Legal Medicine 5 (2003) 7–14

www.elsevier.com/locate/legalmed

Elder abuse and neglect:

social problems revealed from 15 autopsy cases
Kayoko Akazaa, Yasuo Bunaia,*, Masatake Tsujinakaa, Isao Nakamuraa, Atsushi Nagaia,
Yukiyoshi Tsukatab, Isao Ohyac
a
Department of Legal Medicine, Gifu University School of Medicine, Gifu 500-8705, Japan
b
Department of Bioethics and Social Medicine, Graduate School of Medicine, Gifu University, Gifu 500-8705, Japan
c
Department of Legal Medicine, Graduate School of Medicine, Kanazawa Medical University, Ishikawa 920-0293, Japan
Received 10 December 2001; received in revised form 10 August 2002; accepted 23 August 2002

Abstract
This study examined the elder abuse cases that occurred in Gifu Prefecture, Japan between 1990 and 2000. We conducted a
retrospective study of all the cases in which the victim was 65 years or older and autopsied in the Department of Legal Medicine, Gifu
University School of Medicine. Fifteen victims were classified as elder abuse victims: five men and ten women. The victims ranged
in age from 66 to 87 years (mean age, 74.5 years). The types of abuse were as follows: physical abuse, 13 cases; emotional abuse, five
cases; neglect, four cases; and financial abuse, three cases. In eight cases, the victims were subjected to two or more types of abuse.
The cause of death of the victims varied with the type of abuse. In the physical abuse cases, subdural hemorrhage was the most
common cause, followed by other violence-related deaths and hypothermia. In the neglect cases, the victims died of either starvation
or suffocation after the aspiration offood into the airway. In the domestic abuse cases, one of the victim’s sons was the most common
perpetrator, and little or no income was considered to be a risk factor for perpetrators. In the neglect cases, dementia and difficulty in
performing activities of daily living were considered to be risk factors for victims, in addition to living in social isolation.
q 2002 Elsevier Science Ireland Ltd. All rights reserved.
Keywords: Forensic autopsy; Elder abuse; Elder neglect

1. Introduction gradually come to recognize this problem, and many

Elder abuse is the most recent violence issue to
gain the attention of the public and the medical
community. Child abuse received significant attention
in the 1960s and domestic violence in the 1970s [1],
but elder abuse was not described in medical literature
until, 1975, when two reports of ‘granny battering’
appeared [2,3]. Since then, the medical profession has
* Corresponding author. Tel.: þ81-267-2250; fax: þ 81-267-
2957.
E-mail address: bunaiy@cc.gifu-u.ac.jp (Y. Bunai).
1344-6223/02/$ - see front matter q 2002 Elsevier Science Ireland Ltd. All rights reserved.
doi:10.1016/S1344-6223(02)00172-4
reports of this recently recognized form of violence
have appeared in the United States [4 – 15], Canada
[16 –18] and Europe [19 – 22]. The authors of the
United States studies have estimated that between
700,000 and 2,500,000 older Americans are abused
each year [12]. The National Elder Abuse Incidence
Study (NEAIS) conducted by the National Center on
Elder Abuse at the American Public Human Services
Association suggested that as many as 688,948 or as
few as 210,900 older persons aged 60 years and over
may have been the victims of abuse and/or neglect in
domestic settings in 1996 [15]. By contrast, reports on
8 K. Akaza et al. / Legal Medicine 5 (2003) 7–14
elder abuse in Japan are rare, and little is known about
the actual situation [23]. In Japan, the social concept
that older persons should be treated with great care by
family and medical staff is widely held, and elder
abuse has been thought to occur only on rare
occasions. Nevertheless, elder abuse has occurred in
Japan and is a major hidden social problem. In this
report, we describe 15 cases of elder abuse that
occurred in Gifu Prefecture, Japan.
2. Materials and methods
We conducted a retrospective review of autopsy
cases examined at the Department of Legal Medicine,
Gifu University School of Medicine, between 1990
and 2000 in which the subjects were 65 years old or
older. We found 125 cases (63 males and 62 females)
in our search. The investigative reports, autopsy
findings, and toxicological analysis of all 125 cases
were reviewed, and 15 cases were classified as elder
abuse or neglect, according to the definition of elder
abuse by the National Aging Resource Center on
Elder Abuse (NARCEA) of the United States [24].
The cases of elder abuse were subclassified into seven
categories, according to the NARCEA definitions:
physical abuse, emotional abuse, financial abuse,
sexual abuse, neglect, self-neglect, and
miscellaneous.
In principle, obvious homicides were excluded
from the study; however, two homicidal cases were
included because the autopsies revealed evidence of
physical abuse.
3. Results
Our research revealed 15 victims of elder abuse
who died in Gifu Prefecture, Japan, between 1990 and
2000. During this period, all medico-legal autopsies in
Gifu Prefecture were performed at the Department of
Legal Medicine, Gifu University School of Medicine.
The ages of the victims ranged from 66 to 87 years,
with a mean age of 74.5 years. The male to female
ratio was 1:2. Five victims had difficulty performing
activities of daily living (ADLs) because of dementia
and/or physical disturbances, but the other victims had
no difficulty with their ADLs.
Physical abuse was the most common type of elder
abuse, followed by emotional abuse, neglect, and
financial abuse (Table 1). No cases of sexual abuse
occurred in this study. In eight cases, the victims were
subjected to two or more types of abuse.
The cause of death in the elder abuse victims
varied with the type of abuse (Table 1). Among the
victims of physical abuse, subdural hemorrhage was
the most common cause of death (six out of 13 cases),
followed by other violence-related deaths and
hypothermia. An 80-year-old woman committed
suicide by drowning after being subjected to physical
and emotional abuse. Victims of neglect died of either
starvation or suffocation after the aspiration of food
into their airway.
Thirteen of the 15 elder abuse cases were domestic,
and a son of the victim was the most common
perpetrator, followed by a grandchild, daughter-in-
law, or son-in-law. In one case, the perpetrator(s) was
not identified, despite the fact that the female victim
had obviously been subjected to domestic elder abuse.
In the ten cases where the victim’s son or grandchild
was the perpetrator, eight of the perpetrators were
unemployed and had little or no income. Four of the
perpetrators in the domestic elder abuse cases had a
mental illness, and two were chronic alcoholics.
Among the neglect cases, two victims had devel-
oped dementia and had some difficulty with their
ADLs, with or without physical impairments. In the
other neglect cases, the victims became unable to
perform their ADLs because of trauma caused by
repeated physical abuse.
3.1. Case reports
3.1.1. Case 1
A 76-year-old woman was found dead in her
bedroom by a relative. She had undergone an
operation for proctoptosia and had used diapers
because of scatacratia since then. When she was
discharged from the hospital, she weighed 36.5 kg.
She did not show any signs of dementia and could
walk holding a handrail. She lived with her son’s
family. Her daughter-in-law had been her only
caregiver, but the daughter had held a grudge against
the deceased because the deceased had a dominant
personality and had tried to control the family’s
activities prior to undergoing her operation. Her son
Table 1
Elder abuse victims in Gifu Prefecture from 1990 to 2000a

Case Age (years) Sex Cause of death Dementia Perpetrator(s) Income of Psychological Physical Neglect Emotional Financial

K. Akaza et al. / Legal Medicine 5 (2003) 7–14

of victim perpetrator abnormality of abuse abuse abuse
perpetrator

1 76 F Starvation 2 Daughter-in-law and son þ 2 þ þ

2 81 F Hypothermia 2 Son 2 Alcoholism þ þ þ
3 67 F SDH 2 Son 2 2 þ þ
4 73 M Suffocation1 þ Sons þ 2 þ
5 84 F Suffocation1 þ Son-in-law þ 2 þ þ þ
6 72 F SDH 2 Son 2 Alcoholism þ þ
7 74 F SDH þ Daughter-in-law þ Amentia þ þ
8 80 F Drowning 2 Unknown þ þ
9 71 F SDH 2 Grandson 2 2 þ
10 73 F Suffocation2 2 Son 2 Schizophrenia þ
11 76 F Fire (homicidal) 2 Grandson 2 Schizophrenia þ
12 87 M Strangulation 2 Son 2 Schizophrenia þ
13 71 M SDH 2 Son 2 2 þ
14 67 M TICH 2 Neighbor þ 2 þ þ
15 66 M TP 2 Others þ 2 þ
a
SDH, subdural hemorrhage; Suffocation1, aspiration of gastric content; Suffocation2, aspiration of blood from laryngeal injury; TICH, traumatic intracranial hemorrhage; TP,
traumatic pneumothorax.

9
10 K. Akaza et al. / Legal Medicine 5 (2003) 7–14
had taken little care of her. When she was found dead,
the carpet was soiled with stool and some pieces of
dried bread had been left in the room.
At autopsy, the subject weighed 27.2 kg and was
severely emaciated. Bedsores were observed on the
right side of her body, but no evidence of trauma was
detected. Little food residue was found in the
alimentary tract. The organs revealed no pathological
changes. The cause of death was determined to be
starvation.
Neglect was strongly suspected in this case.
However, no criminal action was taken against the
family because the police could not completely rule
out self-neglect.
3.1.2. Case 2
An 81-year-old woman was found dead in bed. The
bed was wet with urine. She had lived with her son,
who was 56 years old and had been unemployed for 15
years after leaving his position as a teacher because of
alcoholism. Four days before her death, she discovered
that her clothes and rings were missing, and she
accused her son of stealing them. At that time, she was
beaten by the son so severely that she could not stand
up and remained in bed. The day before her death, one
of her son’s friends heard her speak with her son. After
beating her, the son gave her food a few times.
An autopsy revealed severe subcutaneous hemor-
rhages in the head, face, and body. Fresh and old rib
fractures were also observed, but no evidence of
intracranial or organ injury was found. The stomach
showed multiple small erosions. The cause of death
was determined to be fatal hypothermia.
The police interviewed the son, but no criminal
proceedings were instituted.
3.1.3. Case 3
A 67-year-old woman was subjected to more than 20
blows to the head and face and more than ten kicks to her
body by her son. The son was 32 years old and
unemployed. After the beating, she complained of
vomiting and was taken to a hospital. On admission, a
computed tomography examination revealed a right
subdural hemorrhage, and she died 36 h later. She had
been the victim of violence for 4 years and had consulted
a physician, but no help had been offered to her.
An autopsy revealed severe subcutaneous hemor-
rhages throughout the corpse and both fresh and old
subdural hemorrhages. The cause of death was
determined to be subdural hemorrhage.
A criminal proceeding was instituted against the
son.
3.1.4. Case 4
A 73-year-old man with dementia had been given
only a little food over a period of 2 weeks. On one
occasion, his two sons forced him to eat some food,
and he suffocated while eating. His sons left the
corpse for 19 days.
An autopsy revealed food in the trachea. The body
was malnourished, but no injuries were found. The
cause of death was determined to be suffocation.
Neglect was strongly suspected in this case.
However, no criminal action was taken against the
sons because the police could not completely rule out
self-neglect.
3.1.5. Case 5
An 84-year-old woman with dementia had been
physically and emotionally abused by her daughter
and son-in-law. During winter, she was left outdoors
by her son-in-law because she spilt soup on her
clothes. About 1 h later, the son-in-law found her
lying near his house in an unconscious state. He
warmed her and violently put food in her mouth.
However, she died.
An autopsy revealed fresh and old subcutaneous
hemorrhages throughout the corpse and food in the
mouth and trachea. The cause of death was deter-
mined to be suffocation.
No criminal proceedings were instituted against
the son-in-law.
3.1.6. Case 6
A 48-year-old man beat his 72-year-old mother
while he was under the influence of alcohol. Then she
became unconscious and was found dead the next
morning. The son had been unemployed, and the
mother had been taking care of him.
An autopsy revealed fresh subcutaneous hemor-
rhages in the head and face and a subdural
hemorrhage. Old subcutaneous hemorrhages were
also observed in the face. The cause of death was
determined to be subdural hemorrhage.
A criminal proceeding was instituted against the
son.
 K. Akaza et al. / Legal Medicine 5 (2003) 7–14
3.1.7. Case 7
A 74-year-old woman was the victim of violence
from her daughter-in-law. The victim fell unconscious
and died in hospital 2 weeks later. The relationship
between the victim and her daughter-in-law had been
poor and they had frequently quarreled.
An autopsy revealed severe subcutaneous hemor-
rhages in the head and face and a subdural
hemorrhage. The cause of death was determined to
be subdural hemorrhage.
A criminal proceeding was instituted against the
daughter-in-law.
3.1.8. Case 8
An 80-year-old woman who had been living with
her husband, son and daughter-in-law ran away from
home and committed suicide by drowning.
An autopsy revealed findings typical of drowning
and severe subcutaneous hemorrhages in the head and
face.
Domestic elder abuse was suspected in this case,
but the perpetrator(s) was not specified.
3.1.9. Case 9
A 21-year-old man beat his 71-year-old grand-
mother while he was under the influence of alcohol. The
victim fell unconscious and was sent to a hospital. She
died 3 days later. The perpetrator had been unemployed,
and the victim had been taking care of him.
An autopsy revealed severe subcutaneous hemor-
rhages throughout the corpse and a subdural hemor-
rhage. The cause of death was determined to be
subdural hemorrhage.
A criminal proceeding was instituted against the
grandson.
3.1.10. Case 10
A 73-year-old woman was killed by her son. The
son had thrust his hand into her mouth and severely
injured the laryngeal wall. The son suffered from
schizophrenia and was unemployed. The victim had
been taking care of him.
An autopsy revealed subcutaneous hemorrhages in
the face, a fractured nasal bone, and a severely injured
laryngeal wall. The airway was filled with blood. The
cause of death was determined to be suffocation from
the aspiration of blood.
The son was admitted to a psychiatric hospital.
11
3.1.11. Case 11
A man poured kerosene on his 76-year-old grand-
mother and set her fire on. The grandson suffered from
schizophrenia and had been unemployed.
An autopsy revealed fresh subcutaneous hemor-
rhages suggesting that the victim had been the victim
of violence prior to her death. Burns on the airway
were apparent. The cause of death was determined to
be asphyxiation from fire.
The grandson was admitted to a psychiatric
hospital.
3.1.12. Case 12
An 87-year-old man quarreled with his son about
the selection of a television program and was killed by
ligature strangulation. The son suffered from schizo-
phrenia and had been unemployed.
An autopsy revealed a ligature mark on the neck.
The cause of death was determined to be ligature
strangulation.
The grandson was admitted to a psychiatric
hospital.
3.1.13. Case 13
A 71-year-old man was the victim of violence from
his son because the victim had decided to sell his
house without consulting the son. After the violent
episode, the victim fell unconscious and died in
hospital 12 days later. The son had been unemployed.
An autopsy revealed severe subcutaneous hemor-
rhages in the face and a subdural hemorrhage. The
cause of death was determined to be subdural
hemorrhage.
A criminal proceeding was instituted against the
son.
3.1.14. Case 14
A 67-year-old man was the victim of violence from
a neighbor and died in hospital. The neighbor was a
27-year-old man who had often quarreled with the
victim.
An autopsy revealed subcutaneous hemorrhages
throughout the corpse and a skull fracture. Epidural,
subdural and subarachnoid hemorrhages and cerebral
contusions were also observed. The cause of death
was determined to be traumatic intracranial
hemorrhage.
12 K. Akaza et al. / Legal Medicine 5 (2003) 7–14
A criminal proceeding was instituted against the
neighbor and he was sentenced.
3.1.15. Case 15
A 66-year-old man was the victim of violence from
two young men and a young woman and died from his
injuries. The young men and the woman were
strangers to the victim.
An autopsy revealed subcutaneous hemorrhages
throughout the corpse, multiple rib fractures and
bilateral pneumothorax. The cause of death was
determined to be traumatic pneumothorax.
Criminal proceedings were instituted against the
young men and the woman and they were sentenced.
4. Discussion
The definitions and terminology related to elder
abuse vary considerably among researchers and
among the laws of different countries and states in
the United States [12]. Even the minimum age for
inclusion in the geriatric category is debated. In some
studies, the category has been defined as 65 years of
age or older [5,7,11], while in other studies it has been
defined as 60 years of age or older [15 –18,20]. Many
authors have defined four types of elder abuse:
physical, emotional, financial, and neglect. However,
other types of abuse have also been described.
NARCEA has proposed seven categories of elder
abuse, consisting of the four noted above plus self-
neglect, sexual abuse, and miscellaneous [24]. NEAIS
has also proposed seven elder abuse categories,
including the four noted above plus self-neglect,
sexual abuse, and abandonment [15].
Physical abuse is defined as the use of physical
force that may result in bodily injury, bodily pain or
impairment and is a common type of elder abuse. In
the present study, 13 of the 15 victims were subjected
to physical abuse, and nine of these victims were
female. Emotional abuse is defined as the infliction of
anguish, emotional pain or distress, and is another
common type of elder abuse. In our study, five victims
were subjected to emotional abuse and four of them
were female. Women have traditionally been thought
to be the most common victims of abuse [5,12,16].
However, some large surveys have found no gender-
related differences [4,8,11,15]. The abuse of women is
thought to be reported more often than that of men,
because the severity of the injury is usually greater
[4]. The high incidence of abuse in women based on
the autopsy cases in the present study may also reflect
the above idea. Neglect is defined as the refusal or
failure to fulfill any part of a person’s obligation or
duties to an older person, and is also a common type of
elder abuse. In some reports, neglect has been the
most frequent type of abuse, and followed by physical
and emotional abuse [13,15]. Older persons who have
difficulty performing ADLs have a higher risk of
becoming victims of neglect, particularly if their
problem involves eating [4,8,11]. The victims of
neglect in the present study exhibited dementia and/or
physical impairments.
Various risk factors for elder abuse, including
psychological health, have been described with regard
to both the victims and the perpetrators. Poverty [11]
and high alcohol consumption by the perpetrator [19]
are considered to be risk factors of elder abuse. The
physical and mental health and the functional ability
of the victims are also considered to be risk factors for
physical abuse [4,8,11]. The classic image of elder
abuse is described by the caregiver-stress hypothesis,
in which the older person becomes increasingly
dependent on the caregiver for physical, emotional
and financial needs, and the caregiver slowly but
steadily becomes overburdened and resentful of the
elder’s demands, eventually lashing out or with-
holding the basic needs from the older person.
However, such relationships, which create more
caregiver stress and anger, do not increase the
incidence of elder abuse [6,12]. Abuse is more
strongly correlated with the financial and emotional
dependence of the caregiver on the older victim [15].
Such dependence is often the result of an underlying
problem of the caregiver, such as alcoholism, legal
difficulties, psychiatric condition or deviant behavior
[5,12,16,19]. Neglect is also associated with socially
dysfunctional caregivers [19]. Older persons who live
in social isolation are more frequently abused [15].
Abuse sometimes occurs in families where the older
person has a dominant personality and the activities of
child(ren) are strictly controlled and decided by the
parent [22]. Children or grandchildren who are
unemployed, depend financially and mentally on an
elder, and live in social isolation have a high risk of
becoming perpetrators [6,11,19]. Among the present
 K. Akaza et al. / Legal Medicine 5 (2003) 7–14
cases, four female victims who were subjected to
physical abuse and/or neglect by an unemployed son
had been taking daily care of the son and had
supported him financially. They also lived in social
isolation. In these cases, the victims probably
tolerated and/or accepted abuse with resignation. In
such situations, it may be difficult for the victims to
break the cycle of abuse and the perpetrator’s
dependency on the victim without the help of others.
The education level of the perpetrator does not seem
to be risk factor [10,22]. This idea is supported by our
case 2, in which the perpetrator had graduated from
university and been on the teaching staff of a high
school for 20 years.
Large community-based trials have revealed cer-
tain patterns of abuse. Neglect was commonly
experienced by those who had no one to ask for
help [17], lived alone [17], or were in poor health [6].
Living with someone increased the risk of physical
and emotional abuse [17]. Financial abuse was more
common among those who had no one to turn to or
who lived alone [17].
One of the difficulties with regard to elder abuse is
that some abused elders do not disclose their abuse
and remain silent. Their reasons for not speaking out
may include fear for their personal safety or that of
others, isolation from their family, threats of institu-
tionalization, family break-up, or the withdrawal of
the services by caregivers who abuse them. Shame
over having raised an abusive child may be another
reason for their silence, and older victims sometimes
blame themselves for the abuse or deny that the
behavior is abusive. However, abused elders fre-
quently show indications of abuse: unexplained
bruises, wounds and burns from physical abuse,
unusual habits, neurotic or conduct disorders from
psychological abuse, and dehydration or malnutrition,
poor hygiene, inappropriate dressing, extensive bed-
sores, urine burns, or fecal impaction from neglect [9,
10,13,18]. If elder abuse is suspected, physicians and
professional caregivers should examine the subjects
carefully, including a cognitive evaluation, and should
ask about their living arrangements, financial status,
social support, and emotional stress [9,10,13,18,21].
This may be the first step in preventing elder abuse
and abuse-related deaths.
Some old Japanese tales have described elder
abuse, one of which concerns the abandonment of a
13
grandmother on a mountain because of poverty.
However, elder abuse has been ignored in Japan and
has not been openly discussed either socially or
medically. In the present paper, we have reported 15
autopsy cases of elder abuse victims that occurred
between 1990 and 2000 in Gifu Prefecture, where
approximately 2,050,000 – 2,100,000 individuals
lived during that period. Today, child abuse and
domestic violence are attracting attention and are
discussed as major social problems in Japan. How-
ever, there were 35 autopsy cases of domestic
violence and only ten autopsy cases of child abuse
in Gifu Prefecture during the above period. The
number of autopsy cases for child abuse was fewer
than that for elder abuse. The iceberg theory should
always be kept in mind whenever elder abuse, child
abuse, or domestic violence are discussed. This theory
states that the reporting sources only receive infor-
mation on the most visible types of abuse and neglect,
while a large number of other incidents remain
unidentified and unreported [15]. The present cases
represent the severest type of elder abuse and neglect,
and a considerably larger number of unreported elder
abuse cases are thought to occur in Gifu Prefecture. A
nationwide survey of elder abuse and neglect is
needed to reveal the presence of elder abuse in Japan,
and the creation of laws to prevent elder abuse is
considered to be one way of dealing with these abuse
cases.
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