Section 5 -

Investigating Sudden, Unexpected Death in the Elderly Gregory G. Davis 1515 Sixth Avenue South, Room 611 Birmingham, Alabama 35233-1601, U.S.A.

Introduction Forensic pathology is concerned with the investigation of sudden, unexpected deaths, because sudden, unexpected deaths serve as a marker for possible foul play. In the elderly, however, what constitutes a sudden and unexpected death is less clear, and thus in the elderly this paradigm for finding suspicious deaths works poorly. The death of an elderly individual may lead to a call for a forensic examination for several reasons, including: 1) suspicion of foul play, 2) suspicion of abuse or neglect, 3) distress of family caregivers, or 4) potential liability action against a healthcare facility or long-term care facility. Even when the suspicions of foul play seem ill founded to the pathologist, such cases may merit a forensic investigation in order to establish the medical facts in the presence of allegations of wrong doing. Knowledge of age-related changes in physiology and presentation will help a pathologist determine the cause of death of an elderly individual accurately. Clinical Features of Aging and Dementia The changes that occur to the human body are most obvious in infants and children, but change continues to occur throughout life. A common physiological change intrinsic to aging is loss of reserve, but loss is not invariable, nor does loss of reserve necessarily mean loss of function. In some cases various interrelated physiological processes rearrange dwindling reserves to maintain the proper physiological output, making the changes of aging less severe than they are commonly perceived to be. Physiological Changes of Aging by Organ System Cardiac System In the absence of intrinsic cardiac disease, e.g., coronary artery disease, hypertensive heart disease, etc., cardiac output at rest in an 80 year old individual is unchanged from that of individuals 20 years of age. This is not to say the changes do not occur to the heart with age. The left ventricular mass increases, the heart rate decreases (by about 10%), the stroke volume increases (by about 10%), the end diastolic volume increases (by about 10%), and the compliance of the heart and of the arteries decreases as the elasticity diminishes. The cumulative effect of all these changes, however, is that the cardiac output remains unchanged. [1] The elderly do differ from younger individuals in their perception of the symptoms of heart disease. Individuals over the age of 75 years experience less chest pain and diaphoresis during a myocardial infarction than do those individuals younger than 75 years of age. Consequently, the sudden onset of dyspnea, which remains unchanged, is often the main symptom of myocardial infarction in the elderly. Those older than 75 years of age are also more likely to present with syncope, stroke, weakness, palpitations, agitation, or confusion induced by myocardial infarction than are younger individuals. Myocardial infarction is silent in about 10% of the elderly victims of infarction, and infarction occurs more often during sleep or rest, accounting for decedents found dead in bed. [2] Pulmonary System As with the heart, the lungs of non-smokers undergo many shifts in various functional components with aging, but the sum of the shifts is that the total lung volume remains essentially unchanged. Lung function is diminished by only about 10% from the ages of 25 years to 75 years. Pulmonary dysfunction in the elderly is not related to age per se, but rather to the cumulative effects of asthma and cigarette smoking. [3] Being older than 65 years of age remains the major risk factor for death from community acquired pneumonia, and cardinal findings, such as productive cough, chest pain, and fever, are often less pronounced in the elderly. Radiographic findings of pneumonia may be obscured by non-infectious changes in the elderly. Only 10-15% of blood cultures in elders with pneumonia will grow organisms. Streptococcus pneumoniae remains the most common etiologic organism, but the elderly are prone to develop pneumonia due to gram negative bacilli (especially Klebsiella pneumoniae and Eschericia coli) and to pneumonia caused by Haemophilus influenzae. [4] The incidence of nosocomial pneumonia in hospitals is similar to that in long term care facilities such as nursing homes, i.e., roughly three times the incidence rate in the community. Nosocomial pneumonia is twice as likely to cause death as is a community acquired pneumonia. Factors that make the long term care resident more susceptible to pneumonia are poorer health, malnutrition, and aspiration. Chronic indwelling lines, such as a nasogastric tube or Foley catheter, greatly increase the risk of developing pneumonia. The organisms responsible for nosocomial pneumonia are frequently gram negative bacilli or H. influenzae. [4] Central Nervous System Dementia Dementia is manifest by impairment of memory and of at least one other cognitive domain such as abstract thinking, judgment, language, or visual-spatial abilities. [5] Loss of abstract thinking, judgment, or visual-spatial abilities increases the risk of death due to some violent (as opposed to natural) cause. Moreover, impulsive, aggressive behavior occurs in all stages of dementia, especially in the middle or later stages. The aggression can be verbal or physical. [6] Demented patients with visual agnosias may fail to recognize family members, and they may even consider family members as intruders and attack, possibly using a gun if one is available. Loss of judgment and visual-spatial abilities also makes the operation of equipment such as a motor vehicle dangerous. Depression The elderly are less likely than are younger adults to demonstrate dramatic behavioral symptoms or other signs to suggest suicidal intent. Many older persons manifest the symptoms of depression through somatization, i.e., complaints about multiple vague physical ailments. A clear history of depression defined by DSM criteria may be absent. Those 75 years of age or older commit suicide at a greater rate than their younger counterparts [7], and an elderly individual who dies suddenly and unexpectedly merits serum and urine toxicology tests to exclude the possibility of lethal overdose if no overt evidence of suicide, such as hanging or a self-inflicted gunshot wound, is present. Skin With aging the skin becomes thinner and weaker, and injuries that do occur heal more slowly because of a decrease in the rate of keratinocyte proliferation. An immobile elderly person with delicate skin presents a particular, and particularly common, challenge to nursing care for an individual who requires frequent turning but who has abnormally fragile skin. The loss of basement membrane and dermis makes it easy for elderly, delicate skin to tear with trivial trauma. Skin tears, bruises, and decubiti are sometimes unavoidable complications in the long-term care setting; however, excessive numbers or severity of these lesions implies abuse or neglect. [8] Bruising and Skin Tears Bruising must be distinguished from senile purpura, an age-related skin lesion. Geriatricians favor the term actinic purpura over senile purpura because the change is caused by sun damage to perivenular connective tissue in the skin. The most common sites for actinic purpura site are the hands and forearms, which are exposed to the sun more than other portions of the body over the course of an individual's life. Actinic purpura form just as contusions do, by extravasation of blood from damaged vessels into surrounding connective tissue. [9] Bruising is common in the elderly and can be produced by medical problems, trauma, or a combination of both. Patients receiving coumadin, anti-platelet therapy, or other anti-coagulants are at increased risk for bruising. Thrombocytopenia is common in older patients, producing additional skin lesions. The pattern and distribution of bruising can help to determine whether trauma occurred from routine care or from abuse and neglect. Falls are common in older persons, especially those with dementia. A contusion from a fall does not imply poor care as some falls are unavoidable. Contusions from a fall would be expected over exposed surfaces or bony prominences. As with infants and small children, contusions on the medial aspects of the thighs or on the medial aspects of the arms would not be expected to occur during an ordinary fall. Unlike infants, elders have the ability to injure themselves, so each case must be considered on its own merits. The significance of multiple contusions depends on the severity, duration, distribution, and etiology of the lesions. Clinicians and families are expected to take reasonable precautions to reduce the likelihood of falls for the older person in the long-term care setting or at home. The presence of bruises (or decubiti) in the absence of assessments or interventions raises the suspicion of abuse or neglect for the individual. Decubiti Decubiti, also referred to as pressure ulcers, bed sores, or stasis ulcers, are largely avoidable complications in the long-term care setting. Geriatricians prefer the term pressure ulcer, because it is unrelieved pressure that leads to tissue necrosis and ulcer formation. Pressure ulcers do not form from the epidermis down, but rather begin deeper within the body. The pressure put on blood vessels that run between a bony prominence and the overlying skin is greater than blood pressure, so that with time ischemia develops. In individuals who have an intact sensorium the body registers discomfort, and the individual shifts position, even in sleep, provided the individual is able to move. In an individual who lacks such sensation or the ability to move himself the ischemia caused by pressure will lead to necrosis of tissue deep to the skin. Because decubiti are produced by excessive or prolonged skin pressure, the most common reason for these skin lesions is failure to adequately turn or rotate patients to reduce pressure positions. [10] Decubiti become colonized with bacteria, and when the decubitus has reached Stage 4 (extends to bone), then sepsis or osteomyelitis is likely. Culture of the pressure ulcer alone is useless, for the ulcer will always be infected. Culture of blood or spleen is necessary to show sepsis. Culture of the ulcer in conjunction with culture of blood or spleen may help show the source of the sepsis. While decubiti are preventable, it is unrealistic to expect that no pressure ulcer will ever form in any patient in every nursing home and hospital. When present, decubiti must be interpreted in the unique clinical setting of that specific case in order to assess civil or criminal liability. The evaluation of a pressure ulcer requires removal of the overlying eschar to determine the depth of the lesion. The pathologist confronting a pressure ulcer should document the severity and extent of the skin lesion, just as the pathologist would document any other significant injury. In assessing the quality of care provided to the decedent, it is helpful to know that failure to recognize or treat Stage 3 or Stage 4 decubiti is a serious deficiency of basic, clinical care that raises the possibility of abuse or neglect. Finding untreated Stage 3 or 4 decubiti warrants referral to appropriate protective service agencies or law enforcement. Responsible healthcare professionals can be subject to criminal or civil liability for these skin lesions. Bone Aging often leads to loss of bone strength. Fracture of the hip, vertebral column, and wrist commonly occur in association with osteoporosis, but other bones become weak and brittle as well. Pelvic, foot, rib, and shoulder fractures can all occur due to loss of bone density caused by osteoporosis. Not all bones are affected by osteoporosis, however, and fractures of the fingers, skull (including facial bones), elbow, and ankle are not related to osteoporosis. [11] Abuse Certain circumstances are more common in a setting of elder abuse. The following characteristics in an elderly individual are associated with abuse: 1) short-term memory loss, 2) any psychiatric diagnosis, 3) substance abuse, 4) abnormal or poor social functioning and support. Examples of poor social functioning are expressions of conflict with family or friends, loneliness, difficulty interacting with others, and poor support from family and friends. [12] Unfortunately, these characteristics are more sensitive than specific, and many elders have at least one of these risk factors. The features that distinguish cases which are suspicious for abuse or neglect remain undetermined. Table 5. Summary of Physiological Changes with Increasing Age and Forensic Implications Organ Change Effect and Implication Heart decreased heart rate increased left ventricular mass rearrangement of preload, afterload reduced aerobic capacity constant ejection fraction exercise tolerance Lungs loss of peak lung capacity loss of elastic recoil of lung stiffer chest wall, weaker accessory muscles of respiration reduced respiratory drive little meaningful change Kidneys decreased glomerular filtration rate decreased renal blood flow decreased ability to concentrate urine loss of renal mass, glomeruli, and tubules rate of clearing medications eliminated by kidney Liver little loss of function due to tremendous reserve, but decreased clearance of drugs by microsomal enzymes rate of meperidine metabolism slowed Brain Dementia Depression risk of accident or suicide Skin Decreased proliferation of keratinocytes Loss of basement membrane Loss of dermis and its neural elements wound healing blistering fragility loss of sensation Bones loss of properly calcified bone due to osteopenia (intrinsic loss) or osteomalacia (metabolic deficiency in Ca or P) more common in women than men more common in whites than blacks fracture of hip, vertebral column, wrist; less commonly of pelvis, foot, rib, shoulder Taken from Hazzard WR, Blass JP, Ettinger. 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