Radiologists: Watchdogs of elder abuse
Physical abuse of elderly individuals can be difficult to identify and even more difficult to prove. When elderly patients with injuries serious enough to require emergency department or physician treatment, it is important for physicians to scrutinize the injuries to determine if they may be the result of mistreatment. Radiologists are uniquely positioned to help detect abuse.
The characterization of imaging findings in elder abuse is not well documented, but an article published in the Canadian Association of Radiologists Journal in which two cases are documented add to the literature. A multi-institutional team of radiologists, emergency and primary care physicians, and geriatric specialists wrote the article aiming to encourage radiologists to be as alert to elder abuse patients as they are to child abuse.
In the first case, a 98-year-old woman with a history of dementia was taken to a primary care physician one week after sustaining an injury to her upper left arm that continued to cause pain. An X-ray showed an acute, displaced transverse fracture through the proximal humeral metadiaphysis. Suspecting abuse, emergency physicians treating the patient ordered additional imaging which included a CT of the left shoulder, a CT of the head, and X-rays of the left wrist and forearm, pelvis, left femur, and bilateral hips.
The left wrist and forearm radiographs demonstrated a chronic fracture deformity of the distal ulnar and distal radial diaphyses. An acute comminuted intertrochanteric fracture of the left proximal femur and an age-indeterminate fracture deformity of the right inferior pubic ramus were identified on the left hip and pelvis radiographs. Unfortunately, the patient was released without confirmation of physical abuse.
Co-author Tony Rosen, MD, an emergency physician at the Weill Cornell Medical College in New York City, and co-authors, argue that this case shows the importance of a radiologist’s determination of whether imaging findings correlate with a patient’s history and discussing it with the treating physician. They recommend radiologists without access to the patient’s medical record talk with the treating physician. In this case, the transverse humeral fracture would most often require a high-energy mechanism of injury. This was inconsistent with the explanation provided that the patient repeatedly banged her arm in her hospital bed in her residence.
The second case also involved a woman in her 90’s with dementia. She was brought to a hospital emergency department disheveled, covered in feces, and in a fetal position. She was admitted for weakness and altered mental status. The patient had a history of coronary artery disease, stroke with residual right-sided deficits, diabetes mellitus, and frequent falls.
Emergency physicians saw multiple skin discoloration from bruises on the woman’s face and body including bilateral periorbital bruising. They also determined that she was hypothermic, hypertensive, had a slow heart rate, and a high blood sodium content. She also appeared to have been sexually abused.
A chest radiograph showed an acute, comminuted fracture of the right distal clavicle and multiple acute and chronic bilateral rib fractures. Right clavicular radiography and a CT of the chest were ordered. The chest CT showed multiple, acute, right-sided fractures of the ribs and nonacute, healing fractures and deformities. An abdominal and pelvic CT also showed an acute, nondisplaced fracture of the right, inferior pubic ramus and chronic fractures of the L2-L4 left transverse, and a head CT scan revealed bilateral nasal bone fractures and a left frontal scalp hematoma. The patient was ultimately discharged to a shelter for elderly abuse victims.
The authors noted that injuries common with falls should not necessarily be presumed to be the result of accidental falls. They advise radiologists to report all findings, even if they are not relevant to the injury for which an imaging exam was ordered. Detailed documentation may alert to the potential of abuse if a patient returns with injuries that may be caused from abuse.
The authors stated that large-scale studies need to be implemented to identify imaging correlates of elder abuse. They recommend that radiographic findings of abuse cases are compared with cases of unintentional injuries to identify patterns. They also recommend the use of registries and large databases to assess the frequency and circumstances surrounding suspicious injury patterns.
“We hope that radiologists consider elder abuse as a possibility on their differential diagnosis, or this mistreatment may continue to be unrecognized,” they concluded.
REFERENCES
- Rosen T, Bloemen EM, Harpe J, et al. Radiologists’ training, experience, and attitudes about elder abuse detection. AJR Am J Roentgenol. 2016 207; 6: 1210-1214.
- Wong NZ, Rosen T, Sanchez AM, et al. Imaging findings in elder abuse: A role for radiologists in detection. Can Assoc Radiol J. Published online October 13, 2016. (dx.doi.org/10.1016/j.carj.2016.06.001)