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Injury Patterns in Older Adults

Tony Rosen, MD, MPH, FACEP

Study Looks at Differentiators between Abuse, Accident

When an older adult patient presents with injuries, it can be difficult to distinguish whether the trauma was the result of a fall or physical abuse. For patients with dementia or trouble communicating, deciphering what led up to the injury is all the more challenging.

Tony Rosen, MD, MPH, FACEP, assistant professor of Emergency Medicine at Weill Cornell Medical College and director of the Vulnerable Elder Protection Team based at New York-Presbyterian/Weill Cornell Medical Center's Emergency Department, served as lead author on a recently published study that looks at injury patterns as a method of helping providers distinguish between unintentional injury and abuse. Rosen, who has focused his academic career on geriatric emergency medicine with a particular emphasis on elder abuse, was awarded the Society of Academic Emergency Medicine (SAEM) Young Investigator Award last year for his research efforts to improve care for this particularly vulnerable population.

This most recent work - "Identifying Injury Patterns Associated with Physical Elder Abuse: Analysis of Legally Adjudicated Cases," published in the Annals of Emergency Medicine - compared injury patterns in legal records of successfully prosecuted cases of physical abuse in victims aged 60 years and older with patients who presented to a large, urban, academic ED after an unintentional fall.

"The first place that many vulnerable older patients turn for care is the Emergency Department," said Rosen. "Emergency physicians have a unique opportunity to identify the 'red flags' for elder abuse."

Although it is estimated between 5-10 percent of older Americans are victims of mistreatment annually, the issue is widely recognized to be underreported. "Elder abuse is common and very serious but is seldom identified," said Rosen. He added the literature suggests as few as 1 in 24 cases of elder abuse is ever reported to the authorities.

The analysis matched 78 cases of elder abuse with visible injuries adjudicated between 2001 and 2014 to 78 patients with unintentional falls prospectively enrolled in the study between September 2014 and June 2018. Rosen explained researchers used the validated Elder Abuse Suspicion Index as part of the enrollment process for patients who reported injuries from a fall. Anyone suspected of being a victim of abuse was excluded from the study, with the research team's concerns reported to the clinical care team and on-duty social worker for appropriate follow-up. The research team used a matching algorithm to align abuse victims and unintentional fall patients as closely as possible based on a number of characteristics.

The comparisons resulted in some eye-opening findings highlighting differences in injury patterns between accident and abuse. "Physical abuse victims were more likely to have maxillofacial - face and neck - injuries," Rosen explained. "Abuse victims were less likely to have fractures and less likely to have injuries to their lower extremities," he continued, noting 8 percent of abuse victims had scrapes, fractures and injuries below the waist compared to 50 percent of those who fell.

"It's not just the presence of injury but the presence and absence at the same time," he stressed of the emerging patterns, "so injuries to the face in combination of no injuries to the legs are suggestive of abuse."

Looking at the precise location of trauma, Rosen said abuse victims were more likely to have zygomatic bruising or injury on the left side compared to those who fell. The left cheek would be the side naturally struck by a right-handed person. He added more assailants are right-handed because more people are right-handed.

Neck injuries are another red flag for abuse. "When you fall, your face protects your neck, and also your shoulder protects your neck," explained Rosen. "If you were to see any injuries to the neck in the setting of a purported fall, that should at least raise concern."

Rosen added the reason it's critical to identify injury patterns aligned with abuse versus a fall is because the most common false story for elder abuse is to claim the patient fell.

"We think healthcare providers, and particularly Emergency Department providers, have a real opportunity to identify this (abuse) and initiate intervention. Yet, current research suggests Emergency Room providers very seldom do," he continued. "Elder abuse is still a field in which there is so much to be done."

It's also an area of growing concern as baby boomers are rapidly aging, swelling the ranks of the U.S. senior population. "This is a particularly vulnerable population," Rosen said. "And as such, this is a population where we can really have an impact."

He concluded, "Recognizing injury patterns helps encourage an environment where more of these troubling cases of harm against some of the most vulnerable, at-risk older adult patients can be reported and addressed."

Abuse vs. Accident

  • Abuse victims are more likely than those who fall to have injuries on the face, head and neck area (67% vs. 28%) and are much more likely to have injuries on the face, head and neck area combined with no upper and lower extremity injuries (50% vs. 8%).
  • Abuse victims are less likely to have fractures (8% vs. 22%) or lower extremity injuries (9% vs. 41%).
  • Facial injuries to the left cheek or zygoma are more common among abuse victims (22% present with such injuries) than those suffering falls (only 3%).
  • Researchers found neck (15% vs. 0%) and ear (6% vs. 0%) injuries occurred in abuse patients but very seldom in falls. A potential explanation is that the neck is often protected in an unintentional fall.
  • Of the 100 cases of physical elder abuse examined, 22% of victims had no visible injury recorded. However, in many of those cases, victims indicated pain in the arms, chest, abdomen, back, face and jaw.


Annals of Emergency Medicine Research Article


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Accidental Falls, ACEP, America College of Emergency Physicians, Annals of Emergency Medicine, Elder Abuse, Senior Health, Tony Rosen, Weill Cornell
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