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Bruising in Elderly

Bruising in Elderly. Adult Protective Services Meeting July 21 st 2010 Sowmya S Kurtakoti, MD. Dr. Laura Mosqueda. Is the director of Geriatric Program at University of California , Irvine.

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Bruising in Elderly

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  1. Bruising in Elderly Adult Protective Services Meeting July 21st 2010 Sowmya S Kurtakoti, MD

  2. Dr. Laura Mosqueda • Is the director of Geriatric Program at University of California , Irvine. • A national leader in geriatrics and one of the country’s leading experts on the important issue of elder abuse. • Also was instrumental in the recent opening of the nation’s first Elder Abuse Forensic Center, which brings together UCI medical experts and representatives of Orange County Adult Protective Services and other agencies in a coordinated battle against elder abuse.

  3. Review of 2 major studies • Bruising in Geriatric population done in 2001 – goal was to study the occurrence, progression and resolution of accidently inflicted bruising in adults aged 65 and older • Bruising as a forensic maker of physical elder abuse done in 2005 – goal was to document location and size of bruise and assess whether they were inflicted during physical abuse

  4. Bruising in Geriatric Population Comparing bruising in children and adolescents: • Accidental bruises less than 2% occurred on buttocks, pelvis, abdomen or thorax; less than 1% on chin, ears or neck. • Bruise from abuse were greater in length mostly in head and neck • Bruises tend to go from purple/black to green to yellow with red appearing throughout the duration of the bruise.

  5. Bruising in Geriatric Population Accounting for increased likelihood of accidental bruising in older adults: • Normal age related changes: thin epidermis, fragile capillaries and less subcutaneous fat • Common age related changes: Medical conditions like diabetes, hypertension also falls and gait instability • Medications that prolong bleeding time

  6. Bruising in Geriatric Population Four research questions guide the current study: (1) Do accidental bruises occur in a predictable pattern in older adults? (2) Do color changes in bruises occur in a predictable pattern in older adults? (3) How do medications and medical conditions that interfere with normal blood clotting impact bruising in older adults? (4) Do older adults with compromised mobility and/or functional ability have more bruising?

  7. Bruising in Geriatric PopulationMethods Study Population: • 101 subjects from community based setting (77) and 2 skilled nursing facility (24) • Inclusion Criteria: 65 and older; able to provide consent or assent to surrogate consent, no suspicions of elder mistreatment. • 66% were female, average age 83 and all were Caucasian • 77% ambulated without assistive device at home, 67% ambulated independently in the community.

  8. Bruising in Geriatric PopulationMethods Study Population: • 47 % required assistance with their ADL’s • 17 were cognitively impaired and assented to surrogate for informed consent process A subject was considered cognitively impaired if he or she had a legally authorized representative as a result of documented incapacitation; or was deemed to be impaired by the geriatrician on our research team who evaluated all potential subjects who showed any confusion or disorientation to time, place, or person.

  9. Bruising in Geriatric PopulationMethods Data Collection: • One of two trained interviewers went to his/her home each day and examined the subject from head-to-toe for any bruises • If a bruise was present at the first visit, this bruise was documented and was not included in the study. If however a new bruise appeared on the second to the fourteenth day, it was known to have occurred during the prior 24 hours and was then documented every day until resolution or up till 6 weeks. • Subjects and/or caregivers were asked if they knew what caused the bruise.

  10. Bruising in Geriatric PopulationMethods Measures: • The location, size, and colors of each bruise were measured everyday until resolution through visual inspection, detailed charting, and digital photographs. • Age, gender, ethnicity, functional status, handedness, medical conditions, medications, cognitive status, depression, and history of falls. • Functional status was measured using the Katz activities of daily living (ADL)12 and Lawton intermediate activities of daily living (IADL)13 scales. • Mobility was measured using the Tinetti Gait and Balance scale, and the self-reported Ambulation Scale. Subjects were asked to report how many falls they had taken in the past week, month, six months, and year.

  11. Bruising in Geriatric PopulationResults Location and size: • 72 had at least 1 bruise in the 2 week tracking period • Total of 108 bruises in 72 participants; of which 89% were on the extremities with 76% being on the dorsal surface of the arm. • No bruises observed on the neck, ears, genitals, buttocks or soles

  12. Bruising in Geriatric Population Diagram 1. Combined Summary of 108 Bruises Observed on 73 subjects at Day 1

  13. Bruising in Geriatric PopulationResults Small (0.1-1 cm): 5 trunk (41.7%), 31 extremities(32.3%) Medium (1.1-4.9cm): 6 trunk (50%), 46 extremities (47.9%) Large (5-50cm):1 trunk (8.3%), 19 extremities (19.8%) Ability to recall: when on trunk 42% knew how it had occurred, when on extremities only 17% knew

  14. Bruising in Geriatric PopulationResults Timing and sequence of Color change: • The period that the bruises were visible varied from 4 to 41days (Mean=11.73, SD=7.13). • Half of the bruises (54%) resolved by Day 6, and most (81%) resolved by Day 11. • In the first 48 hours, most bruises were observed as red (90%) and/or purple (80%) with fewer displaying black (25%), yellow (20%), green(10%) and blue (8%).

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  16. Bruising in Geriatric Population

  17. Bruising in Geriatric Population Medications : • Mean of 6.7 prescribed medications and 3.6 OTC medications ( 86%) • Medications expected to have a minimal or moderate effect on bleeding time/bruising, 46% had multiple bruises. • For those not on such medications, 26% had multiple bruises (p=.08). • No significant correlation between medications known to impact bruising and the duration of bruises, nor color change.

  18. Bruising in Geriatric Population Medical Conditions: • No significant impact on number or duration of bruises • 100 % of bruises on trunk were on subjects with hypertension, i.e 12 bruises on 10 subjects were on trunk, all 10 subjects had Hypertension.

  19. Bruising in Geriatric Population Function: • Fifty percent of those who require ADL assistance had 2 or more bruises as opposed to 25% of those not requiring ADL assistance (p = .037). • There were no relationships between ADLs and the location of the bruises or days until resolution. • Statistically significant difference in the number of bruises between those who require assistance with one or more ADL and those who required no assistance

  20. Bruising in Geriatric Population Residential setting: • Of those residing in a SNF, 79% developed a new bruise during the two-week observation period which was similar to the rate of 71% if those living in the community. • There were no correlations between the residential setting and the location of the bruise on the body, or days to resolution.

  21. Bruising in Geriatric Population Mobility: • No significant differences were observed in the number of bruises, location of bruises, or number of days until resolution between those who ambulate independently and those who use assistive devices. • No significant correlation between gait or balance and number or location of bruises

  22. Bruising in Geriatric PopulationSummary • Accidental bruises occur in a predictable pattern in older adults. • Nearly 90% of the bruises were on the extremities and in daily observation of 101 older adults, not a single accidental bruise was observed on the neck, ears, genitals buttocks, or soles of the feet. • Most large bruises that are accidentally inflicted are on the extremities. Of the 20 large bruises (5-50 cm) in this study only 1 was on the trunk. • Moreover, older adults are significantly more likely to know how the bruise happened if the bruise is on the trunk.

  23. Bruising in Geriatric PopulationSummary • Initial color and color changes over time are less predictable. • Medications known to have at least a moderate impact on bruisability were more likely to have multiple bruises • Older adults with compromised functional ability were more likely to have multiple bruises.

  24. Bruising as a Forensic Marker of Physical Elder Abuse The research questions addressed by this study are as follows. (1) In cases of confirmed physical elder abuse reported to APS, what percentage of the victims have bruises? (2) In cases of confirmed physical elder abuse, what is the location, color, number and victim-stated cause of bruises? (3) Are there differences between bruises in older adults who have not been abused (Mosquedaet al., 2005) as compared to bruises in those who have been physically abused?

  25. Bruising as a Forensic Marker of Physical Elder Abuse Study Population: • 67 adults aged 65 and older reported to APS for suspected physical elder abuse • Inclusion Criteria: (1) age 65 or greater, (2) an allegation of physical elder abuse occurring within the last six weeks, (3) alleged perpetrator was someone in a position of trust to the older adult (i.e., not a stranger). • Formally consented and if lacked capacity then a qualified surrogate was identified to consent for them. • Sites: Home(60), relative’s house (5), inpatient (2)

  26. Bruising as a Forensic Marker of Physical Elder Abuse Data Collection: • Location, width and length and colors present were recorded along with the participant’s or surrogate’s recollection of the cause of the bruise and the time elapsed since the alleged abuse incident. • Participants answered questions about their medical conditions and use of prescription and over-the-counter (OTC) medications and use of assistive devices. • Functional status was measured using the Katz ADL (Katz, Downs, & Cash, 1970) and Lawton IADL (Lawton & Brody, 1969) scales. • Mobility was measured with the Tinetti Gait and Balance scales (Tinetti, 1986; Tinetti & Glinter, 1988). Participants or surrogates were asked to report falls over the last week, month, 6 months and year.

  27. Bruising as a Forensic Marker of Physical Elder Abuse • To collect evidence of physical abuse, participants or surrogates responded to the twelve item Revised Conflict Tactics Scales (CTS2) Physical Assault Scale. The CTS2 is widely used in studies of domestic violence to measure conflict by direct questioning. • RN also used the Elder Abuse Inventory (EAI) to rate 12 Possible Abuse Indicators, including other types of injuries. Each participant was also asked to describe the abusive incident

  28. Bruising as a Forensic Marker of Physical Elder Abuse • (LEAD) methodology was applied as a criterion standard to assess whether the study participants had experienced physical elder abuse. • Panel of elder abuse experts included four board certified geriatricians with a combined experience of 37 years working in the field of elder mistreatment elder abuse experts • Conceptual definition: physical elder abuse is the non-accidental use of physical force by someone in a trust relationship that may result in bodily injury, physical pain or impairment of an older adult (age 65 or greater).

  29. Bruising as a Forensic Marker of Physical Elder Abuse Operational definition clarified specific issues, as follows: o Does not include sexual abuse (because it presents differently and has low prevalence compared to other physical abuse) o Does not consider the perpetrator’s intent o Does include improper physical restraint, however there is a concern about defining physical restraint too narrowly when restraint can also be used to enhance the elder’s safety. o Does not include physical neglect or deprivation by others; these are categorized as neglect not physical abuse. o Does not include threats with a weapon, but does include use of a weapon that may result in bodily injury, physical pain or impairment. o Does not include chemical restraint o Does not require evidence of harm. Evidence of risk of harm is sufficient.

  30. Bruising as a Forensic Marker of Physical Elder Abuse • The LEAD panel met monthly to review oral and written information for each participant assessed since the last meeting. • The APS worker related the findings of the physical abuse investigation (confirmed, inconclusive, unfounded), and panel members were allowed to ask questions of the RN and APS workers. • The panel was not allowed to hear any information related to the presence/absence or characteristics of bruises.

  31. Bruising as a Forensic Marker of Physical Elder Abuse Results: • 407 were approached, of which 234 were categorized as failed attempts. Another 93 were initially interested but then refused. • Finally 80 were enrolled, of which 13 were excluded. • Of the 67, 3 lacked decision making capacity and a surrogate was consented for participation. • Ensured that none had dementia, cognitive impairment, delusions or hallucinations.

  32. Bruising as a Forensic Marker of Physical Elder Abuse • 57 (85%) endorsed items on CTS2 physical assault scale; EAI indicated evidence of physical abuse other than bruising for 42(62.7%)of the abused sample. • Of the 67 victims, 48 had bruises. • Mean Age 76.7, 48 (71.6%) female, 62 (94%) Caucasian and 11 (16.4%)Hispanic. • 15 scored 24/< for MMSE, 53 were independent with ADL’s and 34 independent with IADL’s, 29 required a cane/ walker, 1 bedbound.

  33. Bruising as a Forensic Marker of Physical Elder Abuse • Medications that interfere with coagulation pathways were being taken by 17 (25.4%). • Abuse perpetrators were predominantly family members (86.6%) and 32.8% of them were suspected substance abusers or had a mental health diagnosis. • Bruises were found on 71.6% (48 of 67) of participants. All participants were seen within 30 days of an incident of physical abuse (10.3±6.5 days). 22 of them had 1-2 bruises; 26 had 3-9 bruises.

  34. Bruising as a Forensic Marker of Physical Elder Abuse

  35. Bruising as a Forensic Marker of Physical Elder Abuse

  36. Bruising as a Forensic Marker of Physical Elder Abuse

  37. Bruising as a Forensic Marker of Physical Elder Abuse

  38. Bruising as a Forensic Marker of Physical Elder Abuse Summary: • Inflicted bruises are larger with mean size of 5 cm or greater. 1 cm or less are not associated with physical abuse. • When a bruise is inflicted rather than accidental, older adults are likely to remember the circumstances that caused the bruise. • Bruises on the head, neck, lateral right arm or posterior torso should arouse suspicion of physical elder mistreatment. • Bruises associated with elder mistreatment are large and occur on the face and posterior trunk. • Bruising specific to the lateral aspect of right arm found on physically abused older adults is not documented in the pediatric abuse literature.

  39. Bruising as a Forensic Marker of Physical Elder Abuse • Bruising emerges as the most prevalent medical marker of physical abuse., found on 71.6% of abused elders who are APS clients seen within 30 days of abusive events. • Other physical indicators like lacerations, fractures, burns, skin tears, scratches, abrasions and swelling occurred in only 41.8% of those who had been abused.

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