Dr. Veronica LoFaso

The NYC Elder Abuse Center (NYCEAC) welcomes back Dr. Veronica LoFaso, Associate Professor of Clinical Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital within the Division of Geriatrics and Palliative Medicine. Dr. LoFaso provides geriatric medicine consultations to NYCEAC’s multidisciplinary teams, serving to help the teams evaluate and respond to the myriad medical issues that are presented to them. In addition, she has developed and conducted numerous elder abuse trainings for a variety of institutions throughout the greater New York City area and beyond.

In her second guest post for the Elder Justice Dispatch, Dr. LoFaso provides an overview of the important insights and clues forensic medicine can offer to elder abuse practitioners.

I was attracted to the field of Geriatrics in part because of its complexity. My patients rarely come in with a single complaint and my charge as their physician is to make sense of a series of seemingly unrelated ailments. Are they all pieces of a larger picture that I’m missing? Is there one elegant, unifying diagnosis that can bring it all together? Sometimes yes…and sometimes no.

I see my work in elder abuse and neglect much the same way. I have learned that there is rarely a straight path to unmasking abuse. It‘s a more circuitous journey: picking up pieces of evidence along the way until a fuller, clearer picture emerges. Each case is a big jigsaw puzzle, unfolding before the eyes, often with people’s lives at stake.

My work on the NYC Elder Abuse Center’s multidisciplinary teams (MDTs) has sparked my interest in the forensic medicine aspects of physical abuse. For example. what clues are going unnoticed by doctors when patients present after a “fall”? Are the bruises that were documented on multiple planes of the victim’s body really consistent with falling? Did the stage 3 pressure ulcer really just appear 2 days ago? Are there key pieces of the puzzle being innocently thrown away by medical practitioners because their value is underappreciated? Too often, yes.

Years of experience as well as participation in the academic discourse of elder abuse have taught me to pay attention to all of these little details. My focus on elder abuse is regrettably rare in the medical world; the majority of physicians and medical practitioners who regularly interact with older adults have little to no training in elder abuse. However, there are several basic concepts from forensic medicine that all practitioners can incorporate into their work with older adults to aid in their detection of abuse.

A few landmark studies have moved the forensic field forward:

• Mosqueda et al did wonderful work to better understand victims’ bruising patterns. Bruises on the upper back, neck, ears, undersurface of arms and inner thighs are rarely accidental. The age of a bruise cannot be accurately determined from its color: older bruises can be dark purple and early bruises can be yellow, contrary to what was commonly held knowledge.
• An important study of pressure ulcers demonstrated that even well cared for patients can develop pressure ulcers, but they are usually single ulcers in an area of pressure like the sacrum. Multiple poorly dressed ulcers on different planes and in areas where they can be easily prevented by positioning (such as between the knees) are suspicious.

Other clues can be found in laboratory data:

• Evidence of dehydration from neglect can manifest as abnormally high sodium levels and abnormalities in kidney function tests.
• Malnutrition may be suspected when there are in low protein levels in the blood. Unexplained weight loss, muscle wasting, very low cholesterol and anemia are other possible indicators of malnutrition from neglect or active starvation of a victim.
• Evidence of trauma to muscles (from physical harm or restraints) can cause elevations in muscle enzymes (creatine kinase) that can be tested in the blood.
• Toxicology testing can reveal potential abuse through either the absence – or inappropriate dosage – of a medication that a patient should be getting. Such testing can also reveal the presence of a substance with sedative properties that is not prescribed by the victim’s physician.
• Certain infections may raise the question of abuse. An older adult without capacity that presents with a new vaginitis or STD is highly suspicious for sexual abuse.

In younger patient populations, some of these results would immediately raise suspicion that would translate into action. For example, if the circumstances of a death are deemed suspicious, medical examiners are able to test hair (for illicit drugs) and blood for a variety of indicators of abuse and cause of death. However reporting of elder abuse cases by medical examiners has been historically poor throughout the country. This is in large part because so much of what we see in abuse – e.g., bruising, weight loss, poor nutrition and dehydration, pressure ulcers – can also be ascribed to findings of a frail, demented older adult at the end of life.

Like a good puzzle master, over time I continue to get better at knowing where to look for and find the clues. Much more work has to be done to help practitioners focus on physical and laboratory findings that will allow them with high degree of certainty to suspect abuse. A validated tool that could be used by emergency room physicians, medical examiners and even primary care practitioners to give greater certainty to their gut suspicion of abuse would be a welcome addition to our toolbox.

With or without a tool, practitioners must learn to look at all the pieces and put them together into a bigger picture. When all of the information gleaned in a medical and laboratory evaluation is evaluated in the context of the dynamics of the family unit, presenting scenario and risk factors and understanding of normal aging, we stand to greatly improve our response to elder abuse.