How to Identify Suspicious Bruising in Older Adults

Accidental or Abusive? Reporting Injuries of Unknown Origin

Elderly Care- Bruising
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One of the many signs of physical abuse in older adults is bruising. Sometimes, it appears fairly obvious that the bruises are related to abuse. They might be accompanied by other signs of trauma, or the individual might clearly report what happened and who hurt them. At other times, it's not nearly so clear. As a medical professional, the difficulty comes when bruising is present and no one knows how it got there.

Is it accidental, as many bruises are, or is it suspicious and a possible sign of abuse?

Mandated Reporting of Abuse

Physicians, social workers, nurses, emergency personnel including police officers and fire fighters, clergy, mental health clinicians, and other workers are required to report abuse or neglect of older adults. This is called mandated reporting.

If the person lives in a community, this report must be filed with the local Adult Protective Services department. APS reports are usually generated when someone tells a healthcare worker, either voluntarily or in response to questioning, that they are being hurt, whether that's due to physical, emotional, verbal, sexual, or financial abuse.

If the person is residing in a nursing home, the staff there are mandated reporters and must file that report with the state survey agency. They face significant consequences if they don't report an incident, including a citation for not reporting the possibility of abuse, a citation for not following the required policy of reporting abuse, and additional citations and fines if abuse was found to actually have occurred.

CMS's Requirement to Report Abuse Allegations and Injuries of Unknown Origin

The Centers for Medicare and Medicaid Services has many requirements of participation if skilled nursing facilities wish to receive financial reimbursement for providing care to their residents. One such requirement is that the facility must report an allegation of abuse or an injury of unknown origin to their state agency within two hours of its discovery.

The state agency (which is overseen by CMS) then decides whether to investigate the allegation of abuse or that injury of unknown origin immediately, within a few weeks or months, or at the next unannounced state survey.

If a resident makes an allegation of abuse, regardless of the resident's cognitive ability, nursing home staff must report the allegation, conduct a complete investigation and file the investigation with the state agency within 5 days of the incident. Although distressing to facilities, it's fairly easy to know that these allegations need to be reported.

The more difficult decision for nursing home administration is determining what incidents should be classified as injuries of unknown origin and thus require reporting. According to CMS, an injury of unknown origin is defined as follows:

  • The injury wasn't observed by anyone or can't be explained by the resident.
  • The injury is suspicious because of the location (in an area not usually vulnerable to trauma), extent of the injury, number of injuries that occur at the same time, or the number of injuries over time.

The goal of CMS in requiring the reporting of injuries of unknown origin is to minimize and prevent any abuse of older adults.

However, operationalizing this definition becomes challenging when there are different interpretations of what is deemed “suspicious,” especially for injuries that occur frequently, such as bruises.

Bruising on nursing home residents has often been interpreted as accidental in nature, and understandably so because of the vulnerability of older adults to bruising. However, some state agencies are now interpreting some bruising as suspicious in nature and are citing facilities for not reporting those injuries to them for investigation.

The challenge of CMS, state agencies, and nursing homes is to not miss those bruises which could be indicative of abuse, but not require or practice over-reporting of bruises, many of which are accidental in nature.

Over-reporting, which includes investigating, documenting and writing lengthy reports, requires the use of significant resources that instead could be used to provide a higher level of care for the residents.

Using Research to Help Decide When Bruising Is Suspicious

In absence of more specific guidelines from CMS, some facilities are utilizing scientific research to assist in objectively identifying characteristics of bruises on older adults that are likely to be suspicious in nature and thus would require reporting.

The Risk of Bruising in Older Adults

First, we need to recognize that bruising is very common in older adults, with many bruises occurring without a clear cause. In one study of accidental bruising, 72 of 101 research older adult participants experienced at least one bruise in a 2-week time period.

Second, there are several factors that increase the likelihood of bruising in older adults. They include:

  • Accidental bruising in older adults is more likely to occur due to decreased fat under the skin, thin skin, and fragile capillaries.
  • People who receive certain medications are at increased risk of bruising. Research identifies daily doses of prednisone, Aspirin 325 mg, Warfarin and Plavix, as well as inhaled corticosteroids, as notably increasing the risk of bruising. A smaller but still increased risk is tied to adults receiving aspirin 81 mg, NSAIDs (for more than three days per week), and ginkgo.
  • Falls and gait disturbances all increase the likelihood of bruising.
  • Residents who require assistance with ADLs are more likely to experience bruising.
  • Use of an assistive device (such as a walker, cane, or wheelchair) increases the chance of bruising.
  • Atrial fibrillation is a condition that is correlated with bruising because it often triggers the use of over the counter and prescription medications called anticoagulants that decrease clotting of blood.

Dementia, Abuse, and Recall of Injury

People with Alzheimer's disease or other kinds of dementia are at an increased risk for abuse. Their memory impairment, decline in communication abilities, and poor judgment make them an easier target than others whose cognition is intact. Their recall or accusation of abuse may also be discounted because of their poor memory or history of paranoia or hallucinations. Thus, it's important that we work to protect these individuals from the risk of abuse.

Interestingly, if an older adult doesn't know how a bruise occurred or doesn't remember it, it is far more likely to be an accidental injury. Research on accidental bruising found that only 17 percent of older adults could remember how their bruise occurred.

In contrast, 91 percent of abused participants in a different study could recall the cause of their bruise, despite many of those individuals scoring less than 24 on the MMSE. (A score of 19-24 is indicative of early Alzheimer's disease.) The recall of their abuse was verified by other evidence to ensure accuracy. The researchers of this study pointed out that this tendency of abused persons to recall the origin of their bruising or other abuse despite memory problems was also seen in geriatric physician office visits with their patients.

This tendency to remember emotionally-laden events (such as abuse) despite dementia has been researched and demonstrated multiple times. Additionally, feelings in dementia tend to last longer than specific memories, so noting the person's emotional state is important.

Due to this potential for recalling abusive events, adults should always be gently questioned about the origin of their bruising, regardless of cognitive ability or inability.

Aging of Bruises

You may be familiar with the idea that a bruise changes color as it ages. While color changes typically do occur, they often don't do so in a predictable pattern. For example, contrary to "common sense," research has demonstrated that just because a bruise is yellow, it does not necessarily indicate that it is older than a bruise that is purple. This means that attempting to identify when a bruise first occurred based on the color of the bruise is not an accurate method to date the bruise.

Characteristics of Accidental Bruising

  • The extremities (arms and legs) of older adults are easily bruised from minor injuries. In one study of accidental bruising, 90 percent of bruises were located on the extremities.
  • Most accidental, large bruises (defined as larger than 5 cm across in any direction) are located on the extremities.
  • Women tend to bruise more easily from minor injuries than men, especially on the thigh, upper arms and buttocks.

Characteristics of Abusive Bruising

  • Large bruises (defined as greater than 5 cm across in any direction) that are not on the extremities are more likely to be related to abuse.
  • Bruising located on the neck, ears, head, face, thumb side of the right arm, palm side of the arm, back, buttocks, genitals, and soles of the feet are more likely to be related to abuse. However, the palm side of the arm is also a common location for accidental bruising.
  • Patterned bruises that suggest hand marks or finger marks are more likely to be related to abuse.
  • Other possible physical indicators of abuse include bilateral bruising to arms, bilateral bruising of the inner thighs, “wrap around” bruises that encircle the legs, arms or torso, and multicolored bruises which could indicate that several injuries were acquired over time.
  • Be aware that inconsistent stories, changing explanations or sudden behavioral changes may be indicative of abuse.
  • Bruises that are from abuse are at times combined with other injuries.

Investigating Accidental vs. Abusive Bruising

While bruising is sometimes flagged as a possible indicator of abuse, there is unfortunately limited research about how to determine if bruising is accidental or related to abuse. As healthcare workers, we need to practice due diligence to protect vulnerable adults, yet not use resources irresponsibly on a "witch hunt" for suspicious bruising in a population that is extremely susceptible to bruising.

A good investigation will help in determining your next steps when it comes to bruising, skin tears, or other injuries to older adults. Your investigation should include the following:

  • Interviews with the person, responsible party, caregivers, and any other possible witnesses
  • A review of the medical record to identify if medications or diagnoses are present that increase risk of bruising or injury
  • A review of any recent falls that may have resulted in bruising
  • A review of physical environment to assess if anything may have caused the bruise or other injury

Your decision of whether to classify the bruise as suspicious or accidental will be easier to defend to your state surveyors if you take credit for your thought processes by documenting your rationale and your interviews.

A Word From Verywell

It's important to note that these suggestions for evaluating if bruising in older adults is suspicious are based on limited research studies. Additional research could help us more accurately identify risks for abuse, as well as reassure us regarding accidental bruises and other injuries.

The challenge of keeping residents and patients safe, as well as adhering to the regulatory requirements of reporting abuse and injuries of unknown origin, is significant. Becoming familiar with the research available enables all of us to make informed decisions and use best practices in our clinical work.

Sources:

Mosqueda, L, Burnight, K, , Liao, S. Executive Summary Bruising in the Geriatric Population, NIJ Grant #2001-IJ-CX-KO14. https://www.ncjrs.gov/pdffiles1/nij/grants/214649.pdf

National Institute of Justice. Identifying Elder Abuse. May 6, 2013. https://www.nij.gov/topics/crime/elder-abuse/pages/identifying.aspx

University of Michigan. Michigan Medicine. Bruises and Blood Spots Under the Skin. March 20, 2017. http://www.uofmhealth.org/health-library/bruse

Wiglesworth, A, Mosqueda, L. People with Dementia as Witnesses to Emotional Events. https://www.ncjrs.gov/pdffiles1/nij/grants/234132.pdf 

Wiglesworth,A,  Austin, R, Corona, M, Mosqueda, L. Bruising as a Forensic Marker of Physical Elder Abuse. https://www.ncjrs.gov/pdffiles1/nij/grants/226457.pdf 

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