Elderly abuse , neglect and death : A case report

The elderly abuse is arising problem in Sri Lanka where the total elderly population represents 12.5% of the population. It is expected to rise nearly to 25% by 2040.1 These statistics indicate that the elder population becomes a significant proportion of the population.Hence the need more attention to the issues related to elders and their health. This includes elderly care and invariably elderly abuse will make a part of it. This is an unmapped area as far as the Sri Lankan health system is concerned.


Introduction
The elderly abuse is arising problem in Sri Lanka where the total elderly population represents 12.5% of the population. It is expected to rise nearly to 25% by 2040. 1 These statistics indicate that the elder population becomes a significant proportion of the population.Hence the need more attention to the issues related to elders and their health. This includes elderly care and invariably elderly abuse will make a part of it. This is an unmapped area as far as the Sri Lankan health system is concerned.
The elderly abuse is defined as a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person. 2 It can be categorized as psychological, physical, financial, material and sexual abuse and intentional or unintentional neglect. The survey of literature on elderly abuse have failed to identify any primary studies reporting the test characteristics of any symptoms or signs of elderly abuse. This gives rise to the problem of identifying and proving the offence of elderly abuse. 2 The index case is on a death of an inmate from an elderly home where the autopsy revealedinjuries which were highly suggestive of physical abuse but were not characteristic of elderly abuse. The paper will focus on difficulty in concluding the diagnosis of elderly abuse and maltreatment.

Case History
A 79-year-old unmarried female was found dead on bedin an elderly care home. She was known to have hypertension, diabetes and psychiatric disorder and was on regular treatment. She was mobile with assistance. According to the care giver she had recurrent falls during the last three monthsand as a result she had sustained several injuries. She was reported to have developed difficulty in breathing acutely and was found dead few hours later.According to available evidence no medical attention was given to her.
A medico legal autopsy was performed after the magisterial inquest. A thin built, emaciated pale body with poor hygiene was observed. A healing laceration with scab formation was noted over the right lateral side of the chin.There was blue colorcontusion with a 1 cm laceration was over the inner aspect of lower lip (Fig. 1). There were 0.75 cm wide elongated grooved abrasions encircling each wrists consistent with ligature marks (Fig. 2). The ligature mark on the right wrist was associated with ruptured blisters containing pus. There were numerous abrasions, contusions with different stages of healing. The dissection of the body revealed subcutaneous contusions on the scalp, left sided 2nd and 4th rib fractures (Fig. 3) and hemorrhages under the skin on different areas of the body. The dissection of the neck area revealed hematoma on the left lobe of thyroid gland. The care giver was unable to explain how these injuries were caused.
A retrospective scene visit was performed to understand causation of injuries. There were pieces of clothes which were tied on the side bars of the bed with loops which were cut. The histology sections obtained from the ligature marks revealed epidermal separation with polymorph cell infiltration in the dermis. The section from the thyroid gland revealed collection of red cells in the parenchyma (Fig. 4).

Discussion
The recurrent falls in this autopsy could explain the some of the injuries. However some of the injuries are typical of non-accidental in nature. In considering all the injuries especially the ligature marks a case of elderly abuse was considered as a high probability.
Multiple injuries following recurrent falls are common among elders with physical disabilities. Therefore the injuries on the deceased could be due to falls. Multiple anterior rib fractures are possible with falls on pointed objects and it could be following assaults. Minor injuries on the body may have caused due to multiple falls or even rough handling of elderly, disabled patients. The thyroid gland ante mortem contusionwhich was confirmed with histology is most likely caused due to pressure on the neck. This isolated contusion most likely has resulted from manual compression rather than with a ligature. This is definitely of non-accidental in nature.
Although it was difficult to conclude the physical elder abuse the overall injury pattern including the suspicious circumstances at the scene and the behavior of the caregiver were suggestive of elder abuse. The poor hygienic state of the deceased was significant2 and the emaciation and the state of pallor may be due to the neglect or due to the systemic illnesses the deceased suffering. This again suggestive of lack of appropriate action orintentional or unintentional neglect by the care giver. That again amount to elderly abuse according the definition. Protection of the right of elder act No.9 of 2000 of Sri Lankaprotects and promotes the welfare and rights of elderly person. 3 However we do not have a reporting system of elderly abuse and neglectwhich is a great drawback to minimize the crime. Many countries including the USA has a reporting requirement for elderly abuse similar to child abuse and sexual abuse. 4

Conclusion
Elder abuse in Sri Lanka is an unmapped area.It is essential and to invest time and resources in investigation to development of an evidence base on elder abuse. The evidence base can be utilized to plan and implement the interventions to prevent elder abuse. Guidelines should be developed for the diagnosis, treatment and management of elder abuse and neglect. The value of evaluation of the history, scene examination, thorough external and internal autopsy examination and histopathological confirmation are emphasized in this report.