ORIGINAL ARTICLE
Elder Neglect and the Pathophysiology of Aging
Kim A. Collins, MD, and S. Erin Presnell, MD
Abstract: Elder neglect, one of the 6 forms of elder maltreatment,
is difficult to diagnose and is underreported both in the scientific
literature and to law enforcement. Recognizing fatal neglect is even
more challenging especially with concurrent organic disease. Many
entities can mimic elder neglect, and many age-related changes can
result in pathology that may be confused with maltreatment. We
retrospectively reviewed all forensic cases of individuals age sixty-
five years and older which were referred for autopsy. Cases of fatal
neglect were analyzed as to age, sex, race, cause of death, location
of incident, perpetrator, victim-to-perpetrator relationship, and au-
topsy and ancillary findings. The cases studies totaled 8. The age
range was 74 to 94 years. Two were white, 6 black, one male, and
7 female. The causes of death were sepsis due to severe decubitus
ulcers and severe dehydration. Five cases occurred in the victim’s
home, and 3 occurred in an institution (nursing home/care facility).
In 5 cases, the perpetrators were family members. The pathophysi-
ology of aging with respect to elder maltreatment is reviewed.
Key Words: elder maltreatment, elder abuse, elder neglect,
geriatric, forensic, autopsy, dehydration, sepsis
(Am J Forensic Med Pathol 2007;28: 157–162)
E ach year, millions of elderly persons suffer as the result of
maltreatment.1 As the number of elders age 65 and older
increases, the number of elder maltreatment cases is expected
to rise.2,3 Elder maltreatment can be divided into 6 categories:
physical abuse, sexual abuse, neglect, psychologic abuse,
financial exploitation, and violation of rights.4 – 6 Elder ne-
glect is complex and sometimes fatal. The forensic patholo-
gist and investigator need to be familiar with the typical
victim, scenario, perpetrator, and significant autopsy findings.
The characteristic findings can be documented grossly, his-
tologically, and by a variety of ancillary studies such as
full-body radiographs, toxicology, microbiology, and chem-
istry. As important as documenting these findings is, so is the
understanding of certain pathophysiologic changes of aging
that can be mistaken for maltreatment.
Manuscript received September 6, 2005; accepted November 14, 2005.
From the Medical University of South Carolina, Charleston, South Carolina.
Reprints: Kim A. Collins, MD, Department of Pathology, Forensic Section,
Medical University of South Carolina, 165 Ashley Avenue, Charleston,
SC 29425. E-mail: collinsk@musc.edu.
Copyright © 2007 by Lippincott Williams & Wilkins
ISSN: 0195-7910/07/2802-0157
DOI: 10.1097/PAF.0b013e31805c93eb
The American Journal of Forensic Medicine and Pathology • Volume 28, Number 2, June 2007
MATERIALS AND METHODS
Twenty years of forensic files at the Medical University
of South Carolina were reviewed and cases of elder death
examined. An elder was defined as 65 years of age or greater.
Cases that documented elder neglect as the cause of the death
were further analyzed as to victim age, sex, race, cause of
death, manner of death, location of incident, perpetrator,
victim-to-perpetrator relationship, autopsy findings, and an-
cillary studies.
RESULTS
The total number of elder neglect cases examined
was 8. Complete autopsies were performed on all cases
(Table 1). The age range was 74 to 94 years. Seven were
women, and 1 was a man. The black:white ratio was 6:2.
The causes of death included sepsis due to severe decub-
itus ulcers (5 cases) and severe dehydration (3 cases).
Cachexia was documented in 7 cases. The one case without
cachexia was a small, thin woman (114 lbs), who was
usually cared for by her nieces, but over a 2-week period,
an institution cared for her.
Electrolyte analysis was documented in all cases: 6
postmortem and 2 premortem. In the 3 cases with dehydration
as the cause of death, vitreous chemistry ranges were as
follows: sodium ⫽ 164 –180 mmol/L, chloride ⫽ 133–186
mmol/L, and urea nitrogen ⫽ 76 –310 mg/dL. Tenting of the
skin, “stickiness” of the serosal surfaces, sunken orbits, and
hard feces/fecal impaction were identified. Postmortem blood
cultures were performed in 5 of the 8 cases and were positive
for Staphylococcus aureus, Enterococcus, Proteus penneri, P
mirabilis, and/or Pseudomonas aeruginosa. Postmortem cul-
tures of decubitus ulcers were reported in 3 of the cases and
corresponded with blood culture positivity for P penneri,
Pseudomonas aeruginosa, P mirabilis, and/or S aureus. Pre-
mortem blood cultures were performed in 2 cases, one of
which also had a premortem decubitus ulcer culture. The
premortem cultures were confirmed by postmortem cultures.
(Table 2).
Toxicology was not performed in 2 cases, due to the
extended hospital stay and the lack of admission blood.
The remaining 6 cases were negative in 3 cases, positive
for blood ethanol in 1 case (2.7 mg/dL, insignificant),
positive for subtherapeutic levels of phenytoin in the blood
in 1 case, and positive for oxycodone (100 ng/mL, thera-
peutic) and acetaminophen (15 ␮g/mL, therapeutic) in the
blood in 1 case.
Other medical findings included cachexia (weight
ranges 63–114 pounds), contractures (⫻2), dementia (Alz-
157
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Collins and Presnell

TABLE 1. Fatal Elder Neglect Cases

Victim: Age, Scene Postmortem
Race, Sex Weight/History COD MOD Location Investigation Perpetrator Culture* Toxicology Electrolytes Cx
74 BF 90 lbs Sepsis H Home None Grandson ⫹ None Premortem blood ⫹
Alzheimer Decubitus Na ⫽ 153 Blood
Cl ⫽ 108
UN ⫽ 141
87 BF 83 lbs Sepsis H Home None Granddaughter ⫹ None Premortem blood ⫹
Alzheimer Decubitus Na ⫽ 134 Blood
Seizures Cl ⫽ 97
UN ⫽ 22
90 WF 97 lbs Sepsis H Home Feces on patient and Son and ⫹ Ethanol Vitreous ⫹
Schizophrenia Decubitus bedding; poor daughter 2.7 mg/dL Na ⫽ 140 Blood
hygiene Cl ⫽ 90 Decubitus
UN ⫽ 56
87 BF 114 lbs Dehydration H Institution Assigned food not Staff None Negative Vitreous None
Dementia given to patient Na ⫽ 180
Cl ⫽ 186
UN ⫽ 76
74 BF 71 lbs Sepsis H Home Feces and urine on Husband ⫹ Phenytoin Vitreous ⫹
CVA Decubitus patient and bedding (subtherapeutic) Na ⫽ 153 Blood
Poor hygiene Cl ⫽ nd Lung
UN ⫽ nd Decubitus
85 WF 85 lbs Sepsis H Home Feces on floor, bed, Son ⫹ Oxycodone Vitreous ⫹
CVA Decubitus and clothing; Acetaminophen Na ⫽ 142 Blood
medication missing (therapeutic) Cl ⫽ 116 Lung
UN ⫽ 30 Decubitus
94 BF 63 lbs Dehydration N Institution Feces on patient and Staff None Negative Vitreous None
Renal failure bed; no bedding; Na ⫽ 165
no water Cl ⫽ 146
UN ⫽ 310
77 BM 85 lbs Dehydration, A Institution Body on floor Staff None Negative Vitreous None
SS trait fat emboli, Na ⫽ 164
CVA fractures Cl ⫽ 133
UN ⫽ nd
CVA indicates cerebrovascular accident; nd, not done.
*See Table 2.

© 2007 Lippincott Williams & Wilkins

The American Journal of Forensic Medicine and Pathology • Volume 28, Number 2, June 2007
The American Journal of Forensic Medicine and Pathology • Volume 28, Number 2, June 2007
TABLE 2. Microbiology Cultures
Case Premortem Postmortem
1 Blood ⫽ MRSA Blood ⫽ coagulase negative
Staphylococcus sp
2 Decubitus ⫽ MRSA Blood ⫽ MRSA,
Enterococcus
3 None Blood ⫽ Proteus penneri,
Clostridium, coagulase
negative Staphylococcus,
Corynebacterium
Decubitus ⫽ Proteus penneri,
P vulgari, E coli
4 None None
5 Blood ⫽ S aureus Blood ⫽ Pseudomonas
aeruginosa, coagulase
negative Staphylococcus
Decubitus ⫽ Pseudomonas
aeruginosa, Staphylococcus
aureus, coagulase negative
Staphylococcus
Proteus mirabilis
Lung ⫽ S aureus, coagulase
negative Staphylococcus
6 None Blood ⫽ Proteus mirabilis, E
coli, S aureus,
Streptococcus
Decubitus ⫽ S aureus,
Proteus mirabilis,
Enterococcus, mixed
Gram-negative bacilli,
Gram ⫹ cocci
Lung ⫽ Staphylococcus,
mixed Gram ⫹,
Streptococcus
7 None None
8 None None
MRSA indicates methicillin-resistant Staphylococcus aureus.
heimer disease ⫻2, cerebral infarction ⫻3), schizophrenia
(1), seizure history (1), meningioma (1), cystitis, vaginitis,
perineal excoriations, chronic rotator cuff tear, femur frac-
ture, and healing rib fracture.
The perpetrators were also analyzed. In 5 of the 8 cases,
the perpetrator was a relative of the victim. In 2 domestic
cases, the perpetrator was the grandchild (1 grandson, 1
granddaughter); in 1 case, the son and daughter were respon-
sible; in 1 case the son; and in 1 case the husband was the
perpetrator. A staff member working in an institution was the
perpetrator in 3 of the 8 cases. The locations of 5 incidents of
neglect occurred in the home, and 3 occurred in an institution
(nursing home or care facility).
The scene investigation was essential in deducing man-
ner of death and was available in 5 of the 8 cases. The
scenarios included feces in the bed/clothing and/or on the
floor, poor hygiene of immediate environment, lack of bed-
ding, and lack of running water. In one case, food left with
the institution staff was discovered not to have been provided
to the decedent; she was also dehydrated.
© 2007 Lippincott Williams & Wilkins
Elder Neglect
DISCUSSION
In 1992, the United States Congress enacted the Family
Violence Prevention and Services Act, which directed that a
study of the national incidence of abuse, neglect, and exploi-
tation of elderly persons be conducted.7 The National Elder
Abuse Incidence Study (NEAIS) was conducted. Neglect was
defined as the refusal or failure to fulfill any part of a person’s
obligation or duties to an elder.7 Neglect typically means the
refusal or failure to provide an elderly person with such life
necessities as food, water, clothing, shelter, personal hygiene,
medicine, comfort, personal safety, and other essentials as a
responsibility or agreement.7,8 With elder neglect cases,
47.6% of perpetrators were men. The large majority of
perpetrators was adult children (43.2%), and the second
largest group was the elder’s spouse (30.3%).7
Risk factors for abuse and neglect by family members
include psychopathology of family member, transgenera-
tional violence, economic dependency upon victim, isolation,
family member unengaged outside of the household, care-
giver stress, and living arrangement (perpetrator living with
victim, overcrowding).8 –12 Inherent factors in the elder that
appear to put him/her at risk include dementia, physical
impairment, provocative actions of the elder, guilt, and a fear
of retaliation.11,13,14
In the current study, the majority of the perpetrators
were family members, 3 men and 2 women. Most incidents
occurred in the home. Only 1 of the victims was a man, and
he was in an institution. Of the institutionalized victims, the
perpetrator was a staff member. This is not surprising, but it
does differ from physical and sexual abuse, where the perpe-
trator within an institution may be another resident or a
visitor.15 Previous reports have documented that the victim
gender of elder maltreatment in general is virtually evenly
divided between male and female. The predominance of
female neglect victims, as in the current study, has not been
reported.
Common physical findings in cases of elder neglect
consist of dehydration, malnutrition/starvation, poor hygiene,
untreated decubitus ulcers, contractures, overmedication/un-
dermedication, and neglect of existing medical condi-
tions.16 –19 The 8 cases examined not only documented poor
hygiene but also dehydration, cachexia, and severe decubitus
ulcers. Four cases had an element of medical neglect with
untreated fractures and subtherapeutic medication levels. Un-
safe living conditions seen in cases of elder neglect include
no air conditioning/heating, no food in house, no running
water, infestation, improper clothing, poor immediate envi-
ronmental hygiene, overuse of restraints, isolation/locked in a
room, and lack of provisions of dentures, glasses, hearing
aids, etc.1,7,8,20,21 The scene investigation is very important to
assess these latter factors. The scene provided valuable infor-
mation in 6 of the current 8 cases of fatal elder neglect; i.e. all
cases in which there was a scene investigation (Table 1).
The manner of death of all cases resulting from elder
maltreatment should be ruled homicide.22 However, since elder
maltreatment has not been fully recognized until recently, we see
that remote cases may be assigned a different manner. In the
159
Collins and Presnell The American Journal of Forensic Medicine and Pathology • Volume 28, Number 2, June 2007
current retrospective study, 1 case was designated natural and 1
as accident. Both of these were cases of dehydration and ca-
chexia in an institution. Today, these 2 cases, just as fatal child
neglect cases, would be ruled as homicide.
Pathophysiology of Aging
Age-related changes make the elder more prone to
injury and may result in physical findings that can be mis-
taken for elder abuse and neglect.3,23 The forensic investiga-
tor and pathologist must be aware of such changes to properly
assess inflicted neglect or trauma. The elder’s skin is atrophic,
with a 30%–50% decrease in epidermal proliferation.19,24
The dermal-epidermal junction is flattened, with decreased
interdigitations. The weakened supporting structure of blood
vessels and capillary fragility often leads to large ecchymoses
with little trauma. Senile purpura is seen in 10%–20% of
elders, especially on the extensor surfaces. Previous sun
damage, with a decrease in elasticity and a history of steroid
cream use, also results in skin fragility. Organic diseases such
as liver disease, acquired coagulopathies, and Cushing syn-
drome can also cause purpura. Elders can have an acquired
factor V and factor VIII deficiency due to spontaneous
antibodies.16 Platelets can also become dysfunctional. Drug-
induced thrombocytopenia has been associated with digoxin,
diuretic, barbiturates. Anticoagulant medications can cause
easy bleeding. Some other drugs such as cimetidine potenti-
ate the action of anticoagulants.19 Cerebral atrophy is seen in
elders, increasing the likelihood of a subdural hemorrhage
secondary to a fall. This is even more likely with acquired
coagulopathies and anticoagulant medications. On the other
end of the spectrum is the tendency for thrombosis. Throm-
bocytosis can be seen with iron deficiency, chronic inflam-
matory diseases, cancer, and infections. Elders can have an
acquired lupus anticoagulant, which can lead to thromboses.
Decubitus ulcers are a major problem in this age
group.17 With immobility, dementia, and incontinence, skin
ulcerations can occur in the most well-cared-for individuals.
Pressure from prolonged positioning of the already compro-
mised aged skin and subcutaneous tissue can cause significant
breakdown. Fecal and urinary incontinence accelerate skin
breakdown and provide a source for infection. Fecal incon-
tinence can be secondary to such entities as diabetes, anal
sphincter function, inflammatory bowel disease, and demen-
tia. Oftentimes, the elder is not incontinent but is immobile,
unable to go to the bathroom independently. Delay in wound
healing is noted especially in elders with diabetes mellitus
and peripheral vascular disease. Peripheral vascular stiffen-
ing, a natural change of aging, results in poor perfusion.
Elders have decreased cellular and humorally mediated im-
munity responses. The lymphocyte function is decreased, as
well as the level of cytokines and interleukins.25 The de-
creased perfusion, poorly responsive immune system, and
delayed wound healing prolong the period of ulceration and
increase the likelihood of sepsis.
Full-body radiographs should be performed in cases of
suspected elder neglect. Such radiographs will delineate frac-
tures, demineralization, and osteomyelitis.17 Elders have
muscle atrophy, decreased flexibility, and decreased bone
160
mass.26 Osteoporosis is common in elders, resulting in a
higher frequency of fractures.17,26 Vitamin D production is
decreased secondary to a decrease in the precursor 7-dehy-
drocholesterol.19 Proprioception and sensory input are im-
paired, resulting in more falls and a slower reaction to the fall.
Organic diseases such as arrhythmia, diabetic neuropathy,
orthostatic hypotension, and osteoarthritis make the elder
susceptible to falls.23 Previous strokes can result in an im-
paired gait, balance, and seizures.27 Fractures that are com-
monly seen in elders are hip (femoral neck), proximal hu-
merus, and vertebrae.28 Rib fractures secondary to a fall or
CPR are most commonly 4 –9.29 There is an overall loss of
subcutaneous fat, which can be confused for malnutrition/
starvation, predispose the elder to decubitus ulcers, and affect
the body temperature.17,26
Elders are prone to hypothermia and hyperthermia.30
Hypothermia may occur in this group due to the decrease in
the muscle mass and adipose tissue.31,32 The basal metabolic
rate is decreased, as well as shivering. There is a decreased
perception of temperature, including skin sensory percep-
tion.33 Vasoconstriction is decreased and the body’s overall
ability to regulate its temperature is impaired. Entities which
predispose an elder to hypothermia are diabetes mellitus,
hypothyroidism, malnutrition, polypharmacy, liver disease,
adrenal and pituitary insufficiency, and cerebrovascular dis-
ease.34 Medications such as benzodiazepines and narcotics
can impair thermoregulatory ability.35 Alcohol consumption
can cause vasodilation, which accelerates hypothermia.35
Hyperthermia can also occur in this group. As elders have
decreased vasoconstriction, they also have decreased vasodi-
lation. A major contributor to this is peripheral vascular
disease. Furthermore, cardiac output is decreased, so less heat
is lost.30 The sweat response is decreased, promoting a rise in
the core body temperature. As above, benzodiazepines can
also cause hyperthermia as they impair thermoregulatory
ability.35 If an elder is on diuretics and possibly has decreased
thirst sensation, volume depletion can result, which can
produce dehydration with hyperthermia.30
The overall cardiac output decreases with age, affecting
the physiology of many organ systems.26,30,36 A noticeable
effect includes decreased blood flow to the kidneys. The
glomerular filtration rate is decreased, and water absorption is
impaired. Dehydration can result from decreased water ab-
sorption from the kidneys, decreased urine concentration
ability (more water lost), decreased thirst sensation, and the
use of diuretics.30 We can see fecal impaction with dehydra-
tion secondary to decreased peristalsis, or a combination of
the 2. Overall, the kidneys have a decreased ability to elim-
inate waste, and with this we see a decrease in creatinine
clearance. This can have a detrimental effect on the elimina-
tion of toxins and drugs.
Gastric secretions and intestinal enzymes are decreased
in the elder. This results in decreased absorption of nutrients
such as vitamin B12, folate, and iron. Peristalsis is decreased
and constipation is not uncommon. Forty percent to 60% of
nursing home residents have been reported to have dyspha-
gia.37 Many elders have xerostomia (dry mouth) and tem-
© 2007 Lippincott Williams & Wilkins
The American Journal of Forensic Medicine and Pathology • Volume 28, Number 2, June 2007
poromandibular joint dysfunction, both preventing proper
chewing and swallowing. Compounding this, many elders are
edentulous. Malnutrition is a concern of the geriatric age
group.32 Elders have a decreased sense of taste, and up to
50% have a decreased sense of smell.19 Many medications
can also disrupt taste. Various infections with inflammatory
cytokines can cause anorexia. Even if the individual con-
sumes proper nutrients, malabsorption can occur, resulting in
weight loss and cachexia. Malabsorption can be the result of
aging of the gastrointestinal system, diabetes mellitus, or
hypothyroidism.
In women, vaginal bleeding and excoriation may be
seen secondary to decreased estrogen. This finding can be
worrisome when differentiating sexual assault or poor hy-
giene.38 Decreased glycogen deposition causes an increased
pH and promotes infection. Even in noncatheterized individ-
uals, the prevalence of urinary tract infections is increased.
The pelvic structures and vaginal walls are weakened with
age, leading to cystocele and uterine prolapse. These 2
structures can become very erythematous, with excoriation
secondary to friction, and appear traumatized, especially with
postmortem drying. The pertinent endocrine and metabolic
changes associated with the geriatric population are acquired
diabetes mellitus, a decrease in estrogen, and hypothyroid-
ism. Diabetes can result in poor wound healing, increased rate
of infection, and neuropathy. Hypothyroidism is associated
with malabsorption.39 Decreased estrogen can result in vag-
inal atrophy, bone resorption, decreased skin collagen, blad-
der atrophy, and incontinence.
Very little research has been conducted on geriatric
pharmacokinetics.40 Overall, there is a decrease in hepatic
metabolism, as well as the renal clearance. Much of this is
believed to be secondary to organic diseases such as
alcoholism, as opposed to decreased enzymatic pathways.
A decrease in plasma cholinesterases has been documented,
especially in cases of pneumonia. Gastric alcohol dehydro-
genases have decreased activity, so more alcohol is absorbed
by the stomach (first pass). This results in a higher blood
alcohol concentration for amount consumed. Alcohol can
have a CNS effect, as well as coagulation and temperature
regulatory effects.
An impaired immune system predisposes the elder to
other infections besides those of the skin. In addition, an
increased susceptibility to develop pneumonia is due to de-
creased lung mechanics, decreased elastic recoil, decreased
chest wall compliance, decreased strength of the respiratory
muscles, decreased pulmonary reserve and PO2, and a de-
creased gag reflex resulting in a decreased ability to
cough.26,41 Aspiration is a common occurrence secondary to
this change in pulmonary physiology, dysphagia, and mental
pathology seen in this group.
Creating new forensic expertise in geriatrics, similar to
that in child abuse, would promote detection and accurate
classification of cause and manner of death. Certain elders are
typical victims just as certain caregivers are typical perpetra-
tors. However, even when the case history is initially lacking,
physical and laboratory findings should alert the forensic
© 2007 Lippincott Williams & Wilkins
Elder Neglect
pathologist and investigator to a situation of elder neglect.
The natural changes and pathophysiology of aging must be
understood so that elder neglect is not overcalled and so that
elder neglect is not viewed as “just age” and ignored. Like
fatal child neglect, fatal elder neglect is a homicide. Elders
often have many natural diseases; however, the cause of
death may not be due to their diseases but due to active or
passive neglect of a vulnerable individual by a caretaker.
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