Problems and Challenges with Inflicted Trauma at the Extremes of Life
Moderators: Gregory G. Davis and Roger W. Byard
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.
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
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. 
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. 
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.
 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. 
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. 
Central Nervous System
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.  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.
 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
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
, 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.
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. 
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. 
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, 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. 
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.
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. 
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.
 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
Taken from Hazzard WR, Blass JP, Ettinger. WH Jr, Halter JB, Ouslander JG, editors. Principles of Geriatric Medicine and Gerontology. 4th ed. New York, NY: McGraw-Hill, 1999.
|Organ ||Change ||Effect and Implication|
|Heart ||decreased heart rate|
increased left ventricular mass
rearrangement of preload, afterload
reduced aerobic capacity
|constant ejection fraction|
|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|
| risk of accident or suicide|
|Skin ||Decreased proliferation of keratinocytes|
Loss of basement membrane
Loss of dermis and its neural elements
| wound healing|
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|
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