Fran Lowry

November 29, 2012

CHICAGO — Think elder abuse when an older person presents to the emergency department or the doctor's office with a subdural hematoma, bruises to the head and neck, maxillofacial and dental injuries, and upper extremity injuries, researchers said here at the Radiological Society of North America 98th Scientific Assembly and Annual Meeting.

Dr. Kieran Murphy

Those types of injuries, along with a wasted and unkempt appearance, are almost sure signs that the person is a victim of physical abuse, said Kieran Murphy, MD, acting chief of radiology at the University Health Network, Toronto General Hospital, in Ontario, Canada.

Radiologists have a key role to play in identifying abuse in weak, vulnerable, elderly people, Dr. Murphy told Medscape Medical News.

Dr. Murphy said that he has wanted to study the scope and extent of elderly abuse "for some time."

He explained that when he was on call in the emergency department, "I'd be looking at these films and thinking, 'How did this little old lady break her maxilla? How did she get that swelling around her eye?' I'd look at these injuries and think there's got to be some trend here."

"In pediatric radiology, we know very well that children who are beaten by a parent or [other] adult get fractures in a characteristic way. We call that Caffey's syndrome. It is hard-wired into us to look for child abuse because their fractures are very typical; their bones are like bamboo and they bend," he said.

In adults, the pattern is quite different, not only in terms of where the injuries are found, but in the context in which they occur, Dr. Murphy noted.

"The radiological evidence is part of the pattern, but the injuries tend to take place at home, where the patient is living either with a spouse or child caregiver. Usually, the patient has had a stroke and may be physically disabled or slightly demented. The person looking after the patient is typically dependent on them financially, and may have a drug or alcohol problem or some other psychological problem... This occurs in the home, not nursing homes," Dr. Murphy said.

He and his team conducted a meta-analysis of the existing literature and data from the Ontario Trauma Registry and the Ontario Coroner's Office on types of injuries and radiological findings in people 60 years and older.

Their literature review yielded 1100 injuries from elder abuse. The trauma registry yielded 2 confirmed cases of elder abuse, 21 cases of assault by unknown persons in the previous 5 years, and 3 deaths as a result of assault in long-term care facilities.

The most frequent injuries were due to maxillofacial trauma, dental trauma, subdural hematomas, periorbital and laryngeal trauma, rib fractures, and upper extremity injuries.

These patients were more likely to be socially isolated. They also often had bed sores and tended to be cachectic, Dr. Murphy explained.

"The stereotypical thinking is that this happens in a nursing home, but the reality is that those are professional caregivers and usually there is some standard," Dr. Murphy said. "It's the stuff that is going on in an environment where there is a nonprofessional, perhaps financially dependent, person who is beating up on the person they depend on."

Dr. Murphy believes that abuse of the elderly is probably more common than we think.

"The literature is there. For example, a lot has been written about this in the dental literature.... Radiologists have a role to play in this, just as they do in the detection of children's physical trauma. It was a radiologist who first shed publicity on child abuse," Dr. Murphy said.

Dr. Gary Whitman

"I think this paper has increased our awareness of elder abuse and some of the things that we may find in imaging studies. We have to be attuned to that. Radiologists have to be engaged and aware of it, not just as film critics but as very active members of the multidisciplinary team," said Gary Whitman, MD, professor of radiology at the University of Texas M.D. Anderson Cancer Center in Houston, who moderated the press briefing.

Barry Daly, MD, professor of radiology at the University of Maryland School of Medicine in Baltimore, told Medscape Medical News that major underreporting of elder abuse is very likely.

"We did a study here in Baltimore. We found few positive cases of physical abuse in the suspicious deaths referred to the medical examiner that were investigated with a postmortem CT. However, we suspect that many positive cases are never reported because they occur in dysfunctional home settings, where family members with substance abuse or other major mental health issues are the caregivers, and the death certificates are signed off by primary care physicians who are not familiar with the patient and not sensitized to the possibility of abuse," Dr. Daly said.

"Radiologists becoming more aware of this problem will be very helpful, especially when they see repeated trauma in the same victim. Head or face traumas seem to be the most suspicious injuries," he noted.

Dr. Murphy, Dr. Whitman, and Dr. Daly have disclosed no relevant financial relationships.

Radiological Society of North America (RSNA) 98th Scientific Assembly and Annual Meeting: Abstract LL-HPS-TU. Presented November 27, 2012.