 2008, NCJ 221893.
[note 7] See Lindbloom, et al. (2005) and Lindbloom, et al. (2008).
Bruising in the Geriatric Population
Bruising as a Marker of Physical Elder Abuse
Factors That Impact the Determination by Medical Examiners of Elder Mistreatment as a Cause of Death in Older People (Final Report)
Coroner Investigations of Suspicious Elder Deaths
Role of Forensic Science in Identification of Mistreatment Deaths in Long-Term Care Facilities: Final Report
Mandatory Reporting of Nursing Home Deaths: Markers for Mistreatment, Effect on Care Quality, and Generalizability Final Report