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European Geriatric Medicine
https://doi.org/10.1007/s41999-021-00550-z
REVIEW
Types, characteristics andanatomic location ofphysical signs inelder
abuse: asystematic review
Awareness and recognition of injury patterns
MiriamE.vanHouten1,2,3 · LilianC.M.Vloet2,4· ThomasPelgrim5· UdoJ.L.Reijnders6· SiveraA.A.Berben2,4
Received: 18 April 2021 / Accepted: 28 July 2021
© The Author(s) 2021
Key summary points
Aim Identify types, characteristics and anatomic location of physical signs in elder abuse.
Findings Physical signs in elder abuse are most common bruises and anatomically predominantly located on the head, face/
maxillofacial area, neck, upper extremities and torso.
Message Increase knowledge on physical signs in elder abuse so as to enhance timely detection and intervention.
Abstract
Purpose Elder abuse is a worldwide problem with serious consequences for individuals and society. The recognition of elder
abuse is complex due to a lack of awareness and knowledge. In this systematic review, types, characteristics and anatomic
location of physical signs in elder abuse were identified.
Methods Databases of MEDLINE, COCHRANE, EMBASE and CINAHL were searched. The publication dates ranged
from March 2005 to July 2020. In addition to the electronic searches, the reference lists and citing of included articles were
hand-searched to identify additional relevant studies. The quality of descriptive and mixed-methods studies was assessed.
Results The most commonly described physical signs in elder abuse were bruises. The characteristics of physical signs can
be categorized into size, shape and distribution. Physical signs were anatomically predominantly located on the head, face/
maxillofacial area (including eyes, ears and dental area), neck, upper extremities and torso (especially posterior). Physical
signs related to sexual elder abuse were mostly located in the genital and perianal area and often accompanied by a signifi-
cant amount of injury to non-genital parts of the body, especially the area of the head, arms and medial aspect of the thigh.
Conclusions Most common types, characteristics and anatomic location of physical signs in elder abuse were identified.
To enhance (early) detection of physical signs in elder abuse, it is necessary to invest in (more) in-depth education and to
include expertise from a forensic physician or forensic nurse in multidisciplinary team consultations.
Keywords Bruises· Physical signs· Elder abuse· Distribution· Forensics
* Miriam E. van Houten
Miriam.vanhouten@radboudumc.nl
* Sivera A. A. Berben
Sivera.Berben@han.nl
1 Department ofGeriatrics, Radboud University Medical
Centre, PO Box9101, 6500HBNijmegen, TheNetherlands
2 Research Department ofEmergency andCritical Care,
Knowledge Centre ofSustainable Healthcare, School
ofHealth Studies, HAN University ofApplied Sciences, PO
Box6960, 6503GLNijmegen, TheNetherlands
3 Trompetter andPartners Social Medical Expertise,
Utrechtseweg 75, 3702AAZeist, TheNetherlands
4 Radboud Institute forHealth Sciences IQ Healthcare,
Radboud University Medical Centre, P.O. Box9101,
6500HBNijmegen, TheNetherlands
5 School ofHealth Studies, Knowledge Centre ofSustainable
Healthcare, HAN University ofApplied Sciences, PO
Box6960, 6503GLNijmegen, TheNetherlands
6 Department ofForensic Medicine, Amsterdam Public
Health Service, PO Box2200, 1000CEAmsterdam,
TheNetherlands
European Geriatric Medicine
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Background
Elder abuse is a worldwide problem with serious conse-
quences for individuals and society, due to increased mor-
bidity, mortality and use of healthcare resources, especially
emergency services [1–3]. The definition of elder abuse is
formulated by the World Health Organization (2017) as “a
single or repeated act, or lack of appropriate action, occur-
ring within any relationship where there is an expectation
of trust, which causes harm or distress to an older person”.
There are various forms of elder abuse: financial, physical,
psychological and sexual abuse. Elder abuse can also be the
result of intentional or unintentional neglect. Based on avail-
able evidence it is estimated that 15.7% of people of 60years
and older worldwide are subjected to abuse [4]. This preva-
lence rate is likely to be an underestimate, as many cases of
elder abuse are not reported. Furthermore, studies on preva-
lence rates in elder abuse often show heterogeneity due to
regional and cultural differences between countries or vary-
ing definitions of elder abuse (for example with regard to age
cutoff point) used. In the Netherlands, 1 in 20 people aged
65years and over living at home experience elder abuse at
some point in their lives, and 1 in 50 people aged 65years
and over living at home experience elder abuse on an annual
basis [5].
There is complexity in the recognition of elder abuse. The
level of awareness and knowledge on elder abuse in health-
care professionals is still poor and there is a strong need for
education and specific training on recognition [6, 7]. On the
other hand, older persons will not always report circum-
stances of abuse because of cognitive and/or speech impair-
ment [8]. But even if they are able, they will not always
report being a victim of elder abuse because of fear from
repercussions from the abuser, issues of shame or loyalty
[8, 9]. Interactions with healthcare professionals, such as
physicians and nurses in the hospital setting, present cru-
cial opportunities to recognize elder abuse and to intervene
or to refer to the appropriate authorities [8]. Also signs of
elder abuse are often detected in acute situations such as
admittance to the ED (emergency department). Professionals
in the ED may be the first healthcare professionals to have
contact with the older persons. A study from Dong etal. [10]
showed that older persons who experienced two or more
types of elder abuse also had significantly higher rates of ED
use. Also, they were less likely to hide signs of elder abuse
in acute situations such as admittance to the ED.
Different types of elder abuse, such as physical abuse,
sexual abuse and neglect, can cause physical injuries. The
detection and recognition of physical signs related to elder
abuse may be complicated because it is not always easy to
discriminate from signs of underlying diseases. For example,
age-related changes or certain medication can make the skin
more vulnerable to injury, which makes it difficult to assess
whether skin bruising is either of an accidental or of a non-
accidental nature. Furthermore, there are no known pathog-
nomonic physical signs of elder abuse described, unlike in
certain cases of child abuse [11–13].
In this systematic review, we aimed to identify the types
(e.g., bruises), characteristics (e.g., size, shape and distri-
bution) and anatomic location of physical signs in elder
abuse to increase the awareness and recognition on injury
(patterns) by clinical geriatricians and other healthcare
professionals.
Methods
Design
A systematic review of the literature was performed accord-
ing to the steps of the Cochrane Handbook for Systematic
Reviews of Interventions [14], and reported in concordance
with the Preferred Reporting Items for Systematic reviews
and Meta-Analyses (PRISMA) statement [15].
Search strategy
The databases of MEDLINE, COCHRANE, EMBASE
and CINAHL were searched. The publication dates ranged
from March 2005 to July 2020. In addition to the electronic
searches, the reference lists and citing of included articles
were hand-searched to identify additional relevant studies.
The search strategy was partly based on available MeSH
terms from the search strategy protocol of the Cochrane
review on Interventions for preventing abuse in the elderly
[16]. Furthermore the (modified) search strategy protocol
from the chapter on the recognition of physical signs related
to elder abuse from the Dutch guideline on suspected elder
abuse (NVKG 2018) was used [17]. The full search strategy
per database is provided in Supplementary Information Text
1.
Study selection procedure
All types of reviews, quantitative and qualitative study
designs were included, with the limitation of studies pub-
lished in the Dutch, German, French and English language.
The inclusion criteria were: studies containing a description
of types of physical signs (related to elder abuse) with regard
to their characteristics and/or anatomic location of physical
signs. Excluded were: conference proceedings, editorials, or
other personal communications and studies that focused on
the prevalence of elder abuse, or legislation and education
in elder abuse not related to physical injuries. Furthermore,
studies on suicide, homicide, histological examination, use
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of restraints from a professional perspective or self-neglect
of older persons were excluded. All articles were screened
on title and abstract by two independent reviewers (SB,
MVH). In case of doubt, a third reviewer (LV) was asked to
make a final decision. In addition, reference lists and citing
of included articles were screened (SB, MVH) and poten-
tially relevant new publications were screened in a similar
way (see Fig.1 for study selection process).
Quality assessment
To assess the quality of the descriptive studies, we used
the 14-criteria quantitative tool from Kmet etal. [18]. We
deleted three criteria from the tool (criteria five, six, and
seven) regarding experimental research. The quality assess-
ment was performed by two independent researchers (SB,
MVH). To assess the quality of the mixed methods stud-
ies, a multimethod validated appraisal tool (MMAT ver-
sion 2018) was used [19]. The MMAT is the only tool that
includes specific criteria for mixed methods studies. With its
five different sets of criteria, the MMAT uses a combination
of individual component and mixed methods approaches.
Any disagreements in criteria ratings between reviewers
were discussed until a consensus was reached. No quality
assessment was performed for the narrative reviews and case
report studies. Instruments for the quality assessment of nar-
rative reviews have been developed, but were not used in this
systematic review because the results of narrative reviews
were mostly based on the primary studies that were already
included in this systematic review. The case report stud-
ies were mainly descriptions of individual patients where
a quality assessment was not deemed to be of added value.
Data extraction
Data were extracted by two independent researchers (SB,
MVH). Outcomes extracted were:
1. Types of physical signs in elder abuse.
2. Characteristics of physical signs in elder abuse.
3. Anatomic location of physical signs in elder abuse.
Fig. 1 Study selection process
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Table 1 Characteristics descriptive and case report studies (n = 11)
1st author
Year
Country
Design Aim Methods/data resources Setting Patients (n) age
Abath
2010
Brazil
Retrospective document study To describe the profile of physi-
cal abuse among older people
Forensic examination reports
(n = 1.027) of physical abuse
patients (2004—2007) were
analyzed for the following
variables:
-Characteristics of the event,
victim and aggressor
-The consequences of the physi-
cal abuse
Institute of Forensic Medicine Patients (n = 1.027) who were
victims of physical abuse and
underwent forensic examination
Sex: 59.2% male. The most
common age bracket was
60–69years. The proportion of
cases in this age bracket was
12.3 times that of the 80-and-
older group
Burgess
2005
USA
Retrospective document study To describe essential forensic
markers unique to older adult
victims of sexual abuse
Patient records of sexual abuse
cases (year not described)
submitted by experts were
analyzed for the following
variables:
-Victim/offender characteristics
and patterns of behavior
-Mechanisms/patterns of injury
-Forensic data
-Criminal justice process and
outcomes
-Comparison community-based
victims/nursing home victims
Home setting (53%)
Inpatient setting (44%)
Other place (3%)
Patients (n = 125) who were vic-
tims of sexual abuse
Sex: 100% female
Mean age: 78.48 ± ? Years (min
60; max 98)
Cham
2000
Singapore
Retrospective document study To describe the frequency and
characteristics of elder abuse
Elder abuse cases were
selected from elderly patients
(n = 62,826) visiting the
emergency department (ED)
(1994–1997)
From the elder abuse cases
the following variables were
analyzed:
-Characteristics of the victims/
perpetrators,
-Characteristics of injuries
-Event circumstances
-Involvement police/social
workers
Emergency department Patients (n = 17) who were victims
of elder abuse
Sex: 82.3% female Mean age:
74.6 ± ?years
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Table 1 (continued)
1st author
Year
Country
Design Aim Methods/data resources Setting Patients (n) age
Kavak
2019
Turkey
Retrospective document study To describe the radiologic imag-
ing characteristics of trauma-
related lesions in elder abuse
patients
Patient records and radiologi-
cal images of patients (n = 92)
visiting the emergency depart-
ment (ED) with fracture(s)
(2013–2018) who were estab-
lished to be abused (n = 92)
were analyzed for the following
variables:
-Age, gender
-Reason for adm. to the hospital
-Presence/absence comorbid
disease(s)
-Bone fracture location and
number
-Characteristics of the fracture(s)
-Presence/absence soft-tissue
damage or old fracture(s)
-Mortality
Emergency department Patients (n = 92) with a diagnosis
of elder abuse and a minimum
one fracture in at least one bone
in radiologic imaging
Mean age 73.2 ± 5.87years
Rosen
2016
USA
Retrospective document study To describe patterns and cir-
cumstances surrounding elder
abuse-related and potentially
elder abuse-related injuries in
older adult ED patients
Elder Protective Service (EPS)
physical abuse cases (n = 111)
(between 1985 and 1992) were
matched to patient records of
emergency department (ED)
visits during a 5-year period
(1981–1994) before or after
the date of the verified physical
abuse and each ED visit was
evaluated
The following variables were
analyzed:
-Probability of injuries related to
elder abuse
-Characteristics victims/perpe-
trators
-Household items used to inflict
injuries
-Injury patterns
-Presence of suspicious cir-
cumstances surrounding the
ED visit or suspicious injury
patterns
Emergency department ED patients (n = 26) with abuse-
related injuries, 81% female,
age not described ED patients
(n = 57) with injuries not identi-
fied as due to abuse, 81% female,
age not described
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Table 1 (continued)
1st author
Year
Country
Design Aim Methods/data resources Setting Patients (n) age
Rosen
2020
USA
Prospective study with matched
case control group
To describe differences between
injury patterns associated with
physical elder abuse and those
associated with unintentional
falls
Elder abuse cases (successfully
prosecuted) from the King’s
County District Attorney’s
Office (n = 100) were retro-
spectively examined for the
following variables:
-The injuries
-The victim
-The abuser
-The circumstances surrounding
the physical abuse incident and
its detection
Patients aged 60years or older
who presented to the ED
after an unintentional fall
(n = 578) were prospectively
enrolled (2014–2018) andwere
examined for the following
variables:
-Demographics
-Health
-Functional status
-Circumstances surrounding the
fall injury
-The characteristics of the
injuries
Elder abuse cases: not mentioned
Prospective group: emergency
department
Patients (n = 78) with successfully
prosecuted elder abuse cases
with visible injuries (n = 264)
resulting from the abuse
Matched patients (n = 78) with
visible injuries (n = 217) after an
unintentional fall
case patients and controls had a
mean age of 71years ± 9years
Sex: 73% female
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Table 1 (continued)
1st author
Year
Country
Design Aim Methods/data resources Setting Patients (n) age
Wiglesworth
2009
USA
Prospective observational study To describe bruising as a marker
of physical elder abuse
Patients from APS (adult
protective services) (n = 407)
(2006–2008) who were physi-
cally abused were approached
to participate in the study
within 30days of the abuse
incident
The following variables were
measured:
-Age, sex, ethnicity, race
-functional status
-Medical conditions
-Cognitive status
-History of falls
-Bruise size and location
-Recall of cause
-Responses to Revised Conflicts
Tactics Scale and Elder Abuse
Inventory
A baseline comparison group
from a prospective documenta-
tion study of older persons with
accidental bruising (not related
to elder abuse) was added to
the study
Home or inpatient setting Patients from APS (n = 67) who
were victims of physical abuse,
n = 48 had bruises
Age: 77.5 ± 8.1
Sex: 32.2% male
Patients (n = 68) with accidental
bruising
Age: 88.5 ± 5.7
Sex: 27.9% male
Ziminski
2013
USA
Secondary data analysis Wig-
glesworth 2009
To describe mechanisms of
injury in association with
characteristics of bruising in
physical elder abuse
Data from patients from adult
protective services (APS)
(n = 67) (2006–2008) were
included and evaluated
The following variables were
collected:
-Demographics
-Number of falls
-Medical history/diagnoses and
medications
Furthermore characteristics of
bruises were analyzed and
CTS2 (Revised Conflict Tactics
Scale) items were used to
represent the mechanisms of
injury and the association with
bruising locations
Home or inpatient setting Patients from APS (n = 67) who
were victims of physical abuse,
n = 48 had bruises
Age: 77.5 ± 8.1
Sex: 32.2% Male
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Table 1 (continued)
1st author
Year
Country
Design Aim Methods/data resources Setting Patients (n) age
Speck
2014
USA
Case report series To describe cases of (possible)
sexual abuse
Nine cases are described to
show:
-Perpetrator schemes,
-Traumatic reactions from
victims
-Interventions to care for the
victims
Institutional setting
Domestic community setting
Patients (n = 9) Mean age ± SD
(sex):
Case 1: 84 (female) = no elder
abuse, urethral trauma after trau-
matic removal during reactions
to paranoid hallucinations
Case 2: 65 (female) = no elder
abuse, was sexual assault by
stranger and no formal caretaker
Case 3: 68 (male)
Case 4: 70 (female) = no elder
abuse, sexual assault by stranger
Case 5: 88 (female)
Case 6: 65 (female)
Case 7: 78 (female) = no elder
abuse, consenting sexual activity
Case 8: 72 (female) = no elder
abuse, fungal infection and
mental illness
Case 9: 70 (male) = no elder
abuse, sexual abuse by resident
Young
2014
USA
Case report study To describe cases and presenting
symptoms of physical elder
abuse
Four cases are described to show
variety of symptoms in physi-
cal elder abuse
Institutional setting
Domestic community setting
Patients (n = 4) Mean age ± SD
(sex):
Case 1: 90year (female)
Case 2: 75year (male)
Case 3: 91year (female)
Case 4: 82year (female)
Wong
2017
USA
Case report study To describe the imaging charac-
teristics in cases of elder abuse
Two cases are described to show
radiographic findings in elder
abuse
Primary care setting
Emergency department
Patients (n = 2)
Mean age ± SD (sex):
Case 1: 98year (female)
Case 2: 90 Year (female)
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Table 2 Characteristics review studies (n = 5)
1st author
Year
Country
Design Aim Databases Search strategy Inclusion criteria Included articles
Brown
2004
Country not described
Review Aim not described,
overview regarding
position of nurse prac-
tioners in the inter-
vention and detection
of elder abuse
Not described Not described Not described Not described
Clarysse
2018
Belgium
Review To describe visible
injuries of physical
abuse, sexual abuse,
and neglect
Not described Not described Not described Not described
Collins
2006
USA
Review To describe current
medical and psycho-
logical understanding
of elder maltreatment
Not described Not described Not described Not described
Murphy
2013
Canada
Review To describe risk factors
and signs of elder
abuse
1. PubMed
2. CINAHL
3. EMBASE
4. TRIP
Databases were
searched from 1975
to March 2012 using
the following words
and phrases: “physi-
cal elder abuse”,
“older adult abuse”,
“elder mistreatment”,
“geriatric abuse”,
“geriatric trauma”,
and “nonaccidental
geriatric injury” in
the titles of articles.
Additional papers
identified through
reference lists
Exclusion criteria: arti-
cles non-pertinent or
duplication on screen-
ing of abstracts
To summarize all the
findings from these
studies, physical inju-
ries were classified
according to anatomic
location
Description of the types
and distribution of
physical injuries in
elder abuse
9 articles:
1 case report
4 case series
2 case–control
studies
2 cross-sectional
descriptive
studies
Pearsall
2005
USA
Review To describe and analyze
forensic biomarkers
for elder abuse
Not described Not described Not described Not described
Data synthesis andpresentation
Due to the paucity of original studies, we analyzed and syn-
thesized all studies, by scrutinizing and categorizing data.
The case report data from the mixed methods studies were
considered as original data and were therefore analyzed as
case report studies. The primary outcomes were based on
descriptive studies. Additionally, information from other
study designs was added. First, studies were categorized
according to their design or publication form. Second, three
themes based on the taxonomy for visible intentional and
unintentional acute injuries by Rosen etal. [20] were modi-
fied for this study and used for classification of the data
extraction: (1) Types of physical signs. (2) Characteristics
of physical signs. (3) Anatomic location of physical signs.
The following anatomic locations were chosen to catego-
rize the physical signs:
1. Skull/brain/maxillofacial/dental/neck.
2. Chest/abdomen/back.
3. Extremities (upper/lower).
4. Pelvis/gluteal.
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Table 3 Characteristics: mixed methods studies (n = 6)
1st author
Year
Country
Design mixed methods Design Aim Databases Search strategy Inclusion criteria Included articles
Chang
2013
USA
Review and case reports Review To describe cutaneous
manifestations of elder
abuse
Not described Not described Not described Not
described
Danesh
2015
USA
Review and case reports Review To describe role of
dermatologists in
detecting elder abuse
and neglect
Not described Not described Not described Not described
Gibbs
2014
USA
Review and case reports Review To describe visible signs
of physical abuse,
sexual abuse, and
neglect
Not described Not described Not described Not
described
Rohringer
2020
Canada
Review and case reports Review To identify injury find-
ings specific to elder
abuse
1. MEDLINE
2. Reference lists of
selected articles were
also explored
Databases were searched
from 1995 to 2019
using the following
search terms:
Search terms included
were: “radiological
findings” or “radio-
graphic findings” or
“imaging” or “imaging
findings” or “diagnos-
tic imaging” or “medi-
cal imaging” or “CT”
or “MRI” or “X-ray”
and “elder abuse.” The
reference lists of the
selected articles were
also explored
English-language
articles relevant to the
characterization of
elder abuse
Not
described
Palmer
2013
USA
Review and case reports Review To describe risk fac-
tors, signs, reporting
requirements, and pre-
vention of elder abuse
Not described Not described Not described Not
described
Russo
2019
Italy
Review and case reports Review The describe role of
diagnostic imaging in
the detection of lesions
in domestic abuse in
elderly patients and
domestic abuse in
women
Not described Not described Not described Not
described
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Table 3 (continued)
1st author
Year
Country
Design mixed methods Design Aim Databases Search strategy Inclusion criteria Included articles
Chang
2013
USA
Review and case reports Case reports To demonstrate cutane-
ous manifestations of
elder abuse
Photo case reports Emergency department
and outpatient setting
Not described Case reports (n = 3)
Case 1: age/sex: not
described
Case 2: female, age not
described
Case 3: age/sex: not
described
other cases self-
neglect(n = 1) or no
elder abuse (n = 4) or
no proven elder abuse
(n = 2)
Danesh
2015
USA
Review and case reports Case reports To demonstrate visible
physical signs of elder
abuse
Photo case reports Not described Not described Case reports (n = 4)
Case 1: age/sex: not
described
Case 2: age/sex: not
described
Case 3: age/sex: not
described
Case 4: age/sex: not
described
Other cases: no elder
abuse (n = 4)
Gibbs
2014
USA
Review and case reports Case reports To describe and demon-
strate visible signs of
physical abuse, sexual
abuse, and neglect
Photo case reports
Case report(narrative)
Photos: not described
Narrativecase report:
community setting
Not described Photo case reports (n = 23)
of elder abuse (no age/
sex)
Narrative case
report:(n = 1) male, no
age
Rohringer 2020
Canada
Review and case reports Case reports To describe imaging
findings in elder abuse
Case report Not described Not described Patients (n = 2)
Mean age ± SD (sex):
Case 1: female, 63
Case 2: male, 70
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5. Extragenital in sexual elder abuse.
6. Miscellaneous.
Results
Review statistics
The initial search identified 5629 unique records, after the
selection procedure 24 studies were included (see Fig.1).
Study characteristics
The design of the included studies concerned eight descrip-
tive studies [13, 21–27], three case studies [28–30], five nar-
rative reviews [11, 31–34], six mixed methods studies [12,
35–39] and two books [40, 41]. See Tables1, 2, 3 and 4 for
characteristics studies.
Quality assessment
Most of the descriptive studies (n = 8) showed moderate to
good quality [13, 21, 24, 26, 27].
Most of the mixed methods studies (n = 6) showed low
quality [12, 35–37]. Despite the varying quality, all studies
were included in our analysis. See Tables5 and 6.
Outcomes: descriptive andcase report studies (see
Tables7 and8)
Types ofphysical signs
The most commonly described physical signs in elder abuse
were bruises [12, 13, 22, 23, 25–27, 29, 30, 35–37].
Characteristics ofphysical signs
Wiglesworth etal. [13] described that with regard to the size
of physical signs, bruises related to physical elder abuse are
often large, e.g., > 5cm wide at its widest point. Other stud-
ies described that with regard to the shape of physical signs,
bruises and injuries related to elder abuse can be body part
marked, e.g., the presence of thumb and finger marks (fin-
gertip bruising) or object marked, e.g., ligature bruising or
tramline bruising due to beating with a narrow shaped object
[12, 22, 35, 37]. Furthermore studies described that the dis-
tribution of physical signs in a stocking or glove distribution
(e.g., due to immersion of the extremities in hot water), the
presence of a cutaneous casal necklace (dermatitis around
the neck due to vitamin B3 deficiency in case of neglect),
and injuries in multiple stages of healing or multifocal frac-
tures to be caused by elder abuse [30, 36]. No description
Table 3 (continued)
1st author
Year
Country
Design mixed methods Design Aim Databases Search strategy Inclusion criteria Included articles
Palmer
2013
USA
Review and case reports Case reports To demonstrate visible
physical signs of elder
abuse
Photo case reports Not described Not described Photo case reports (n = 4)
of elder abuse
Case 1: age/sex: not
described
case 2: age: female, age
not described
Case 3: 70/sex not
described
Case 4: age/sex: not
described
other case no elder abuse
(n = 1)
Russo
2019
Italy
Review and case reports Case reports To demonstrate diagnos-
tic imaging of lesions
in domestic abuse in
elderly patients and
domestic abuse in
women
Photo case reports Not described Not described Photo case reports of elder
abuse (n = 3)
Case 1: male, 72
Case 2: male, 71
Case 3: male, 76
Other case: no elder abuse
European Geriatric Medicine
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of characteristics of physical signs were given in six out of
eight descriptive studies [21, 23–27], two out of nine case
report studies (primary case report studies) [28, 29], and two
out of six mixed methods studies [38, 39].
Anatomic location ofphysical signs
Anatomic locations of physical signs in elder abuse were
described to be predominantly on the head, face/maxil-
lofacial area (including eyes, ears and dental area), neck,
upper extremities and torso (especially posterior). Other
anatomic locations mentioned to be associated with elder
abuse included the lower extremities, abdomen, lumbar area
and gluteal/genital/rectal area, the latter location often men-
tioned as being associated with the presence of sexual elder
abuse or neglect (e.g., decubitus ulcers) [12, 13, 21–27, 29,
30, 35–39].
Some studies described physical signs due to elder abuse
to be specifically located on the left respectively right side
of the body [13, 24, 26, 27, 30, 38, 39]. Furthermore Rosen
etal. [26] described that physical abuse victims were more
likely to have visible injuries in the maxillofacial, dental
or neck area without the presence of injuries to the upper
or lower extremities. Also, certain anatomic locations of
bruises were described to be related to the mechanism of
injury. The odds that a person had head and neck bruises
were greater in case they were choked, punched and beaten
up than in persons who did not report being choked, punched
and beaten up. The odds of having bruises on the lateral/
anterior arm were greater when persons reported to be
grabbed compared to persons who did not report being
grabbed [27]. Physical signs related to sexual elder abuse
were mostly located in vestibular and vaginal tissues (pete-
chiae), the labia minora and majora (bruising), posterior
fourchette (bruising) and the perianal area (contusions).
Victims of sexual elder abuse were furthermore described
to have a significant amount of injury located at non-genital
parts of their body, especially to their head and arms and on
the medial aspect of the thigh [12, 22, 36]. Physical signs of
sexual elder abuse in males were not found. In the article of
Speck etal. 2014, only two cases of sexual abuse in males
were described. Only one case was defined as sexual elder
abuse, but in this case signs of physical injury were lack-
ing [28]. Physical signs related to neglect were described
as cutaneous lesions due to vitamin deficiency, poor oral
dentition, physical signs on the surface of the skin due to
untreated skin cancer or moisture, decubitus ulcers in the
sacrum, buttocks, thighs and stage I–III decubitus ulcers on
heels [36, 37].
Additional outcomes (see Table9)
Additional outcomes of elder abuse were diverse and
involved wounds and unexplainable injuries, combinations
of injuries, mechanism of injuries, sexual elder abuse and
neglect in victims. Additional characteristics of physical
signs were deep and/or foul-smelling necrotic aspects of
ulcers, bilateral or parallel and irregular injuries, multi-
ple and clustered injuries, circular bruising, splash marks
from hot water and traumatic/irregular patches of alopecia.
Although the color of bruises was stated not reliable for the
dating of bruises, bruises with differing colors may point at
recurrent abuse [12, 32, 33, 35, 37, 41]. Anatomic locations
of specific injuries in elder abuse were: a basilar skull frac-
ture due to elder abuse (raccoon sign or periorbital ecchy-
mosis) and bruising over the mastoid process (battle sign). In
(attempted) strangulation, the following physical signs were
described: abrasions on anterior neck and petechiae on neck,
head, face, eyes, ears, conjunctivae and buccal mucosa [37].
Additionally to the anatomic locations of physical signs, it
was mentioned that bruising to the ulnar side of the fore-
arms of victims of elder abuse was often combined with the
presence of a fracture of the distal ulnar diaphysis, and that
bruising to the posterior torso was often combined with rib
fractures [38]. Finally, injuries to palms and dorsal or plan-
tar soles of the feet were also mentioned as physical signs
of elder abuse. In victims of sexual elder abuse, additional
anatomic locations of physical signs were unexplained sexu-
ally transmitted diseases (located on genital area or skin or
oral area), pain or bleeding from the genital area, bruising
Table 4 Characteristics books (n = 2)
1st author
Year
Country
Design Aim Content
Baccino
2020
France
Book Not described The title of the chapter is “Imaging and Elderly abuse”
Described are:
1. Background of elder abuse: definitions, epidemiology, signs and diagnosis
2. Particularities of imaging in elderly
3. Some imaging findings in elder abuse
Dyer
2002
USA
Book Not described The title of the chapter is "The clinical and Medical Forensics of Elder Abuse
and Neglect". Described are several potential forensic markers of elder
abuse and neglect
European Geriatric Medicine
1 3
to the uvula or the palate and lacerations to inner lips and
buccal mucosa [32, 33, 35]. In case of neglect, dry mucous
membranes, sunken eyes or decreased skin turgor in dehy-
dration and poor general hygiene were described [12, 37].
Discussion
The most commonly described physical signs in elder abuse
were bruises. Characteristics of physical signs could be cate-
gorized into size, shape and distribution. Physical signs were
Table 5 Quality of descriptive studies (n = 8)
Criteria/ First author Abath
2010
Brasil
Burgess
2005
USA
Cham
2000
Singapore
Kavak
2019
Turkey
Rosen
2016
USA
Rosen
2020
USA
Wigles-
worth 2009
USA
Ziminski
2013
USA
Question / objective
sufficiently described?
Study design evident
and appropriate?
Method of subject
/comparison group
selection or source of
information/
input variables
described and
appropriate?
Subject (and
comparison group)
characteristics
sufficiently described?
Outcome and exposure
measure(s) well
defined and robust to
measurement /
misclassification bias?
means of assessment
reported?
Sample size
appropriate? N/AN/A N/A N/AN/A N/AN/A N/A
Analytic methods
described/justified and
appropriate?
Some estimate of
variance is reported for
the main results?
Controlled for
confounding? N/AN/A N/A N/AN/A N/AN/A N/A
Results reported in
sufficient detail?
Conclusions supported
by the results?
Summary score 0.55 0.72 0.77 1.0 0.77 1.0 1.0 1.0
Yes Partial No, N/A: not applicable; Total sum = (number of “yes” * 2) + (number of “partials” * 1); Total possible sum = 22 −
(number of “N/A” * 2); Summary score: total sum/total possible sum; please note: 22 instead of 28 total possible sum because of only 11 items
instead of 14 items
European Geriatric Medicine
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anatomically predominantly located on the head, face/max-
illofacial area (including eyes, ears and dental area), neck,
upper extremities and torso (especially posterior). Physical
signs related to sexual elder abuse were mostly located in
vestibular and vaginal tissues, the labia minora and majora,
posterior fourchette and the perianal area. Victims of sexual
elder abuse were furthermore described to have a significant
amount of injury located at non-genital parts of their body,
especially on their head and arms and the medial aspect of
the thigh. Unfortunately, with regard to the characteristics
and anatomical location of physical signs in sexual elder
abuse in older males, information was absent.
This is the first systematic review on the state-of-the-art
knowledge on physical signs in elder abuse where a quality
analysis of observational studies was performed and addi-
tional findings of other designs were included. Furthermore,
physical signs were described and classified along the lines
of the taxonomy instrument for visible intentional and unin-
tentional acute injuries based on the study by Rosen etal.
[20]. By identifying the types, characteristics and anatomic
location of physical signs in elder abuse, this review contrib-
utes to the awareness and recognition of elder abuse by clini-
cal geriatricians and other healthcare professionals. Detect-
ing specific injury patterns suggestive of elder abuse can
aid healthcare professionals in their physical examination
and strengthen the need for a head to toe examination. The
use of a taxonomy instrument for a structured and uniform
description of characteristics and location of physical signs
in elder abuse can help healthcare professionals to system-
atically assess physical signs, especially insituations where
it is not easy to discriminate from signs of other underlying
diseases. To move forward on the road to early detection and
awareness of physical and other signs of elder abuse, it is
necessary to invest in education. In contrast to pediatricians
educatedin the recognitionof and care for child abuse vic-
tims, education on the recognition of physical signs in elder
abuse (and other signs of elder abuse, e.g., in financial and
physiological abuse) is not yet common for clinical geriatri-
cians and other healthcare professionals (such as nurses) in
clinical care. Also, the sense of ownership and commitment
regarding the recognition and care of elder abuse victims
is not yet self-evident in geriatric healthcare professionals.
The authors of this review strongly recommend education on
this topic, not only for clinical geriatricians but for all other
healthcare professionals with a caseload of older patients.
Furthermore, to effectively deal with elder abuse, a system-
atic screening for a timely identification of signals, as well
as a systematic approach in case elder abuse is (suspected
to be) present, is necessary. With regard to an effective
screening on elder abuse, no single tool has yet been found
appropriate [42, 43]. In absence of an appropriate validated
tool for signalling elder abuse, the Dutch guideline on (sus-
pected) elder abuse [17] recommends that healthcare profes-
sionals working in the hospital setting should be aware of an
internal sense of alarm with regard to the (possible) presence
of elder abuse, by asking themselves a “gut feeling” question
in 70 + individuals that visit the hospital setting. Unfortu-
nately, effective screening on elder abuse is not enough. It is
equally important to have an adequate approach and follow-
up process in each hospital or nursing home, when cases
of elder abuse are suspected and/or present. Since 1 July
2013, it is mandatory for professionals in the Netherlands
to follow a mandatory reporting code in case of (suspected)
domestic violence and child abuse (source: Government of
the Netherlands (https:// www. gover nment. nl/ topics/ domes
tic- viole nce/ domes tic- viole nce- and- child- abuse- proto col).
In the Netherlands, elder abuse is categorized as a form of
domestic violence and thus in case of elder abuse the manda-
tory reporting code in case of (suspected) domestic violence
and child abuse is followed.Cases of elder abuse as a result
of abuse by healthcare professionals are primarily reported
to the healthcare inspectorate.
The reporting code offers a five-step plan detailing the
best course of action and helps healthcare professionals
Table 6 Quality of mixed methods studies (n = 6)
Criteria/first author Chang
2013
USA
Danesh
2015
USA
Gibbs
2014
USA
Rohringer
2020
Canada
Palmer
2013
USA
Russo
2019
Italy
Is there an adequate rationale for using a mixed methods design to
address the research question?
Can’t tell Can’t tell Can’t tell Yes Can’t tell Yes
Are the different components of the study effectively integrated to
answer the research question?
Yes Ye s Yes Yes Yes Ye s
Are the outputs of the integration of qualitative and quantitative compo-
nents adequately interpreted?
Yes Ye s Yes Yes Yes Ye s
Are divergences and inconsistencies between quantitative and qualita-
tive results adequately addressed?
No No No No No No
Do the different components of the study adhere to the quality criteria
of each tradition of the methods involved?
No No No Yes No No
European Geriatric Medicine
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Table 7 Results descriptive and
case report studies: types elder
abuse and physical signs
1st author
(Year)
Country
Types: elder abuse Types: physical signs
Descriptive studies
Abath
2010
Brazil
1. PA 1. Burns
Burgess
2005
USA
1. SA 1. Abrasions
2. Bruises
Cham
2000
Singapore
1. PA 1. Blunt trauma
2. Bruises
2. Contusions
3. Dehydration
4. Fracture
Kavak
2019
Turkey
1. PA
2. N
3. PsA
4. FA
1. Fractures
2. Soft tissue lesions
Rosen
2016
USA
1. PA 1. Bruises
2. Fracture
3. Hematoma (subdural)
4. Laceration
Rosen
2020
USA
1. PA 1. Abrasion
2. Bruises
3. Fractures
4. Laceration
5. Skin tear
Wiglesworth
2009
USA
1. PA 1. Bruises
Ziminski
2013
USA
1. PA 1. Bruises
Case report studies
Chang
2013
USA
1. PA 1. Abrasions
2. Bruises
3. Defensive injury
Danesh
2015
USA
1. PA
2. N
3. SA
1. Bruises
2. Burns
3. Contusions
4. Defensive injury
5. Signs of nutritional deficiency
Gibbs
2014
USA
1. PA
2. SN
3. SA
1. Abrasion
2. Blunt trauma
3. Bruises
4. Burn
5. Hematoma
6. Laceration
7. Moisture-associated.skin damage
8. Poor oral dentition
9. Pressure sore/ulcer (decubitus, pressure)
10. Untreated skin cancer
Palmer
2013
USA
1. PA
2. SN
3. SA
1. Bruises
2. Ligature marks
Rohringer
2020
Canada
1. PA 1. Contusion
2. Hematoma
3. Fracture
4. Soft tissue swelling
European Geriatric Medicine
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in and outside (clinical) geriatric care to decide whether
or not to report the situation to the Adult Protective Ser-
vices (APS). In addition, within each hospital or institu-
tional setting caring for older persons, it would be advis-
able to appointa case manager on domestic violence and
elder abuse, to coordinate and guide compliance with the
follow-up of the reporting code and to support and advise
the healthcare professional in the recognition and care for
victims of elder abuse. The installation of an additional Mul-
tidisciplinary Elder Abuse Team (MEAT), where cases of
elder abuse victims are (anonymously) discussed and course
of action is evaluated, could further enhance a multidisci-
plinary approach to elder abuse investigation. Participants
should at minimum include clinical geriatric and emergency
medicine experts (nurses and physicians), a case manager
on domestic violence and elder abuse, a social worker and
a representative of the regional Adult Protective Services.
With regard to the recognition of physical signs in elder
abuse, it would be advisory not only to include forensic
expertise from a forensic physician or a forensic trained
nurse in the multidisciplinary elder abuse team, but also to
incorporate them as a consultant in the acute setting. They
can help recognize and safeguard forensic evidence during
the assessment process. Finally, thorough reporting and
transfer to healthcare professionals during discharge/care
transition is essential in this process.
A key limitation of this systematic review is that the pri-
mary data studies had moderate methodological quality and
included only a limited number of studies with a (matched)
control group. Furthermore, the narrative reviews mainly
summarized the included observational descriptive studies.
However, with this review, a contribution and an incentive to
achieve higher methodological research quality in the field
of elder abuse have been made, as pitfalls in existing knowl-
edge on physical signs of elder abuse have been identified.
More research regarding for example pathognomic injuries
in elder abuse could eventually provide healthcare profes-
sionals with (more) practical knowledge on adequate and
timely recognition of physical signs in elder abuse.
Conclusions
• The most commonly described physical signs in elder
abuse are bruises.
• Older persons are more likely to have physical signs
of elder abuse located on the head, face/maxillofacial
area (including eyes, ears and dental area), neck, upper
extremities and torso (especially posterior).
• Physical signs related to sexual elder abuse are mostly
located in the genital and perianal area and are often
accompanied by a significant amount of injury to non-
genital parts of their body, especially to the area of the
head, arms and the medial aspect of the thigh.
• The characteristics and anatomical location of physical
signs in sexual elder abuse in males needs to be explored
in future research.
• Knowledge regarding the most common types, charac-
teristics and anatomic location of physical signs in elder
abuse is useful to increase the awareness and recognition
of elder abuse by clinical geriatricians and other health-
care professionals.
EA elder abuse, PA physical abuse, SA sexual abuse, N neglect, SN self-neglect, PsA psychological abuse,
FA financial abuse
Table 7 (continued) 1st author
(Year)
Country
Types: elder abuse Types: physical signs
Russo
2019
Italy
1. PA 1. Contusion
2. Fractures
Speck
2014
USA
1. SA 1. Petechiae
Young
2014
USA
1. PA
2. N
1. Bruises
2. Dislocation
3. Fractures
4. Ulcers
Wong
2017
USA
1. EA 1. Fractures
2. Bruises
3. Hematoma
4. Hemorrhage
5. Ecchymosis
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Table 8 Results descriptive and case report studies: characteristics of physical signs and anatomic location
1st author
Year
Country
Characteristics Anatomic location
skull/brain
Maxillofacial/dental/
neck
Chest/abdomen/back Extremities (upper/
lower)
Pelvis/gluteal Extra-genital (sexual abuse) Miscellaneous
Descriptive studies
Abath
2010
Brazil
1. Face: 13.7% of
victims
2. Skull/neck:6.0% of
victims
1. Chest/abdomen:
5.7% of victims
1. Upper limbs: 27.4%
of victims
2. Lower limb(s)/
pelvic girdle: 6.8% of
victims
1. Lower limb(s)/
pelvic girdle: 6.8% of
victims
1. Injury more than
one part of the
body: 40.4% of
victims
Burgess
2005
USA
1. Thumb/finger
marks
1. Vaginal trauma:
46.2% of victims
2. Bruising labia
minora: 37.8% of
victims
3. Bruising of
posterior four-
chette:37.2% of
victims
4. Bruising labia
majora: 31.1% of
victims other areas
includedclitoris,
fossa navicularis,
vestibule, hymen,
cervix, perineum,
anus, rectum
1. Injury head: 38% of victims
2. Injuries arms: 31%of victims
3. Injuries legs: 24% of victims
4. Injuries chest: 22% of victims
5. Injuries abdomen: 13% of victims
6. Injuries other locations: 20% of
victims
Cham
2000
Singapore
1. Injuries maxillo-
facial/head
1. Bruises chest
2. Contusions
(sexual)
1. Fracture radius/ulna
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Table 8 (continued)
1st author
Year
Country
Characteristics Anatomic location
skull/brain
Maxillofacial/dental/
neck
Chest/abdomen/back Extremities (upper/
lower)
Pelvis/gluteal Extra-genital (sexual abuse) Miscellaneous
Kavak
2019
Turkey
1. Fractures head and
neck:
30.4% of victims
(mostly temporal,
nasal and maxilla-
orbita fracture)
2. Soft tissue lesions
head and neck:
36% of victims
1. Fractures chest:
30.4% of victims
(mostly multiple
fractures of costae
and located in the
posterior segment)
2. Fractures lumbar /
pelvic region: 4.3%
of victims
1. Fractures upper
extremities: 37%
of victims (mostly
humerus and ulna)
2. Fractures lower
extremities:
26.1% of victims
(mostly tibia and
femur)
3. Soft tissue lesions
of upper (32%);
lower (40%)
extremities
4. Long bone frac-
tures: located in
distal end of bone
and diaphyseal bone
segment in 56.9%
and 53.8% of the
cases, respectively
5. 77.2% of the bone
fractures were non-
displaced fractures
and 12% of victims
had a concurrent
joint dislocation
1. Lesions were often
on the left side of
the body (54.3%)
2. Old fractures:
19.6% of victims
Rosen
2016
USA
1. Injuries on head,
face and neck, nota-
bly, fractures and
bruising maxillo-
facial/dental/neck
2. Bruising to eye/
orbit
3. Subdural hematoma
and corneal abrasion
4. Lacerations to skull/
brain
1. Bruises on breast
2. Fracture cervical
spine
3. Fractures ribs
4. Lacerations to
torso
1. Injuries and bruis-
ing/
dislocations on the
upper (45% of vis-
its)/lower extremities
(32% of visits)
2. Fractures tibia/
fibula/hip/femur
3. Lacerations to lower
extremity
1. Fracture pelvis
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Table 8 (continued)
1st author
Year
Country
Characteristics Anatomic location
skull/brain
Maxillofacial/dental/
neck
Chest/abdomen/back Extremities (upper/
lower)
Pelvis/gluteal Extra-genital (sexual abuse) Miscellaneous
Rosen
2020
USA
1. Maxillofacial/
dental/neck without
injuries to the upper
or lower extremities;
(more likely inju-
ries left cheek and
zygoma, or on
neck of ear then in
patients with unin-
tentional injuries)
Injuries chest/back/
abdomen
Upper extrem-
ity > lower extremity
Injuries to pelvis/
buttocks
Physical abuse vic-
tims were signifi-
cantly more likely
to have bruising and
injuries on the max-
illofacial, dental, or
neck region;
Abuse victims were
less likely to have
fractures or injuries
on the lower
extremities;
Injuries to the head
and neck without
injury to other
parts of the body
were much more
common in abuse
victims
Differences that
were not sig-
nificant between
case patients and
controls:
1. Injuries to the ulnar
and posterior aspect
of the forearm on
either or both sides
and to the left ulnar
and posterior aspect
of the forearm;
2. Injuries skull/brain
Wigles-
worth
2009
USA
1. Size
bruises > 5cm
(longest
dimension), no
bruising of 1cm
or less
1. Head (predominant
on face) and neck:
20.8% of victims
(p = 0.006)
1. Posterior torso:
14.6% of victims
(p = 0.02)
1. Lateral aspect right
arm: 25% of victims
(p = 0.008)
1. Burn injuries on the
back and buttocks
from scalding water
1. Physically abused
older adults knew
more often the
cause of their
bruises (43 (89.6%)
vs 16 (23.5%) of the
comparison group
European Geriatric Medicine
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Table 8 (continued)
1st author
Year
Country
Characteristics Anatomic location
skull/brain
Maxillofacial/dental/
neck
Chest/abdomen/back Extremities (upper/
lower)
Pelvis/gluteal Extra-genital (sexual abuse) Miscellaneous
Ziminski
2013
USA
ND 1. Head and neck:
14.9% of victims
2. Victims who
reported being
punched or hit were
signify-cantly more
likely to have bruises
on head and neck
(p = 0.001) and right
lateral upper arm
(p = 0.027)
3. Persons who
reported being
beaten up were
significantly more
likely to report
bruises on head and
neck (p = 0.001)
1. Posterior torso:
10.4% of victims
1. Lateral/anterior
arms: 34.3% of
victims
2. Persons who
reported being
grabbed were
significantly more
likely to have lateral/
anterior arm bruises
(left anterior upper
p = 0.003/lower ar m
p = 0.016)
1. Victims who
reported being
choked were
significantly more
likely to have
bruises on lumbar
region (p = 0.007),
head and nek
(p = 0.039) and left
anterior upper arm
(p = 0.004)
Case report studies
Chang
2013
USA
1. Superficial
abrasions and
dermal hemor-
rhage: beaten
narrow object
2. Stab wounds
1. Truncal injuries
through stab
wounds
2. Chest with super-
ficial abrasions and
dermal hemorrhage
1. Injury on the dorsal
surface of hand
(defensive injury)
Danesh
2015
USA
1. Casal necklace
due to vit B3
deficiency
2. Stocking distri-
bution injury
1. Injury on the back
of right hand (defen-
sive injury)
2. Burn injury in
stocking distribution
at the extremities
Perianal contusions
after sexual abuse
European Geriatric Medicine
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Table 8 (continued)
1st author
Year
Country
Characteristics Anatomic location
skull/brain
Maxillofacial/dental/
neck
Chest/abdomen/back Extremities (upper/
lower)
Pelvis/gluteal Extra-genital (sexual abuse) Miscellaneous
Gibbs
2014
USA
1. Distinct bruis-
ing pattern from
lying on bird
seed on a hard
floor
2. Pattern bruising
from a ligature
3. Bruising in a
tramline fashion
4. Burn from a
curling iron
1. Bruising of the ear,
called boxer ear
2. Poor oral dentition
3. Black eyes
1. Atypical bruising
of the chest in a
case of substanti-
ated abuse
2. Bruising across
the breast and
upper arm from
blunt trauma
1. Stage II heel ulcer 1. Moisture-associated
skin damage and
ulcers in the sacrum,
buttocks, and thighs
2. Stage I and II ulcers
on the buttocks and
stage II–III on the
lower back
3. Stage 3 sacral ulcer/
Sacral decubitus
ulcer
1. Case report author:
male end stage
dementia with
sepsis from stage 4
sacral ulcer due to
neglect
2. Blood tracking
inferior to eye. Point
of impact is seen
as yellow bruising
lateral to the eye
3. Untreated skin
cancer in a case of
neglect of an older
man with dementia
Palmer
2013
USA
1. Fingertip-pat-
terned bruising
2. Patterns injury
suggestive
implement use
1. Bruising medial
aspect thigh
2. Bruising on ear
1. Ligature mark due
to restraint on leg
Rohringer
2020
Canada
1. Subcutaneous
hematoma over
the midline of the
frontal bone
2. Soft tissue hema-
toma over the right
frontal bone
3. Soft tissue swelling
over the left orbit,
fracture of the
medial wall of the
left orbit, and com-
minuted nasal bone
fracture
4. Subcutaneous
hematoma over the
left side of the neck
5. Asymmetric left
mandibular and
parotid soft tissue
swelling
1. Central cord
contusion
2. Bilateral healed
rib fractures
1. Left humeral neck
fracture
European Geriatric Medicine
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Table 8 (continued)
1st author
Year
Country
Characteristics Anatomic location
skull/brain
Maxillofacial/dental/
neck
Chest/abdomen/back Extremities (upper/
lower)
Pelvis/gluteal Extra-genital (sexual abuse) Miscellaneous
Russo
2019
Italy
1. Bruising on the
posterior torso cor-
related to posterior
rib fractures
2. Pulmonary contu-
sion
3. Fracture at the
middle third of the
left clavicle and
multiple ipsilateral
rib fractures
1. Fracture diaphyseal
part of the right
humerus
Speck
2014
USA
1. Punctate petechia
on vestibular and
vaginal tissues
Young
2014
USA
1. Fractures of head
2. Bruises to the face
1. Fractures of cervi-
cal spine/trunk
1. Spiral fractures
of the large bones
of the limbs and
fractures with a rota-
tional component
2. Shoulder disloca-
tion of the nondomi-
nant arm
3. Decubitus ulcers
bilateral heels
Decubitus ulcer over
the coccyx, right
ischium
European Geriatric Medicine
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Table 8 (continued)
1st author
Year
Country
Characteristics Anatomic location
skull/brain
Maxillofacial/dental/
neck
Chest/abdomen/back Extremities (upper/
lower)
Pelvis/gluteal Extra-genital (sexual abuse) Miscellaneous
Wong
2017
USA
1. Injuries in
multiple stages
of healing,
2. Multifocal
fractures
1. Injuries maxillofa-
cial region
2. Bilateral periorbital
bruising, multiple
ecchymoses over
body and face
3. Bilateral nasal bone
fractures
4. Left frontal scalp
hematoma
5. Prior sub-arachnoid
hemorrhage
1. Multifocal
fractures of the
bilateral ribs or
specifically right
posterior ribs
1. Distal ulnar diaphy-
seal fracture/chronic
fracture deformity
of the distal ulnar
and distal radial
diaphysis
2. Injuries upper
extremities
3. Transverse fracture
through the proximal
humeral metadia-
physis
4. Age indeterminate
fracture deformity
of the right inferior
pubic ramus
5. Acute fractures of
the right clavicle
1. Acute fractures of
the pelvis
Injuries inconsist-
ent with reported
mechanism
European Geriatric Medicine
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Table 9 Results reviews and books: Types andcharacteristics of physical signs and anatomic location
1st author
Year
Country
Types EA Types physical signs Summary characteristics: physi-
cal signs
Summary anatomic location physical signs Miscellaneous
Reviews
Brown
2004
Country not
described
1. PA
2. SA
1. Abrasions
2. Bruises
3. Fractures
4. Lacerations
5. Contusion
6. Petechiae /ecchymosis
7. Bleeding
1. Fingertip bruising
2. Punch bruising
3. Strangulation signs
1. Fingertip bruising from restraint on neck, arms, and/
or legs
2. Punch bruising on face, breasts, chest, abdomen, and
extremities
3. Chest wall injuries: rib fractures
4. Fingertip bruising from sexual abuse on inner/outside
thighs
5. Genital injury (bruising or bleeding)
6. Fractures extremities (defense or fall)
7. Cervical spine injuries
8. Location signs in sexual assault (% victims): chest
wall injury (22%), head injury (38%), abdominal injury
(15%), injury arms (30%), bruising on legs (> 20%),
vaginal trauma (45%), anal trauma (17%), oral penetra-
tion (13%)
1. Document physical
injuries and signs using
acronym “TEARS":
Tears or lacerations and/or
tenderness; Ecchymosis;
Abrasions; Redness;
Swelling
2. Skin of elderly has a
slower healing rate
Chang
2013
USA
1. PA
2. N
3. SA
1. Abrasions
2. Alopecia (traumatic)
3. Bleeding
4. Burns
5. Bruises
6. Cutaneous signs nutritional
deficiency
7. Dermatitis
8. Dislocations
8. Erosions
9. Erythema
10. Fractures
11. Lacerations
12. Poor hair/nail care
13. Purpura or petechiae
14. Scars
15. Signs sexual transmitted disease
16. Ulcers (pressure)
1. Patterned shape or distribution
2. Various stages healing
3. Bilateral or parallel injuries
4. Irregular patches of alopecia
1. Cutaneous manifestations female sexual abuse can
involve extragenital and genital sites: (% victims)
-Genital: vagina (46%), labia minora (38%), posterior
fourchette (37%), and labia majora (31%)
-Extragenital: head (38% of all cases) and arms (31%),
oropharynx
and anorectal areas
2. Unexplained sexual transmitted diseases (genital or
skin or oral)
1. Sexual abuse signs: torn
or stained underwear,
difficulty walking or sit-
ting without clear reason,
or pain or bleeding from
the genital area
2. Nutritional deficiencies
from elder neglect can
lead to a variety of skin
manifestations
European Geriatric Medicine
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Table 9 (continued)
1st author
Year
Country
Types EA Types physical signs Summary characteristics: physi-
cal signs
Summary anatomic location physical signs Miscellaneous
Clarysse
2018
Belgium
1. PA
2. N
3. SA
1. Abrasions
2. Alopecia (traumatic)
3. Burns
4. Bruises
5. Cutaneous signs nutritional defi-
ciency/malnutrition
6. Dehydration
7. Fractures
8. Lacerations
9. Multiple ulcers (decubitus)
10. Purpura
11. Signs sexual transmitted disease
1. Patterned shape or distribution
2. Different healing stages of
lesions, e.g., healing by second-
ary
intention
3. Parallel injuries
4. “Tram lines”
5. Irregular patches of alopecia
6. Deep- and/or foul-smelling
necrotic ulcers
7. Stocking, glove distribution
8. Cigarette burns
1. Laceration located around the eye, nose, or mouth
2. Spiral fracture of long bones or in other sites than
wrists, vertebrae, and hips when free from alcohol/sub-
stance abuse
3. Fractures of the zygomatic ark, mandible, and maxilla
4. Ligature marks around wrists and ankles
5. Alopecia outside the vertex and frontotemporal area,
hemorrhages or hematomas present at the site of hair-
loss
6. Glossitis, heilitis and/or dermatitis due to nutritional
deficiencies
7. Fingertip-patterned abrasions and bruises located on
the inner thighs of the victim
8. Oral erosive ulcerations, bruises of the uvula, or the
palate in sexual abuse
1. The color of bruising
is not reliable for age
determination
2. Sudden pain or bleeding
of the anogenital area
and impaired walking of
elderly
Collins
2006
USA
1. PA
2. N
3. SA
1. Abrasions
2. Alopecia (traumatic)
3. Asphyxia signs
4. Bite marks
5. Burns
6. Contusions
7. Dehydration signs
7. Ecchymoses
8. Fractures
10. Poor hygiene signs
11. Malnutrition signs
12. Ulcers (decubitus) non-lumbar/
non-sacral areas
1. Contusions multiple and
clustered
2. Unusual alopecia pattern
3. Sexual abuse: injuries second-
ary to restraints
1. Contusions: Inner arms/thighs, palms/soles, scalp, ear
(pinna), mastoid area, buttocks, on various planes of the
body
2. Abrasions: axillary (restraints) wrist and ankles (liga-
tures)
3. Nasal bridge and temple injury (eyeglasses), periorbital
ecchymoses, oral injury
4. Decubitus ulcers in non-lumbar/sacral area, fracture not
hip/humerus/vertebra
5. Non-genital trauma in sexual abuse: hard and soft pal-
ate trauma
1. Untreated fracture/decu-
bitus ulcers
2. Non-genital trauma in
sexual abuse: signs of
asphyxia
Danesh
2015
USA
1. PA
2. N
3. SA
1. Alopecia (traumatic)
2. Bruises
3. Burns (immersion)
4. Contusions
5. Dehydration
6. Dermatitis
7. Lacerations
8. Malnutrition signs
9. Purpura
10. Ulcers (decubitus)
11. Signs sexual transmitted disease
12. Poor general and/or oral hygiene
1. Size > 5cm
2. Resembles implement used
3. Foul-smelling decubitus ulcers
4. Stocking/glove distribution
(immersion burns)
1. Injury located on face, right side of arm or torso
2. Decubitus ulcer outside of sacral or lumbar region
3. Extragenital manifestations of abuse
4. Genital bleeding
1. Torn or stained under-
wear
2. Difficulty walking with-
out clear reason
3. Pain in genital area
European Geriatric Medicine
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Table 9 (continued)
1st author
Year
Country
Types EA Types physical signs Summary characteristics: physi-
cal signs
Summary anatomic location physical signs Miscellaneous
Gibbs
2014
USA
1. PA
2. SN/N
3. SA
1. Abrasions
2. Avulsions
3. Bite marks
4. Bruises
5. Burns
6. Fractures
7. Poor hygiene signs
8. Rashes
9. Skin tears
10. Moisture-associated skin damage
11. Ulcers (pressure)
1. Bruising in older adults does
not always follow standard
color progression; one cannot
reliably predict the age of a
bruise by its color
2. Bruise size > 5cm
3. Multiple bruises of varying
ages
4. Incised wounds caused by a
sharp-edged object
5. Scalds from hot water with
(struggle) or without (immobile
pt) presence splash marks
6. Bilateral, or stocking and glove
injuries, skin sparing with
surrounding burn area or hot
objects leaving pattern
1. Subgaleal hematoma after traumatic hair pulling
2. Tracking in perineum after genital trauma
3. No accidental bruises are found on the neck, ears,
genitalia, buttocks, or soles
4. Bruising on lateral right arm, and to the head and neck
5. Injuries head and torso
6. Injuries upper extremities and maxillofacial regions,
torso
7. Bruising from sexual abuse located on labia
majora,labia minora, or posterior fourchette
8. Defensive stab wounds on the inner(volar) side of the
wrist or forearm
9. Lacerations and abrasions in the genital area
10. Head, neck, and face are the most common areas of
injury
11. Physical signs strangulation: patterned abrasions or
contusions of the anterior neck; hand marks may be the
victim’s
12. Physical signs strangulation: petechiae on the neck,
head, face, forehead, eyes, ears, conjunctivae, and buc-
cal mucosa
13. Signs of basilar skull fracture (raccoon eyes/battle
signs)
1. Hoarseness in strangula-
tion cases
2. Signs of strangulation:
difficulty swallowing,
dyspnea, and stridor
3. Signs of strangulation:
assuming a sniffing
position to assist with
breathing
4. Injuries from falls:
cranio-maxillofacial
injury, brain trauma,
upper and lower extrem-
ity injury, and thoracic
injury
5. Case report author: male
end stage dementia with
sepsis from stage 4 sacral
ulcer due to neglect
Murphy
2013
Canada
1. PA
2. SA
1. Abrasions
2. Bruises
3. Burns
4. Contusions
5. Fractures
6. Hemorrhages (subdural)
1. Mostly large bruising 1. Injury to the upper extremity
2. Maxillofacial and upper extremity injuries: upper
extremity injuries were mostly categorized as shoulder
and arm nonspecific injury; maxillofacial and head and
the neck injuries were mostly located periocular and
eyelid region
3. Subdural hemorrhages, subcutaneous hemorrhages
(head and neck region)
4. Preponderance of injury to the head and torso
5. Bruises on the face, posterior torso, and lateral right
arm
6. Blunt musculoskeletal trauma
7. Injuries to posterior torso and lower extremity, inner
thigh, or dorsal or plantar aspect foot
Of the 839 injuries in this review, the distribution by
anatomic region was as follows: upper extremity
(43.98%), maxillofacial and neck (22.88%), skull and
brain(12.28%), lower extremity (10.61%), and torso
(10.25%)
European Geriatric Medicine
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Table 9 (continued)
1st author
Year
Country
Types EA Types physical signs Summary characteristics: physi-
cal signs
Summary anatomic location physical signs Miscellaneous
Palmer
2013
USA
1. PA
2. SN/N
3. SA
1. Abrasions
2. Burns
3. Bruises
4. Lacerations
5. Decubitus ulcers
6. Traumatic alopecia
7. Purpura
8. Signs sexual transmitted disease
9. Poor hygiene signs
10.malnutrition
1. Patterns of injury and pat-
terned injury
2. Bruising: most seen lesions
3. Bruises larger than 5cm
4. Punches: shape of fist with
area of central clearing
5. Color of a bruise not indicative
of age
6. Patterns burns elder abuse are
similar to child abuse:
-immersion burn in a stocking
and glove distribution
-injuries resemble implement
7. Abrasions with patterns paral-
lel to the force that inflicted the
injury
8. Single or multiple patchy areas
of alopecia, with or without
hair breakage, outside normal
pattern, especially if with hem-
orrhage or hematoma
1. Bruises located on the face, side of right arm, or back
of torso
2. Bruising by punch on the face, breast, chest, abdomen,
or extremities
3. Laceration or abrasions to the eye, nose, or mouth
4. Lacerations by blunt force most commonly were skin is
closely opposed by bone
5. Abrasions or scars around the ankle, wrist, or axillae
from restraints
6. Bruising of the labia majora, labia minora, or posterior
fourchette
7. Signs genital trauma like: erythema, lacerations,
abrasions, and genital pain or tenderness and sexual
transmitted diseases
8. Fingertip-patterned bruising, and abrasions on the inner
thighs especially in combination with other signs of
elder abuse
9. Oral injury such as contusion or lacerations of the inner
lips, buccal mucosa, or edentulous ridges indicative
sexual abuse or force feeding
10. Signs neglect: dry mucous membranes, sunken eyes,
or decreased skin turgor in dehydration; untreated decu-
bitus ulcers; poor hygiene
Pearsall
2005
USA
1. PA
2. N
3. SA
1. Abrasions
2. Bruises
3. Burns
4. Dehydration
5. Excoriations
6. Fractures
7. Lacerations
8. Ulcera (decubitus)
9. Poor hygiene signs
10. Signs sexual transmitted disease
1. Bruise with the shape of
knuckles or fingers; parallel
discoloration marks a linear
cylindrical object
2. Bruise with central clearing
from fist punch
1. Fingertip bruising from restraint on neck. Arms, and
legs
2. Bruises from punches on breast. Chest. Abdomen, and
extremities
3. Bruising to the inner thigh in sexual abuse
4. Reddened, ecchymosed, itching or painful genital area
in sexual abuse
5. Suggestive sexual abuse: oral venereal lesions, bruising
of the uvula or palate, new diagnosis sexual transmitted
disease
1. Signs of difficulty sitting
or walking, bloody or
stained undergarment in
sexual abuse
European Geriatric Medicine
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Table 9 (continued)
1st author
Year
Country
Types EA Types physical signs Summary characteristics: physi-
cal signs
Summary anatomic location physical signs Miscellaneous
Rohringer
2020
Canada
1. PA 1. Bruises
2. Dislocation
3. Fractures
4. Hematomas
1. study 1: percentage injuries to: upper extremi-
ties (43.98%), maxillofacial, dental and neck region
(22.88%), the skull and brain (12.28%), the lower
extremities (10.61%) and the torso (10.25%)
2. Study 2: percentage injuries to: upper extremities
(45%), followed by head and neck injuries (42%), and
lower extremities (32%)
3. Injured areas: head and neck, followed by chest, breasts
and abdomen
4. Internal injury pelvis, bladder and ureter
5. Fall-related injuries in association with abuse: bruises
on the breast, internal injuries, and upper extremity
dislocations
6. Anterior sternal dislocations, ectopia lentis and
depressed skull fractures
7. Injuries to head and torso
8. Visible bruising on upper extremities
9. Bruising location most common: lateral/anterior arms
(34.3%), followed by the head and neck (14.9%) and the
posterior torso
10. Odds lateral/anterior arm bruises 8 × times greater
when grabbed; odds head/neck bruises greater when
choked or beaten
11. Posterior torso bruising and ulnar forearm bruising
12. Injuries to the neck and left face
13. Multiple (misaligned) healed fractures
14. Injuries upper extremities and maxillofacial region
15. Bruising on the posterior torso in association with
posterior rib fractures, and bruising on the ulnar forearm
in association with distal ulnar diaphysis fractures
16. Anterior sternoclavicular dislocations
17. Upper rib fractures
European Geriatric Medicine
1 3
Table 9 (continued)
1st author
Year
Country
Types EA Types physical signs Summary characteristics: physi-
cal signs
Summary anatomic location physical signs Miscellaneous
Russo
2019
Italy
1. PA 1. Bruises
2. Fractures
1. Restraint marks 1. Bruising of the ulnar forearm from defense measures
2. Fracture of the distal ulnar diaphysis
3. Contusions and abrasions to the axilla and inner aspects
of the arms
4. Bruising on the lateral aspect of the arm
5. Injuries to posterior torso and lower extremity, inner
thigh, or dorsal or plantar aspect of the foot
6. Injuries in upper extremities
7. Injuries to the brain, head, and neck
8. Injuries in multiple stages of healing, particularly
in maxillofacial region and upper extremities; injury
patterns uncommon in accidental injury, such as ulnar
diaphysis fracture
1. Injuries inconsistent
with reported mechanism
Books
Baccino
2020
France
1. PA
2. N
1. Burns
2. Cutaneous ecchymosis
3. Bruises
4. Dehydration
5. Hematomas
6. Scars
7. (poor) (oral) hygiene signs
1. Bruising on the back and lateral aspects of forearms
and wrists
2. Trauma to temporal area, eyes and nose, breast, inner
aspect of arm skin
3. Injuries to upper limbs (43.98%) > maxillofacial
region, teeth and neck (22.88%) > skull and brain
(12.28%) > lower limbs (10.61%) > tr unk (10.25%)
4. Subdural hematoma, possible shaken granny syndrome
exists
1. An injury, which does
not appear to match with
the proposed mechanism
2. Skin lesions of differ-
ent colors suggesting
repeated trauma
European Geriatric Medicine
1 3
Table 9 (continued)
1st author
Year
Country
Types EA Types physical signs Summary characteristics: physi-
cal signs
Summary anatomic location physical signs Miscellaneous
Dyer
2003
USA
1. PA
2. N
3. SA
1. Abrasions
2. Bruises
3. Burns
4. Dehydration
5. Fractures
6. Lacerations
7. Malnutrition signs
8. (poor) hygiene signs
9. Signs sexual transmitted disease
10. Ulcera (decubitus)
1. Bruises can retain shape of
knuckles or fingers; parallel
marks, called tramline bruising,
indicate injury from stick
2. Color of bruise unhelpfull for
dating, but reddish blue, blue
or purplish bruises seem more
recent as opposed to bluish
green, greenish yellow, and
brown bruises
3. Multiple bruises in various
stages of healing
4. Foul-smelling or necrotic ulcer
5. Large skin tears or excessive
scarring from more serious
lacerations without adequate
explanation
6. Circular bruising, especially
bilaterally from forcibly lifting
7. Parallel lines caused by impact
by a rounded or cylindrical
object or an unusual pattern
1. Injury to face and neck, the chest wall, the abdomen,
and the buttocks
2. Intentional injury to head and internal injuries
3. Bruising on the palms and soles
4. Fractures of the head, spine, and trunk are more likely
to be assault injuries than limb fractures, sprains or
strains, or musculoskeletal injuries
5. Scars or wrist wounds of decubitus due to restraints
6. Oral venereal lesions
7. Bruising of the uvula and bruising of the palate and
the junction of the hard palate may indicate forced oral
copulation
8. Bruising, inflammation, tenderness, abrasions, or
trauma of anogenital area
9. Extragenital signs sexual abuse: bruising abdomen
10. Injuries suggestive of defensive maneuvering, such as
on the back of the arms and hands, and injuries related
to grasping, squeezing, or forcible restraint
EA elder abuse, PA physical abuse, SA sexual abuse, N neglect, S N self-neglect, PsA psychological abuse, FA financial abuse, ND not described
European Geriatric Medicine
1 3
• There is a need for education on physical signs in elder
abuse; furthermore, this topic should be included in
clinical curricula at different levels (i.e., pre- and post-
qualification): not onlyin bachelor and master programs
for professionals such as clinical geriatricians and emer-
gency physicians, but also for nursing and other health-
care professionals.
Supplementary Information The online version contains supplemen-
tary material available at https:// doi. org/ 10. 1007/ s41999- 021- 00550-z.
Author contributions Study concept and design: MVH, SB, LV; acqui-
sition of subjects and/or data: MVH and SB; analysis and interpretation
of data: MVH, SB and UR; preparation of manuscript: SB, LV, MVH
and UR.
Funding Sponsor role, related paper presentations, preprints: no.
Availability of data and material In line with the nature of the sys-
tematic review, original research papers included in the article were
provided with references.
Code availability Not applicable for the research design.
Declarations
Conflict of interest On behalf of all authors, the corresponding author
states that there is no conflict of interest. The authors have no relevant
financial or non-financial interests to disclose. The authors have no
conflicts of interest to declare that are relevant to the content of this
article. All authors certify that they have no affiliations with or involve-
ment in any organization or entity with any financial interest or non-
financial interest in the subject matter or materials discussed in this
manuscript. The authors have no financial or proprietary interests in
any material discussed in this article.
Ethics approval Not applicable.
Consent to participate: Not applicable.
Consent for publication: Not applicable.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
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the article's Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
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