THE STAKES ARE HIGH! RECOGNIZING CONDITIONS THAT MAY MIMIC ELDER ABUSE (BREAKOUT SESSION IB)

May 19, 2016 Virginia Coalition for the Prevention of Elder Abuse 22nd Annual Conference Virginia Beach Resort & Conference Center Virginia Beach, VA Melissa Ratcliff Harper, MSN, APRN, SANE-A, SANE-P

This lecture may not be copied, reproduced or recorded in any manner without consent of the writer.

DISCLAIMER: 

Photos may be graphic!!

OBJECTIVES:  Discuss

factors that should be considered in differentiating abuse versus conditions that may mimic abuse.  Identify conditions that may be mistaken for abuse.  Recognize typical presentation of findings in conditions that may mimic abuse.  Review case presentation(s) and differentiate abuse from a condition that may mimic abuse.

CONSIDERATIONS…

OLDER ADULTS AND 







ABUSE:

Cutaneous signs may be most discernible sign of elder abuse.

Rosen et al. (2015)  Mechanism of injury (MOI):  Blunt assault with hand/fists (44%)  Strangulation (4%)  Implements:  Cane, baseball bat, keys, liquor bottle…  Most common injuries:  Bruises (58%) Bruises greater than 5cm are concerning for physical abuse (Wiglesworth et al., 2010). Long bone spiral fractures and fractures with a rotational component are more diagnostic of physical abuse (Dyer, 2003 cited in Young, 2014).

OLDER ADULTS AND 







ABUSE (CONT.):

> 50% of older adults who have been SA- reported to have bruising and abrasions to skin (Burgess, 2005). Murphy et. (2013) Review of the Literature (9 articles):  2/3rds of injuries-upper extremity (43.98%) and maxillofacial (22.88%) region, skull and brain (12.28%) Elder abuse/neglect increases risk of death in older adults (Lachs et al., 1997; Dong, 2005; Dong et al., 2009). 72% of abused older adults had bruises.  Bruises were larger and more often located on face, posterior torso and lateral right arm as compared to those with accidental bruising (Wiglesworth, et. al, 2009).

OLDER ADULTS AND 



Bruising may appear distal to site (blood tracking) of impact due to flow of gravity. Mosqueda et al., 2005:   

90% of accidental bruises on extremities. No accidental bruises noted on ears, neck, genitalia, buttocks or soles. 15% of bruises yellow in color within 24 hours of onset. 



ABUSE (CONT.):

Bruises change as hemoglobin breaks down.

Accidental bruising in an atypical area generally has a good explanation.

OLDER ADULTS AND  Medical

ABUSE (CONT.):

imaging (radiology) role well established in children with nonaccidental trauma, but not with elder abuse.  Linked to major adverse health outcomes:  Depression, dementia, mortality (Rosen et al., 2016).  Due to aging effects on the skin, there is a propensity to attribute injuries to normal or expected events.

CONSIDERATIONS IN CONDITIONS THAT MAY MIMIC ABUSE: 







Mistakes do occur in reporting elder abuse.  Exact numbers of falsely identified abuse in older adults are unknown.  Actual number of missed cases is unknown. Your job is to report suspicions of abuse-not to investigate unless you are the investigator!!  Leave the investigation to investigator(s)! Err on the side of reporting for the safety of the older adult, but remember this type of investigation will put the family/involved parties through H…!  Physiologic states/symptoms may develop and mimic neglect despite a caregiver’s best efforts (Collins, 2007 as cited in Deliema et al., 2016). For cases involving a cultural practice that has injured an older adult, the context of the therapy must be considered first.

THE UNTRAINED EYE… MISTAKEN “DIAGNOSIS”:  The

untrained eye may mistake various accidental injuries, medical conditions, cultural and racial factors, etc. for both physical and sexual abuse.

DIFFERENTIATING ABUSE VS. CONDITION THAT MAY MIMIC ABUSE:  History-History 

is Critical!!

History as reported by the patient and family (as appropriate) regarding skin finding which should include: Onset. Where on body? Any other symptoms?  Duration of symptoms and signs. 



If lesions are present, related to the development of certain medical conditions, observation may help make the diagnosis!!

Itch? Hurt?  Has it spread? Describe?  Change in individual lesions? Describe?  Anything make it worse of better? Heat? Cold? Travel history? Meds…? 

DIFFERENTIATING ABUSE VS. CONDITION THAT MAY MIMIC ABUSE:  History

of present illness?  Past medical history including skin issues?  Family History including skin issues?  Social history including possible exposures…?  Sexual history including risk factors for disease, blood transfusions. STIs…? 

DIFFERENTIATING ABUSE VS. CONDITION THAT MAY MIMIC ABUSE (CONT.):  Review

of Systems:  To connect signs and disease of other organ systems  Physical Exam to include (thorough skin assessment and anogenital exam*):  Nutritional status  Hygiene  Overall health  If injuries noted, open-ended questions in regard to how occurred.  Functional status

DIFFERENTIATING ABUSE VS. CONDITION THAT MAY MIMIC ABUSE (CONT.):  Laboratory and other diagnostic studies as appropriate  “Clinical and Lab Findings Commonly Found in Cases of Abuse and Neglect” LoFaso & Rosen, 2014.  Lab abnormalities in and of themselves are not pathognomonic to elder abuse. Each presenting clinical situation must be taken into consideration. 

DIFFERENTIATING ABUSE VS. CONDITION THAT MAY MIMIC ABUSE (CONT.):  Dermatology or other referral as appropriate

ADDITIONAL CARE CONSIDERATIONS:  Address

pain  Crisis intervention  Neurobiology of trauma, screen for depression, SI/HI  Wound documentation  Evidence collection as appropriate,  STI, HIV and Hepatitis B prophylaxis, baseline testing  Address safety planning, safe shelter, 9-11 cell phone  Mandatory reporting  Discharge, follow-up/and testing…

LESIONS…

LESIONS-QUICK REVIEW: 

Lesions should be described as to the following:  Type:  Macule: Circumscribed area of change in skin color, without elevation, not palpable (i.e. Mongolian spot, Port-wine stain).  Papule: Superficial, solid lesion, usually less than 0.5cm in diameter, elevated above the surrounding plane of skin, palpable.  Plaque: Plateau-like elevation above skin surface, larger surface area as compared to height above skin surface (i.e. Psoriasis).  Nodule: Solid, palpable, round, lesion, longer than a papule, may involve epidermis, dermis or subcutaneous tissue (i.e. may occur as a result of neoplasm, metabolic deposit, inflammatory infiltrate).

LESIONS-QUICK REVIEW (CONT.): 

Lesions should be described as to the following:  Type:  Wheal: Rounded or flat-topped, pale red plaque or papule that often quickly fades-24-48 hours, due to edema (swelling) in the dermis may be round or irregular (i.e. Urticarial exanthem).  Vesicle: Bulla (Blister): Circumscribed, elevated, superficial cavity containing fluid.  Pustule: Circumscribed, superficial cavity of skin that contains a purulent exudate (i.e. infected hair follicle).  Crusts: Dried blood, serum or purulent exudate on the skin surface with varying color and thickness.  Scales: Flakes of the outermost layer of skin (stratum corneum), normally lost without notice.  Ulcer: Defect in skin that extends into dermis or deeper.

LESIONS-QUICK REVIEW (CONT.): 

Lesions should be described as to the following (cont.):  Color: Pink, red, purple…; Uniform or variegated? 

   



Purpuric lesions do not blanch with pressure).

Margination: Well or ill-defined? Consistency: Soft, firm, hard (also should assess temperature, mobility). Shape: Round, oval, iris…? Arrangement: Single or multiple? Grouped or disseminated? Confluent (do the lesions come together?)? Distribution: Extent? Pattern?

ABUSE AND COMMON MEDICAL CONDITIONS: 

Even though an older adult may have a legitimate medical reason for bruising, etc., the possibility of abusive injuries should not be excluded.

CONDITIONS THAT MAY MIMIC ELDER ABUSE: 

Blunt Force Trauma/Bruising:  Allergic reactions  Bleeding disorder due to medications 

  

Salicylate Toxicity

Cushing syndrome Fixed drug eruption Fracture from osteoporosis or Paget disease of bone

Fragile photo-aged skin  Postmortem lividity  Senile purpura  Steroid purpura  Friction blisters  Subdural hematoma secondary to a fall or coagulopathy  Thrombocytopenia 

ITP  Leukemia 



Vitamin C DeficiencyScurvy

SALICYLATE TOXICITY: May present as subconjunctival and skin petechiae and purpura.  Other Sx include: Vomiting, hyperventilation.  Labs: Metabolic Acidosis, + Salicylates on toxicology screen. 

CUSHING SYNDROME: 

 





Body makes too much stress hormone, Cortisol. Can be cured usually. Most common cause is R/T glucocorticoids (steroids, Prednisone). Symptoms as noted:  Thin arm and legs, osteoporosis, thin skin, bruise easily.

Labs: 24h urine for cortisol, Dexamethasone suppression test….

FRACTURE FROM OSTEOPOROSIS: 

Osteoporosis: Condition that causes weakening of bones.  “Brittle bone disease.”  Increases risk of breaking bones.  Diagnostics: 





Bone density testing.

Prevention of simple injuries and falls is critical.

FRACTURE FROM PAGET DISEASE: 







Chronic bone disorder, characterized by disorder of normal bone remodeling process. Often has no symptoms, but can cause joint and bone pain, headaches, hearing loss, bowing of limbs or curvature of spine. Effect older adults more commonly. Diagnostics: 

X-rays, bone scan, blood test (serum Alkaline Phosphatase)

FRAGILE PHOTO-AGED SKIN: Sun damaged skin.  Skin is thin, inelastic, dry, tears easily, uneven pigmentation.  Increased risk for skin cancer, injury.  Sun protection and avoiding smoking critical. 

POSTMORTEM LIVIDITY: Presents as bluish discoloration to dependent areas after death.  Can be confused with bruising/blunt force trauma. 

SENILE PURPURA: Easy skin bruising in older adults due to thinning and more fragile skin.  Usually begin as darkpurple-red color then brown skin discoloration after bruise fades.  Most common on the forearms and backs of hands in older people. 

STEROID PURPURA: Purple-colored spots/patches on the skin and mucous membranes.  Occurs when small blood vessels leak under the skin. 

4-10mm in diameter  Larger than 1cm, ecchymosis 



Numerous causes including steroids.

FRICTION BURNS/BLISTERS, BURNS: 







May occur on the feet, extremities, etc. Burns classified as to degree:  First degree-Epidermis involve, redness noted  Second degree-Dermis involved (partial thickness)  Third degree: Deeper subcutaneous tissue (full thickness) Common causes: Hot water scalds, radiator contact, neglect (elder abuse situations) Burns concerning for elder abuse:  Scalds with or without splash marks  May not be able to struggle if functional issues  Stocking/glove distribution  Skin sparing in flexed surfaces  Patterned

SUBDURAL HEMATOMA R/T FALL OR COAGULOPATHY: 



 





Collection of blood outside the brain (in subdural space). Usually caused by severe head injury. Can be life-threatening. Diagnostics: Head CT, MRI. Patients on blood thinners and with bleeding disorders more likely to develop, even with relatively minor injury. Older adults at-risk.

VITAMIN C DEFICIENCY-SCURVY: 









Wolff, Johnson, & Suurmond (2005)

Acute or chronic disease of infancy, and middle and old age. Dietary deficiency of ascorbic acid (Vitamin C) May present as bone deformities similar to those in child abuse.

Characterized by: Anemia; hemorrhagic skin manifestations (ecchymosis, peri-follicular hemorrhage); hemorrhage into the periosteum and muscles; gum changes (loose teeth, bleeding gums). Usually can be differentiated from abuse by obtaining adequate hx.

LEUKEMIA: Presents as ecchymotic areas, contusions, death.  CBC, PT, PTT, and other labs as appropriate should be evaluated and correlated with the history and physical exam to assist with diagnosis.  Differentiation: Cytopenias. 

(IMMUNE) IDIOPATHIC THROMBOCYTOPENIC PURPURA (ITP):  Presents

as petechiae and purpura that develops over several days, progressing to major hemorrhage from mucosal sites, epistaxis, hematuria, menorrhagia and bleeding gums.  Is considered to be autoimmune in which platelets are destroyed faster than the bone marrow can produce them.  Differentiation: Decreased platelets.

CONDITIONS THAT MAY MIMIC ELDER ABUSE:  Burns

  



and Scalds: Contact dermatitis Phytophotoderm atitis Stevens-Johnson Syndrome from medications Toxic epidermal necrolysis

 Chemical

Restraint:  Iatrogenic polypharmacy or drug to drug interactions  Increased drug levels secondary to decreased renal (kidney) clearance

CONTACT DERMATITIS: 





Acute or chronic inflammatory reactions to substances coming in contact with skin.  Involves epidermis and dermis

Classified as:  Irritant (chemical):  Confined exposure area  Allergic (allergen):  Immune reaction  Tends to spread to surrounding skin. May present with itching, rash, redness, vesiculation, c/o pain, swelling…

Phytophotodermatitis: (AKA- Dermatitis Bullosa Striata, Plant Dermatitis, Weed Wacker Dermatitis)

Phototoxic reaction that occurs when the skin comes in contact with photo-sensitizer and then is exposed to radiation.  Often seen in people who handle furocoumarin containing products (plants): 



Queen Anne’s lace, parsnip, celery, lime, fig, dill, carrot and anise seed.

STEVENS-JOHNSON SYNDROME (SJS) AND TOXIC EPIDERMAL NECROLYSIS (TEN): 









Mucocutaneous druginduced or idiopathic reaction patterns.  Drugs leading cause. Characterized by skin tenderness, redness of skin and mucosa Progresses to extensive skin/mucosal epidermal necrosis and sloughing Course similar to patient with severe thermal burns. 30% mortality in older adults with TEN.

TEN:

Iatrogenic Polypharmacy or Drug to Drug Interactions: 

Polypharmacy: Use of four or more medications by a patient, usually adults over 65 years old. 

May precipitate hypo/hyperthermia.

Iatrogenic Polypharmacy: Illness caused by medication treatment.  Increased risk for adverse drug reactions, drugto-drug interactions, prescribing cascade. 

Iatrogenic Polypharmacy or Drug to Drug Interactions (cont.): 

Normal age-related changes may alter how meds are metabolized:  Liver metabolism, kidney function, nerve transmission or the functioning of bone marrow decrease with age.  Drug levels may be increased secondary to decreased renal (kidney) clearance

OTHER CONSIDERATIONSCHEMICAL RESTRAINT: 



 



In addition to improper restraint, chemicals may be improperly used. More commonly used in persons with agitation, dementia, combativeness.  Dementia patients have increased risk for abuse.  History of IPV, minorities, and those who experience prejudice at risk (Tronetti, 2014). Haldol commonly used. Meds may be found in patient that are not prescribed on postmortem toxicology. May also be undermedicated form of medical neglect.  Meds may be diverted in patients with appropriate doses but uncontrolled pain.

CONDITIONS THAT MAY MIMIC ELDER NEGLECT: 





   

Constipation from meds, hypercalcemia, dehydration Dehydration secondary to medications, normal aging changes (decreased thirst, renal water absorption, concentration of urine)  Diuretics  May also be due to intentional fluid withholding Diabetes mellitus (DM)  Poor wound healing  Poor compliance in a dependent patient is concerning for abuse/neglect Fecal impaction (predisposition with dehydration) Poor wound healing  DM, vascular issues Urinary tract infection (in women) Vaginitis

CONDITIONS THAT MAY MIMIC ELDER SEXUAL ASSAULT:  Behcet’s

Syndrome  Cystocele, uterine prolapse  Decreased anal sphincter function  Fixed drug eruption  Inflammatory bowel disease  Lichen sclerosus  Perineal excoriation from incontinence  Vaginal bleeding and excoriation from low estrogen  Vaginitis

BEHCET’S SYNDROME 

 



Triad of oral apthous stomatitis, ulcers of the external genitalia (10% of patients) and inflammatory disease of the structures of the eye (uveitis, iritis). Ulcers usually painless and heal within 7-14 days with scarring. Recurrence common. May be confused with SA due to lesions being confused with HSV and Syphilis.

CYSTOCELE-PROLASPE OF THE BLADDER:

UTERINE PROLAPSE:

FIXED DRUG ERUPTION: May occur with Tetracycline.  Lesion on penis mimicking sexual abuse or contact burn. 

CROHN’S DISEASE 

May present with vulvar lesions that appear as erythema, edema and ulceration before intestinal manifestations are apparent (Schroeder, 2000 as cited in Giardino et al, 2003).



Perianal lesions seen with Crohn’s (skin tags, fissures, thickened perianal skin, scarring, fistulas and abscesses) may be mistaken for sexual abuse, STDs.

LICHEN SCLEROSUS (LS): 

 

     

 

Chronic, inflammatory skin disease, typically involving the anogenital area that causes pruritus and soreness.  Hymen and vagina are not involved. Females affected more often than males. Hallmark features:  Ivory or white areas of hypopigmentation (and thinned skin) in a welldemarcated hourglass pattern.  Fine wrinkling of skin may be present, as well as bruising and blistering. High susceptibility of trauma and minor injuries. Can be confused with sexual abuse d/t hemorrhagic and ecchymotic areas. May cause atrophy of involved tissue. Cause unknown. Course waxes and wanes-may spontaneously resolve. “…Speculated that trauma, injury, infection and sexual abuse may act as a catalyst to the development of LS (Koebner phenomenon)” (Isaac et al, 2007, p. 484). Patients must be checked for squamous cell carcinoma. Treated with Glucocorticoid preparations for 6-8 weeks.

PERINEAL EXCORIATION FROM INCONTINENCE 





Involuntary loss of control of the bladder, bowels or both. Continuous exposure of skin to urine/feces = loss of barrier function and epithelial breakdown.  pH of skin usually slightly acidic (4.0-5.5), inhibits growth of bacteria.  When more alkaline, ideal for bacterial growth. Increases risk for pressure ulceration and bacteria (cited in Copson, 2006)

VAGINAL BLEEDING

AND EXCORIATION

FROM LOW ESTROGEN



In the postmenopausal women (12 months with no period and postmenopausal age*) , vaginal atrophy is the most common cause of postmenopausal bleeding (unscheduled bleeding after *). 



Usually treated with topical oestrogen.

Any postmenopausal bleeding must be evaluated promptly.

VULVOVAGINITIS: Inflammation of the vulva and vagina.  Common in older adults due to: 

  

Less prominent labia minora to protect the less thick structures of the vulva. Low estrogen. Neutral pH of the vagina, providing optimal situation for growth of bacteria (Jaquiery et al, 1999 as cited in Giardino et al, 2003).

CONDITIONS THAT MAY MIMIC ELDER STARVATION:  Anorexia

caused by mental illness  Inflammatory bowel disease  Malabsorption caused by hypothyroidism  Weight loss from diabetes mellitus (Collins, 2006 as cited in Hoover & Polson, 2014).

CONDITIONS THAT MAY MIMIC PHYSICAL ABUSE CULTURAL CONSIDERATIONS (FOLK MEDICINE): Coining, Cupping, Spoon Rubbing  Maquas  Moxibustion 

COINING (CAO GIO):  



Presents as ecchymotic “stripes” along the rib cage, back and chest bony prominences. Practiced in Southeast Asia and Vietnam.  Treatment of headache, fever, chills. Back or chest is massaged with Mentholated Oil.  Edge of coin is rubbed into the skin until petechiae or purpura appear.  Self-limiting usually (1-2 weeks), but hyper-pigmentation may persist.

CUPPING:  Russian-Presents

as circular ecchymotic

areas to the back.  Latin America (Ventosos)-Presents as circular first degree burns to the back, abdomen and chest  Practiced among Mexican & Eastern European immigrants.  Treatment to decrease pain & inflammation by bringing the offending agent to the surface. 

CUPPING (CONT.): 

Small amount of ETOH is placed in a cup and lit.  The cup is inverted and placed against the skin.  When the ETOH cools, a vacuum is created, leaving a circular-shaped ecchymotic lesion.

SPOON RUBBING (SPOONING (QUAT CHA)): 

   

 

Presents as ecchymotic lesions. Similar to coining. Practiced in China. Treatment for headache & fever. Rids the body of “bad winds causing illness.” Believed to improve health by increasing circulation and relieving inflammation within the soft tissue. Water or Normal Saline is applied to the forehead, neck, back, shoulder or chest.  Area(s) are then pinched or massaged until red.  A porcelain spoon is then used to scratch the reddened areas until ecchymotic. 

Pattern sometimes looks like a Christmas tree in appearance.

MAQUAS:  Presents

as small, deep burns at the site of disease.  Practice of Arabs, Druses, Russians, Oriental Jews and Bedouins.  Hot metal spits are used to produce burns near the region of disease or pain. 

Belief is that when pus oozes from the burn, the disease drains out.

MOXIBUSTION: 





Presents as partial, or full-thickness circular shaped burns. Practiced in Southeast Asia as a form of acupuncture. Moxa Herb is burned on the skin with a piece of yarn, incense or a cigarette near the area of pain. 

Believed to draw out the illness causing the pain.

CONTACT INFO: CRMH ED FNE Program 1906 Belleview Avenue Roanoke, VA 24014 E-mail: [email protected] Blackberry: (540) 521-0365 ED: (540) 981-7337

REFERENCES: Burgess, A. W., Hanrahan, N. P., & Baker, T. (2005). Forensic markers in elder female sexual abuse cases. Clin Geriatr Med, 21, 399-412. Chang. A. L. S., Wong, J. W., Endo, J. O., & Norman, R. A. (2013). Part II: Risk factors and cutaneous signs of elder mistreatment for the dermatologist. J AM ACAD Dermatol, 68(4), 533.e1-e10. Collins, K. A., & Presnell, S. E. (2007). Elder neglect and the pathophysiology of aging. Am J Forensic Medical Pathol, 28(2), 157-162. Collins, K. A. (2006). Elder maltreatment: A review. Arch Pathol Lab Med, 130, 1290-1296.

Collins, K. A., & Presnell, S. E. (2006). Elder homicide: A 20-year study. Am J Forensic Medical Pathol, 27(2),83-187. Copson, D. (2006). Management of tissue excoriation in older adults with urinary or faecal incontinence. Nursing Standard, 21, 57-66.

REFERENCES (CONT.): Danesh, M. J., & Chang, A. L. (2015). The role of the dermatologist in detecting elder abuse and neglect. J AM ACAD DERMATOL, 73(2), 285-293. Dermatology Information System. (2016). Stevens Johnson Syndrome. Retrieved May 12, 2016, from http://www.dermis.net/dermisroot/en/30254/diagnose.htm

Dernet Skin Disease Atlas. (2011). Skin disease: Fixed Drug eruption. Retrieved May 14, 2016, from http://www.dermnet.com/images/Fixed-DrugEruption/picture/12445?imgNumber=17 DeLiema, M., Homeier, D. C., Anglin, D., Li, D., & Wilber, K. H. (2016). The forensic lens: Bringing elder neglect into focus in the emergency department. Annals of Emergency Medicine, 1-6. Dong, X., Simon, M., Mendes de Leon, C., Fulmer, T., Beck, T., Hebert, L., et al. (2009). Elder self-neglect and abuse and mortality risk in community-dwelling population. JAMA, 302, 517-526.

REFERENCES (CONT.): Dong, X. (2005). Medical implications of elder abuse and neglect. Clin Geri Med, 21, 293313. Emedicine. (2016). Dermatologic manifestations of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Retrieved, May 14, 2016, from http://emedicine.medscape.com/article/1124127-overview Giardino, A. P., Datner, E. M., & Asher, J. B. (2003). Sexual assault: Victimization across the life span: A clinical guide. St. Louis: G. W. Medical Publishing, Inc. Gibbs, L. M. (2014). Understanding the medical markers of elder abuse and neglect. Clin Geriatr Med, 30, 687-712. Hoover, R. M., & Polson, M. (2014). Detecting elder abuse and neglect: Assessment and intervention. American Family Physician, 89(6), 453-460.

REFERENCES (CONT.): Lachs, M. S., & Pillemer, K. A. (2015). Elder abuse. The New England Journal of Medicine, 373(20), 1947-1956. Lachs, M. S., Williams, C., O’Brien, S., Hurst, L., Horwitz, R. (1996). Older adults: An 11 year longitudinal study of adult protective service use. Arch Intern Med, 156, 449-453. Leung, A. K. C. (2005). Ecchymosis from spoon scratching. Consultant, 45(2). LoFaso, V. M., & Rosen, T. (2014). Medical and laboratory indicators of elder abuse and neglect. Clin Geriatr Med, 30, 713-728. Mayo Clinic (2016). Types of dermatitis. Retrieved May 12, 2016, from (http://www.mayoclinic.org/diseases-conditions/dermatitiseczema/multimedia/dermatitis/sls-20076203

REFERENCES (CONT.): McCance, K. L., Huether, S. E. (1998). Pathophysiology: The biologic basis of disease in adults and children (3rd ed.). Philadelphia: Mosby. Mosby’s medical, nursing, and allied health dictionary (6th ed.). (2002). Philadelphia: Mosby.

Mosqueda, L. , Burnight, K., & Liao, S. (2005). The life cycle of bruises in older adults. J Am Geriatr Soc, 53(8), 1339-1343. Munot, S. & Lane, G. (2008). Modern management of postmenopausal bleeding. Trends in Urology Gynaecology & Sexual Health, 21(7), September/October 2008. Murphy, K., Waa, S., Jaffer, H., Sauter, A., & Chan, A. (2013). A literature review of findings in physical elder abuse. Canadian Association of Radiologists Journal, 64, 10-14. Olshaker, J. S., Jackson, M. C., Smock, W. S. (2001). Forensic emergency medicine. Philadelphia: Lippincott Williams & Wilkins.

REFERENCES (CONT.): Rosen, T., Hargarten, S., Flomenbaum, N. E., & Platts-Mills, T. T. (March 2016). Identifying elder abuse in the emergency department : Toward a multidisciplinary team-based approach. Annals of Emergency Medicine. Rosen, T., Bloemen, E. M., LoFaso, V., Clark, S., Reisig, C., Floemenbaum, N. E., Lachs, M. S. ( 2015). Mechanisms of injury and implements used in physical elder abuse: Preliminary findings from a pilot study of highly adjudicated cases. Annals of Emergency Medicine, 66(4), S155-156. Rosenberg, L., Sagi, A., Stahl, N., Greber, B., & Ben-Meir, P. (1988). Maqua (therapeutic burn) as an indicator of underlying disease. Plastic Reconstructive Surgery, 82(2), 277-80. Samaras, N., Chevalley, T., Samaras, D., & Gold, G. (2010). Older patients in the emergency department: A review. Annals of Emergency Medicine, 56(3), 2010.

REFERENCES (CONT.): Tronetti, P. (2014). Evaluating abuse in the patient with dementia. Clin Geriatr Med, 30, 825-838. Vaginal Surgery Urogynecology. (2012). Prolapse gallery. Retrieved, May 14, 2016, from http://vaginalsurgeryandurogynecologyinstitute.com/wpcontent/uploads/2012/05/DSC_0204-150x150.jpg Visionary Eyecare’s Blog: “The Eye Journal. (2016). Retrieved, May 14, 2016, from https://visionaryeyecare.wordpress.com/2008/10/01/one-cause-of-red-eyesubconjunctival-hemorrhage/

Wiglesworth, A., Raciela, A., Corona, M., et al. (2009). Bruising as a marker of elder physical abuse. J Am Geriatr Soc, 5, 1191-6.

REFERENCES (CONT.): Women’s Surgery Center. (n.d.). Pelvic organ prolapse. Retrieved, May 14, 2016, from http://www.gyndr.com/genital_prolapse_surgery.php Wolff, K., Johnson, R. A., & Suurmond, D. (2005). Fitzpatrick’s color atlas & synopsis of clinical dermatology (5th ed.). New York: McGraw Hill.

Young, L. M. (2014). Elder physical abuse. Clin Geriatr Med , 30, 761-768. Zyminski, C. E., Wiglesworth, A., Austin, R., Phillips, L., & Mosqueda, L. (2013). Injury patterns and causal mechanisms of bruising in physical elder abuse. Journal of Forensic Nursing, 9(2), 84-91.

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