The Gerontologist

cite as: Gerontologist, 2020, Vol. 60, No. 6, e449–e465

doi:10.1093/geront/gnz084
Advance Access publication July 26, 2019

Review Article

Neglect of Older People: Touching on Forensic and

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Pathophysiological Aspects
Annette Altendorf, PhD,1,* Brian Draper, MBBS, MD, FRANZCP,1,2 Chanaka Wijeratne,
MBBS, MD, FRANZCP,3,4 Jason Schreiber, FFCFM, MForensMed, MFFLM, PGDip,5,6 and
Daniella Kanareck, BA1
1
Older Persons Mental Health Service, Prince of Wales Hospital, Randwick, New South Wales. 2School of Psychiatry,
University of New South Wales, Sydney. 3Sydney School of Medicine, University of Notre Dame. 4Department of Aged Care
Psychiatry, Prince of Wales Hospital, Randwick, New South Wales. 5Clinical Forensic Medicine (CFM), Victorian Institute
of Forensic Medicine (VIFM), Melbourne. 6Department of Forensic Medicine, School of Public Health and Preventive
Medicine, Monash University, Melbourne, Victoria, Australia.
*Address correspondence to: Annette Altendorf, PhD, Older Persons Mental Health Service, Prince of Wales Hospital, Randwick, New South
Wales. E-mail: a.altendorf@unsw.edu.au

Received: October 17, 2018; Editorial Decision Date: May 7, 2019

Decision Editor: Patricia C Heyn, PhD

Abstract
Background and Objectives: Neglect of older people is common and may result in fatal and nonfatal outcomes. Normal
changes of aging and disease-related symptoms may overlap with markers of neglect and lead to under-detection. This
review aims to delineate medical, psychiatric, and pathophysiological indicators in the victim—identified in forensic case
reports—to point out areas of overlap and raise awareness in Health Care Professionals.
Research Design and Methods: Medical and forensic databases were searched with the search terms: neglect, elder, elderly,
forensic, homicide for detailed case reports on elder neglect. Cases were reviewed as to victim age, sex, medical/psychiatric
diagnosis, perpetrator, victim-to-perpetrator relationship, cause of death (if fatal), location of incident, autopsy findings (if
fatal), and ancillary studies. A total of 168 publications were retrieved, of these 11 publications, containing a total of 25
cases, yielded sufficient detail on each case to be included in the qualitative analysis.
Results: Neglect is associated with poor physical, psychological, and mental health. Neglect can be a direct cause of
death or contribute to a fatal outcome by exacerbating existing conditions. Red flags of neglect included malnutrition,
dehydration, poor hygiene, untreated decubitus ulcers, hypothermia, contractures, and an uncooperative caregiver. However,
incontrovertible evidence of neglect is not always easy to obtain due to age and disease-related changes.
Discussion and Implications: The findings document the extent and seriousness of elder neglect and highlight the importance
of detailed documentation as well as collaboration between clinicians, allied health professionals, law enforcement and
medical forensic services to improve patient outcomes and reduce the risk of further incidents.
Keywords: Elder neglect, Autopsy, Homicide, Decubitus ulcer, Malnutrition, Dehydration

Elder neglect, one of several forms of elder abuse, is at Fulmer et al., 2005; LoFaso & Rosen, 2014; Paranitharan
times difficult to identify and may be underreported in & Pollanen, 2009).
the scientific literature and to the criminal justice system Elder mistreatment not only affects an older person’s
(Bonnie & Wallace, 2003; Collins & Presnell, 2007; physical and mental health, but can also significantly

© The Author(s) 2019. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. e449
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e450
shorten older adults’ lives (Dyer, Connolly & McFeeley,
2003; Karch & Nunn, 2011; Lachs, Williams, O’Brien,
Pillemer & Charlson, 1998).
Neglect has been defined as “the failure of a caregiver
or fiduciary to provide the goods or services that are nec-
essary to maintain the health or safety of an older indi-
vidual” (Older American’s Act, 1965; 2016). The World
Health Organization (WHO; and other sources) classify
neglect as a form of violence, especially when the inten-
tional misuse of power is involved (Krug, Mercy, Dahlberg
& Zwi, 2002). Neglect is considered intentional when there
is a conscious objective to cause that result, for example
when an older adult is not provided with adequate food,
clothing, shelter, medical attention, dental care or when the
older adult is abandoned. Neglect may involve lack of per-
sonal care, poor hygiene, improper use of medication or
the refusal to permit other people to provide adequate care.
Unintentional neglect occurs mostly through negligence,
for example when a carer does not have the necessary skills
or knowledge, is not aware of available types of support
or is unable to provide care because they are ill themselves
(Elder Abuse Prevention Unit, 2019; Dolan, 1999).
Although there are subpopulations of “at-risk adults”
(older adults, who have become unable to independently
undertake activities of daily living) by no means all older
people will meet this definition. Most cases of neglect imply
long-term abuse, however, there may be occasions of short-
term neglect. Neglect can occur concurrently with other
categories of maltreatment, and may frequently go unde-
tected (Karch & Nunn, 2011).
Accurate prevalence and incidence estimates of neglect
are difficult to obtain. Estimates depend on the instrument
(definition of neglect, time span, frequency), the study
design, the target population, and sample (e.g., commu-
nity dwelling; residential facility/aged case providers; age
range), the source of information and, the quality of data
collection and analysis (Boyle, 1998). However, data are
available from a number of large-scale population surveys
in a number of countries (Cooper, Selwood & Livingston,
2008; Pillemer, Burnes, Riffin & Lachs, 2016; Yon, Mikton,
Gassoumis & Wilber, 2017).
In 2015 the WHO reported that estimated preva-
lence rates of elder abuse in community settings in high-
or middle-income countries ranged from 2.2% to 14%,
with estimates for neglect from 0.2% to 5.5% (Kaspiew,
Carson & Rhoades, 2015; World Health Organization
[WHO], 2015).
In a systematic review on elder mistreatment, Cooper
et al. (2008) mentions overall abuse prevalence rates in
general population samples between 3.2% and 27.5%.
Prevalence rates for neglect ranged between 0.2% and
4.3%. Pillemer et al. (2016), in a systematic review about
elder mistreatment in population-based studies, reported
that across all studies, 1-year neglect prevalence ranged
from 0.2% to 5.5% (outlier 15.8%), with a mean of 3.1%
(95% CI: 0.6%–5.5%; United States [range 0.4%–5.1%];
The Gerontologist, 2020, Vol. 60, No. 6
United Kingdom [1.2%]; Canada [0.4%]; Ireland [0.3%];
Mexico [0.98%]; the Netherlands, Austria, Belgium,
Finland, Lithuania, Portugal [range 0.2%–5.5%]; India
[4.3%]; China [15.8%]; Nigeria [1.2%]). The aforemen-
tioned prevalence estimates concern community settings.
No robust prevalence studies are currently available for
neglect in nursing homes or other long-term care facilities
(Pillemer et al. 2016; Yon et al. 2018).
An analysis of data from the National Violent Death
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Reporting System revealed that in the United States of 574
homicide victims killed by a single caregiver suspect be-
tween 2003 and 2007, 62 (12%) persons were 50 years or
older and of those 15 (24%) died of intentional neglect by a
caregiver (Karch & Nunn, 2011). Several sociodemographic
and health-related risk factors and correlates of neglect
(e.g., poor health, lack of social support, older age, and
being female), have been researched, some with incon-
sistent results (Supplementary Table 1).
The forensic medical aspect of neglect of older people
in the sense of mistreatment relates to the duty, a person
with caregiving obligation owes to an older adult. The
criminal or harmful refuse or failure of carrying out this
duty, either consciously or unintentionally can inflict phys-
ical or emotional distress on the older person (Krug et al.,
2002). Forensic medicine occupies itself with assisting law
enforcement in finding and gathering evidence of the omis-
sion of relevant caring acts in the course of related duty.
Identifying neglect can be challenging. Old age can
bring physical disorders that may mimic neglect and com-
plicate detection (Collins & Presnell, 2007; Dyer et al.,
2003; Fulmer et al., 2005; Krug et al., 2002; LoFaso &
Rosen, 2014). Overlap among markers of neglect and
normal changes of aging or disease-related symptoms
may pose a challenge for Health Care Professionals. Lack
of professional awareness and training may contribute to
underreporting of neglect. The aim of this qualitative re-
view is to highlight warning signs in the victim and to raise
awareness in Health Care Professionals. Medical, psychi-
atric, and pathophysiological aspects of markers of ne-
glect—identified by forensic case reports in the scientific
literature—are discussed. This review delineates overlap
with disease-related symptoms, which can mimic neglect
despite a caregiver’s best efforts. Additional challenges to
correctly classify the overlap among markers of disease
and neglect are posed by changes that are a normal part of
the aging process, multiple comorbidities and medication
effects.
Methods
To obtain forensic case reports of elder neglect in the sci-
entific literature, medical and forensic databases (Medline,
Cinch, Agis) were searched with combinations of the
search terms “elder,” “elderly,” “neglect,” “forensic,” and
“homicide.” Inclusion and exclusion criteria: case reports
were included if they were published in English in
The Gerontologist, 2020, Vol. 60, No. 6
peer-reviewed journals in the last 20 years and included
sociodemographic, medical and forensic information about
the victim and background information, such as family re-
lationship with the perpetrator, scene investigation and if
fatal, circumstances of death. Case reports on self-neglect
were excluded from the study. A total of 168 publications
were obtained. After review articles, editorials, case reports
not mentioning neglect and duplicates were removed (based
on title and abstract), 11 publications, containing a total of
25 detailed case reports, remained (see Table 1).
Results
Qualitative Case Summary and Discussion
For 23 of the 25 cases listed in Table 1 a fatal outcome
was reported, 19 cases were women, the age range was
72–94 years. Twenty-one older adults lived in the commu-
nity at home whereas four resided in an institution.
In 20 cases, the perpetrator was a relative of the victim;
of these an adult child was involved in 17 cases. Adult sons
were involved (either alone or in conjunction with other
perpetrators) in 15 cases. Other perpetrators included
daughters (x2), medical staff (x5), husband (x1) and other
relatives or in-laws (grandchildren; daughter- or son-in-
law; x4).
The causes of death (in the 23 fatal cases) included:
sepsis (such as bronchopneumonia, septic-toxic heart
failure and sepsis due to severe decubitus ulcers; x11); se-
vere dehydration (x3), suffocation (x2), starvation (x1), hy-
pothermia (x1), and a number of other causes (x5).
The medical/psychiatric history included four main
groups–neurological disorders (x11), dementia and other
cognitive disorders (x9), severe cardiorespiratory disorders
(x7) and mental illness/alcohol use disorder (x6).
Autopsy/medical findings (indicative of elder neglect) in-
cluded malnutrition (x18), dehydration (x6), poor hygiene
(x16; including urine/fecal staining on the patient, bedding,
clothing), (untreated) decubitus ulcers (x15), untreated
medical conditions (x7; including infected decubitus ulcers
and wound infected by maggots), contractures (x4); necro-
tizing fasciitis/gangrene (x1).
The case reports in this study yield a number of poten-
tial warning signs to health- and social services. A constel-
lation of rapid decline in the victim and social isolation
of victim and carer may be one such indicator, as the case
of a 78-year-old Canadian woman, who lived with her
son for more than 35 years, illustrates (Paranitharan &
Pollanen, 2009; Table 1). The son became her caregiver due
to frailty and cognitive impairment. Although there was
no significant cognitive impairment initially at the time of
her husband’s death in 1995, after 10 years her health and
mental status started to decline rapidly (from November
2005 until her death in early 2006). Lack of or unexplained
cessation of medical appointments can be a warning sign
for problems. In this case, the medical history indicates that
the victim had contact with health services, though it is not
e451
clear how long ago the last contact took place. The degree
of violence in some of the case reports—for example in the
aforementioned case, where the son kicked his mother, who
had collapsed on the floor, and left her there for several
days until she died—may be an indicator for problems with
antisocial behavior, violence, or mental illness. The fact that
the son had lived with his parents for more than 35 years
may also indicate financial or emotional dependency on
the victim, both of which can increase the likelihood of
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neglect. Minimal social interaction—as may have been the
case here—is an obvious risk factor. The multiple bruises
of the face, mouth and neck, urine and fecal staining of
skin and clothing, matted hair, malnourishment and others
signs of inadequate care would likely have led to interven-
tion or contact with authorities would it have come to the
attention of interested outsiders. Another case with some
classic warning signs is the case of a 75-year-old woman,
who died in hospital where she had presented with hypo-
thermia, malnutrition, dehydration, multiple severe bruises
to the face, head and extremities and numerous decubitus
ulcers of various stages to the back, hips, fingers and feet
(Shields et al., 2004; Table 1). The victim had lived with her
son, a former public defender and a private sitter, the son’s
girlfriend, and had suffered from dementia, strokes, blind-
ness, a seizure disorder, and undifferentiated schizophrenia.
The high dependency on care and proximity to the perpe-
trator are both potential risk factors for neglect. There had
been several previous hospitalizations and contacts with
health services over a period of 15 years. The severity of
underlying illnesses may have masked the neglect occurring
at home and may explain why neglect, which was thought
to have significantly contributed to her death, was not dis-
covered earlier. The fact that the perpetrator was highly
educated is not necessarily untypical. Mistreatment occurs
across different socioeconomic groups (Chen & Dong,
2015; Yon et al., 2017). The case of a former lawyer, where
legal proceedings were withdrawn, is another case with
classic risk factors, such as living together with the perpe-
trator, isolation, dependence on care, income and money
administration, tendency for self-neglect in the victim, and
unemployment, social isolation, financial and mental de-
pendency on the victim in the offender (Ortmann et al.,
2001; Table 1). Alcohol- and substance use may facilitate
neglect and was mentioned four times in the case reports
of this study. Two were related to alcoholism in sons caring
for their mother. In another case report both son and father
were noted for alcohol- and/or substance use. Neglect may
occur in complicity as illustrated in a case where maltreat-
ment occurred by the hands of son and daughter-in-law.
Discussion and Implication
With changing demographics (including adult children
living further away from their aging parents) and a world-
wide aging population (amongst other factors), the preva-
lence of neglect can be expected to increase. Case scenarios
Table 1. Victim Characteristics (Fatal and Nonfatal Neglect)
e452

Age/sex/
Case/country location Medical history Background- and scene investigation Cause of death/autopsy finding Perpetrator(s)

1a/United 75 years/F/ Strokes; blindness; The victim attended the local emergency department, having Cause of death: Broncho-pneumonia and multiple Son and son’s
States 2004 Emergency frequent falls; hypothermia, hypotension, atrial flutter, dehydration, cerebral infarctions. girlfriend
department schizophrenia; seizure malnourishment, multiple bruises abrasions, and decubitus Autopsy report: cachectic (body mass index
(ED)/home disorder; fractures 2 ulcers. Death occurred in hospital after 5 days. The victim had [BMI] = 17 kg/m2]); multiple pressure ulcers;
and 15 years prior lived in her home with her son and her son’s girlfriend. Members blunt trauma to the head; bilateral chronic and
to death; anorexia of the ambulance reported poor hygiene (feces and urine on bed, acute subdural hematoma; healing rib fractures
(due to inadequate clothing and bedroom and bathroom floor). In spite of very cold and blunt force trauma of the extremities.
oral intake) 12 temperatures the victim’s bedroom had not been heated. The Alzheimer’s disease
years prior to kitchen was dirty and not much food was found
death; hypothermia
and dehydration
occasioning 2
other previous
hospitalizations
2b/United 87 years/F/ Dementia Weight 114 lb; assigned food not given to patient. Usually cared Cause of death: Severe dehydration. Staff
States 2007 Institution for by her niece, but over a 2-week period, an institution cared Autopsy report: Electrolytes (vitreous): Na = 180,
for her Cl = 186, UN = 76; Tenting of skin; “stickiness”
of serosal surfaces; sunken orbits; hard feces/fecal
impaction. Toxicology: negative
3b/United 85 years/F/ Cerebrovascular Weight 85 lb; cachexia; feces on floor, bed, and clothing; Cause of death: Sepsis due to severe decubitus ulcers. Son
States 2007 Home accident medication missing Autopsy report: Electrolytes (vitreous): Na =
142, Cl = 116, UN = 30. Toxicology: Oxycodone
Acetaminophen (therapeutic). Culture:
postmortem: Blood (Proteus mirabilis, Escherichia
coli, Staphylococcus aureus, Streptococcus);
Decubitus (S aureus, Pmirabilis, Enterococcus,
mixed Gram-negative bacilli, Gram + cocci); Lung
(Staphylococcus, mixed Gram +, Streptococcus)
4b/United 74 years/F/ Cerebrovascular Weight 71 lb; cachexia; feces and urine on patient and bedding; Cause of death: Sepsis due to severe decubitus Husband
States 2007 Home accident poor hygiene ulcers.
Autopsy report: Electrolytes (vitreous): Na = 153,
Cl=-, UN=-. Toxicology: Phenytoin
(subtherapeutic). Culture: premortem: Blood
(S aureus); postmortem: Blood (Pseudomonas
aeruginosa, coagulase negative Staphylococcus);
Decubitus (P aeruginosa, S aureus, coagulase neg-
ative Staphylococcus, Pmirabilis); Lung (S aureus,
coagulase negative Staphylococcus).
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Table 1. Continued

Age/sex/
Case/country location Medical history Background- and scene investigation Cause of death/autopsy finding Perpetrator(s)

5b/United 94 years/F/ — Weight 63 lb; cachexia; feces on patient and bed; no bedding; no Cause of death: Severe dehydration/Renal failure Staff
States 2007 Institution water Autopsy report: electrolytes (vitreous): Na = 165,
Cl = 146, UN = 310. Tenting of skin; “stickiness”
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of the serosal surfaces; sunken orbits; hard feces/

fecal impaction. Toxicology: negative
6b/United 77 years/M/ Sickle-cell trait; Weigh 85 lb; cachexia; body on floor Cause of death: Severe dehydration, fat emboli, Staff
States 2007 Institution cerebrovascular fractures
accident Autopsy report: Electrolytes (vitreous): Na = 164,
Cl = 133, UN =-. Tenting of skin, “stickiness” of
the serosal surfaces, sunken orbits, hard feces/
fecal impaction. Toxicology: negative
7b/United 90 years/F/ Schizophrenia Weight 97 lb; cachexia; feces on patient and bedding; poor Cause of death: Sepsis due to severe decubitus ulcers Son and
States 2007 Home hygiene Autopsy report: Electrolytes (vitreous): Na = 140, daughter
Cl = 90, UN = 56. Toxicology: ethanol 2.7 mg/dL.
Culture: postmortem: Blood (Proteus penneri,
Clostridium, coagulase negative Staphylococcus,
Corynebacterium); Decubitus (P penneri, Proteus
vulgari, E coli)
8b/United 74 years/F/ Alzheimer’s disease Weight 90 lb; cachexia; Scene investigation: none Cause of death: Sepsis due to severe decubitus ulcers Grandson
States 2007 Home Autopsy report: Electrolytes (premortem
blood): Na = 153, Cl = 108, UN = 141. Culture:
premortem: Blood (MRSAc); postmortem: Blood
(coagulase negative Staphylococcus sp)
9b/United 87 years/F/ Alzheimer’s disease; Weight 83 lb; cachexia; Scene investigation: none Cause of death: Sepsis due to severe Granddaughter
States 2007 Home seizures decubitus ulcers
Autopsy report: Electrolytes (premortem blood):
Na = 134, CI = 97, UN = 22. Culture: premortem:
Decubitus (MRSAc); postmortem: Blood (MRSAc;
Enterococcus)
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Table 1. Continued
e454

Age/sex/
Case/country location Medical history Background- and scene investigation Cause of death/autopsy finding Perpetrator(s)

10d/United 84 years/F/ Possible stroke The victim died while in the care of her two sons. An unknown Cause of death: Homicide by neglecte Sons
States 2011 Home person reported the sons to authorities. When the fire depart-
ment arrived the sons mentioned that their mother might have
had a stroke. She had been unable to use her legs and had been
deteriorating for days. Scene investigation: poor care (urine soaked
diapers; linens filthy with vomit) and medical neglect (untreated
decubitus ulcers, discontinuation of medication to treat her “natu-
rally,” providing her with cigarettes while connected to an oxygen
machine). The sons had installed cameras in the basement, so they
could monitor the victim without having to go down. The sons
stated to the police that the reason for keeping her downstairs was
that they needed a place to live and her financial support
11d/United 78 years/F/ — The victim, who had lived with her alcoholic son, died after she Cause of death: Homicide by neglecte; died after Son
States 2011 Home fell on the floor in the home she shared with her son. The son, who falling on the floor
was her caregiver, also had power of attorney for his mother. After
an absence of several days he found her deteriorating/delusional
and called the authorities. The son stated that 5 days earlier he
had found his mother on the floor and that she had refused to
receive help. Therefore he had left water, food, and diapers next
to her on the floor. He had then left the house for 5 days. Scene
investigation: the victim was covered with urine and feces, had
open wounds (feet and lower back) and was infested with maggots
12f/Canada 78 years/F/ Significant cognitive The victim, having Alzheimer’s disease had been cared for at home Cause of death: Congestive heart failure. Son
2008 Home impairment; heart by her son, due to frailty and cognitive impairment. According Autopsy report: frail, malnourished; abrasion/
murmur; history to her son’s report he found her lying on the floor after returning bruise on nose; multiple bruises on forehead, right
of iron deficiency from work on a Monday. She would not move from the floor and eyebrow, mouth, neck, upper chest, and extremities
anemia he struck her and kicked her. She remained in the same position in different stages of healing. Extensive left facial
over the next 2 days. Thursday morning the son dribbled some swelling. The injuries, especially to the face, were
water in her mouth. When he returned from work he found his consistent with slapping/beating. End-stage val-
mother dead. Scene investigation: urine and feces on skin/clothing; vular and ischemic heart disease
unwashed dirt encrusted skin; matted hair and overgrown toenails.
Based on the forensic examinations it was concluded that the
victim developed progressive congestive heart failure in the days
prior to her death, which would explain her poor responsive-
ness in the days leading up to her death. It was further reasoned
that the injuries and neglect contributed to the victim’s death by
exacerbating the ischemic heart disease
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Table 1. Continued

Age/sex/
Case/country location Medical history Background- and scene investigation Cause of death/autopsy finding Perpetrator(s)

13g/Mexico 76 years/F/ Unspecified In 1996, the body of an elderly woman was accessioned at a Cause of death: The official cause of death was Medical staff
2013 Psychiatric psychiatric diagnosis Medical School in Mexico from a public psychiatric institution. listed as upper intestinal bleeding, although no
institution Skeletal analysis: complications from unsuccessful surgical additional details were provided
The Gerontologist, 2020, Vol. 60, No. 6

operation for fracture of upper thighbone (incorrectly placed,

broken stainless steel hip plate; screws intended to secure plate
of different length/incomplete/broken, preventing immobilization
of plate, likely moving in vivo; resulting in the left leg being
approximately 2.8 cm shorter; broken edge of plate abraded
cartilage, forming groove in hip socket; screw protruding to the
bone shaft possibly causing further inflammation). Degeneration
suggests the decedent survived with this condition for months.
However, it is unclear whether this resulted from surgical
complications, ineffective postoperative care, or from the decedent’s
limited ability to follow postoperative care instructions. Injuries
to the thorax: several broken ribs in different stages of healing
consistent with direct blunt force impact likely due to accident,
abuse or medical neglect. Other pathological conditions: severe
degeneration of shoulder-, elbow joints, wrist possibly resulting
from crawling as a means of mobility
14h/Japan 76 years/F/ Operation for The victim was found dead in her bedroom by a relative. Poor care Cause of death: Starvation Son and
2003 Home of proctoptosia; use of was apparent (carpet soiled with feces; decubitus ulcers; severe daugh-
son’s family diapers for urinary emaciation [weight 27 kg]; some pieces of dried bread had been ter-in-law
incontinence left in the room).
The weight at discharge of hospital was 37 kg; no signs of de-
mentia; patient could walk holding a handrail. The victim had
lived with her son’s family. Her daughter-in-law had been her only
caregiver, but the daughter-in-law had held a grudge against the
deceased because the deceased had a dominant personality. Her
son had taken little care of her. Next to neglect emotional abuse
was also noted
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Table 1. Continued

Age/sex/
e456

Case/country location Medical history Background- and scene investigation Cause of death/autopsy finding Perpetrator(s)

15h/Japan 73 years/M/ Dementia (some The father, who had dementia, had been given only a little food Cause of death: Suffocation (aspiration of gastric Sons
2003 Home difficulties with over a period of 2 weeks by his two sons. At some stage, they content)
ADLs) forced him to eat and he suffocated while eating. His sons left Autopsy report: food in the wind pipe; body
the body for 19 days. malnourished, but no injuries were found
Neglect was strongly suspected but no criminal procedure was
instituted because the police could not completely rule out self-
neglect
16h/Japan 84 years/F/ Dementia (some The victim, who had dementia, had been sent outdoors in Cause of death: Suffocation (aspiration of gastric Son-in-law
2003 Home difficulties with winter by her son-in-law because she spilt food on her clothes. content)
ADLs) Approximately 1 hr later, the son-in-law found her unconscious Autopsy report: old and new subcutaneous
close to his house. She died despite the son-in-law’s efforts to hemorrhages throughout the corpse; food in
warm her. He had also forced food into her mouth. mouth and windpipe
Next to neglect emotional and physical abuse was also noted
17h/Japan 2003 81 years/F/ History: No dementia The victim was found dead in her bed (wet with urine). She had Cause of death: Fatal Hypothermia Son
Son’s home was reported lived with her 56-year-old unemployed son. The son had been un- Autopsy results: severe subcutaneous hemorrhages in
employed for 15 years after leaving his position as a teacher because the head, face, and body. Fresh and old rib fractures
of alcoholism. Four days before her death she had an argument with (no evidence of intracranial or organ injury)
her son because her jewelry/clothes were missing. He beat her so
severely that she could not get up and had to stay in bed. After that
the son gave her food a few times. A day before her death a friend of
her son’s heard her speak with her son. Next to neglect physical and
financial abuse was also noted
18i/Japan 65+ years/F/ 30-year history of A woman in her late 60s was admitted to hospital after her hus- Cause of death: Systemic S aureus infection Husband, son
2012 Home seropositive rheu- band called emergency. He had found her unresponsive in bed at Autopsy results: cachexia (29 kg/141 cm), large
matoid arthritis; home. Cardiopulmonary arrest was diagnosed. Resuscitation was untreated decubitus ulcers extending through the
frequent hospital unsuccessful. Judging by the deconditioned state of the woman skin and subcutaneous tissues; contractures of
visits/hospitalizations the emergency physician alerted the police. The deceased had been fingers and legs
before becoming cared for by her husband. The son, who also lived at the home
unable to walk. Last seemed unconcerned about the state of her care. The deceased had
hospital visit over half been attended to by a neighborhood doctor. As the victim had
a year ago become unable to walk several years ago the husband had picked
up medication for her once a month. Scene investigation: body
covered in grime; overgrown nails; several large decubitus ulcers.
Indicators of Felty Sydnrome in the underlying rheumatoid ar-
thritis (possibly increasing susceptibility to decubitus ulcers, weight
loss and sepsis) were found in a subsequent postmortem examina-
tion, which served as a mitigating factor in the investigation of the
alleged neglect
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Table 1. Continued
Age/sex/
Case/country location Medical history Background- and scene investigation
19j/Germany 82 years/F/ — The victim had been confined to bed for several years. She was
2001 Home cared for by her son (a former lawyer who was unemployed). Food
was brought to the front door by a charity. After the son discov-
ered his mother dead one day, he declared her death and a doctor
was notified. The doctor recorded an unexplained cause of death
and notified the police. Scene investigation: cold attic (6°C); victim
(covered only with blanket) lying in fetal position on mattress
soiled with excrements; contractures (knee and hip); the right tibia
fractured (due to infected pressure ulcer). The son stated to the po-
lice, that, over the last months, his mother had refused to eat any­
thing but bread with bananas. The heating system was defect. The
mother had rejected outside help and he was not able to afford
professional care. The mother had transferred property ownership
to him and he had wanted to sell the house. When potential buyers
had visited the son refused access to the rooms where his mother
lived
20j/Germany 72 years/M/ Swelling of right arm The deceased was found dead by his son (an unemployed brick-
2001 Home and open wound at layer), who informed the family doctor. The doctor recorded an
elbow (duration:1 unexplained death and informed the police. The victim had an
year) open wound at the elbow (leaking, infected by maggots), which
he treated by fixing a bucket under the elbow. During the last 2
months the victim had been sitting in an armchair, had hardly
been eating and occasionally been given food by the son. The
son stated to police that he had not been able to stand up to his
father and always complied with his wishes. His mother had died
under similar circumstances, hardly moving for a long time after
a tumor operation
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Cause of death/autopsy finding Perpetrator(s)
Cause of death: Septic-toxic heart failure. Son
It was thought that neglect (including malnourish-
ment, food shortage, dehydration, immobilization,
infected decubitus ulcers) was causal for osteomye-
The Gerontologist, 2020, Vol. 60, No. 6
litis, pneumonia and death.
Autopsy: severe marasmus (40 kg/160 cm); dehy-
dration; advanced stage, infected decubitus ulcers
(shoulder, back, legs with local osteomyelitis of
both tibiae, femur, scapula); hypothermia; chronic
lung emphysema, bronchopneumonia
Cause of death: Septic-toxic heart failure. Son
Underlying illnesses and complications due to
neglect, immobilization, mal- nourishment and
dehydration led to death.
Autopsy report: Malnourishment (weight 50 kg/
170cm). Soiled/matted hair; claw-like finger/toe
nails; multiple pressure sores; chronic bursitis
(elbow); inflammation (right arm, hip, and thigh);
tracheobronchitis; chronic hypertension; coronary
arteriosclerosis
e457

Table 1. Continued
Age/sex/
Case/country location Medical history Background- and scene investigation
21k/Germany 80 years/F/ Stroke; diabetes mel- An 80-year-old female was admitted to hospital in August 2000
2001 Home litus; nephrotic in extremely poor care conditions (severe dehydration, mal-
Syndrome; cardiac nourishment, infected decubitus ulcers, soiling over the whole
failure (NYHA II); body). The patient had previously been admitted to hospital in
arterial hypertension September 1999 and January 2000 for a stroke. After the stroke,
she had been cared for by her son who lived in the same apart-
ment. She had been bedridden for several months. The mother
had not seen a physician since being discharged in February
2000. Demyelination must have developed in the 6 months after
the second period of hospitalization because the CCT in January/
February 2000 did not show any changes in the corpus callosum.
The son was not able to divulge any information on his mother’s
neurological/psychiatric status
22l/Italy 79 years/F/ Severe nervous The son, who lived with his mother, called the emergency serv-
2018 Home breakdown ices, because his mother had a “sudden attack of sickness.”
(requiring hospital- When the paramedics arrived, they found the woman dead on
ization 1 year prior the landing of the stairs outside her flat. On the morning of the
to death) woman’s death, the son had noticed that his mother was having
difficulty breathing and her consciousness was impaired. He took
her out onto the landing to get some fresh air and immediately
called for an ambulance.
Scene investigation: foul smell emanated from the flat (invading
the whole stairwell). The victim had poor health and poor per-
sonal hygiene (the whole body was covered with encrusted, fecal
matter; filthy and foul-smelling clothing; multiple excoriations
and necrotic hemorrhagic areas on face, neck and limbs; body
covered in extensive bedsores, stale fecal matter in subcutaneous
tissue; the sacro-coccygeal region presented diffuse necrotic ul-
ceration, which exuded purulent matter)
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e458
Cause of death/autopsy finding Perpetrator(s)
Cause of death: Necrosis of the corpus callosum Son
(Marchiafava–Bignami disease) presumably
caused by malnutrition associated with neglect.
Autopsy results: malnourishment (body weight
46 kg, body height 170 cm), soiling all over the
body, infected decubitus ulcers, gangrenous left
foot, contractures (knee/hip joints), dirty finger
and toe nails with fungal infections, height 170),
deyhydration, generalized arteriosclerosis, left
ventricular hypertrophy, pulmonary emphysema,
arterio-/arteriolosclerosis of both kidneys. Neuro-
pathological examination: necrosis of the corpus
callosum (Marchiafava–Bignami disease)
Cause of death: cardiorespiratory failure sec- Son
ondary to a bedridden syndrome, a state of sepsis
and acute bronchopneumonia.
Autopsy results: Cardiosclerosis; the lungs
presented areas of thickening attributable to
bronchopneumonia; the tracheobronchial
tree contained a yellowish creamy material
The Gerontologist, 2020, Vol. 60, No. 6
Table 1. Continued

Age/sex/
Case/country location Medical history Background- and scene investigation Cause of death/autopsy finding Perpetrator(s)

23l/Italy 2018 80 years/M/ Arterial hypertension; The victim was looked after by a caregiver at home. On a visit, Cause of death: multi-organ failure secondary to Caregiver
Home atrial fibrillation; the victim’s son, who had not seen his father for some time, noted sepsis.
chronic obstructive that his father’s condition had markedly deteriorated. The victim Autopsy results: cachectic;
pulmonary disease; was clearly unwell, severely undernourished, with poor hygiene, Extensive, advanced bedsores (sacral region and
The Gerontologist, 2020, Vol. 60, No. 6

Parkinson’s disease; and very pale skin. The victim was taken to hospital, where he both heels); myocardial sclerosis; pulmonary em-
multi-infarct enceph- was diagnosed with severe dehydration, malnutrition, sunken physema; marked bilateral pulmonary edema
alopathy (for about 3 abdomen, extensive advanced bedsores, infection of the urinary
years); pathways (Streptococcus faecalis). The victim died a month later
cerebral involution; (clinical diagnosis: sepsis due to Serratia Marcenses, dehydration,
multiple electrolyte imbalance). The son reported the caregiver to the judi-
hospitalizations due cial authorities; an autopsy of the body was performed
to worsening mental
state
Nonfatal case reports
1m/United 73 years/M/ Alzheimer’s disease; Responding to a call from adult protective services paramedics — Son
States 2016 Home/ED alcoholism; to- found the victim in a dimly lit bedroom lying in the fetal po-
bacco use; diabetes; sition, clothed in only a T-shirt; emaciated, filthy and in pain.
chronic obstructive Examination emergency department: disorientation, generalized
pulmonary disease weakness, contractures, cachexia, hypoalbuminemia, severe
malnutrition (body mass index of 15.6 kg/m2), decubitus ulcers,
non-small cell lung cancer (metastasized to bone). His son who
lived with him was intoxicated when the paramedics arrived.
Adult Protective Services brought the case to an elder abuse
forensic center for review. The victim had not consulted a phy-
sician in several years and was not receiving any medications
or in-home services. Three years before an examination had
detected a suspicious mass in his lung. He did not attend further
medical appointments, medications were not refilled. When
asked why he did not take his father to a physician or administer
medications, the son, who was intoxicated when adult protective
services arrived, stated that his father did not need a doctor be-
cause he was dying. The son was compensated through the state’s
In-Home Supportive Services program and he was the represen-
tative payee for the victim’s social security benefits
e459

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Table 1. Continued
e460

Age/sex/
Case/country location Medical history Background- and scene investigation Cause of death/autopsy finding Perpetrator(s)

2m/United 85 years/M/ Cognitive The patient was brought to the emergency department by his — Daughter
States 2016 Home/ED decline; end-stage daughter, who lived in his home. He was nonverbal and presented
Parkinson’s disease with significantly deteriorated health, impaired physical and
cognitive function, malnutrition, contractures and multiple decubitus
ulcers (developed during a temporary stay at a nursing facility). The
physician believed that the patient required professional care and
made a report to Adult Protective Services with suspicion of elder
neglect. The daughter, who lived with him, believed that she could
provide better care than he would receive in a nursing facility and
wanted to respect her father’s wishes to be cared for at home (she
sought hospital care for her father in emergency situations). She was
able to demonstrate how she rotated her father to relieve pressure,
changed his dressings, and administered medication, proving she
routinely did these tasks. The bedroom was furnished with a hospital
bed, an air mattress to prevent decubitus, a lift to transport the
patient to a wheelchair, an intravenous-fluid pole to administer
fluids, and a supply of gauze pads. Records showed that a home
care agency had come weekly until the patient’s condition became so
severe that they refused to accept liability for his care. The daughter
admitted that she had difficulties accepting his diagnosis

a
Shields, Hunsaker & Hunsaker (2004).
b
Collins & Presnell (2007).
c
MRSA indicting methicillin-resistant S aureus.
d
Karch & Nunn (2011).
e
Centers for Disease Control and Prevention. (2015). National Violent Death Reporting System (NVDRS) coding manual; Karch & Nunn (2011).
f
Paranitharan & Pollanen (2009).
g
Báez-Molgado, Peñaloza, Spradley & Bartelink (2013).
h
Akaza et al., 2003.
i
Satoh, Seto, Hasegawa & Osawa (2012).
j
Ortmann, Fechner, Bajanowski & Brinkman (2001).
k
Rickert, Karger, Varchmin-Schultheiss, Brinkmann & Paulus (2001).
l
Ventura, Caputo & Molinelli (2018).
m
DeLiema, Homeier, Anglin, Li, & Wilber (2016).
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The Gerontologist, 2020, Vol. 60, No. 6
however can be complex and physiological states may de-
velop in older adults that are not caused by neglect.
To accommodate the complexity of elder maltreat-
ment and the contextual aspects involved in it, a number
of scientists have turned to the ecological model, which
was originally used as a paradigm with which to study
child abuse and neglect (Krug et al., 2002). The ecological
research attempt tries to compile and integrate the com-
plexity of public health problems by considering the re-
lationship between individual, cultural and social aspects
when construing causality (Bonnie & Wallace, 2003;
Fulmer et al., 2005; Pillemer et al., 2016; WHO, 2011).
In the case reports mentioned in this study, most victims
were women cared for by adult children, which may partly
be explained by the sociodemographic characteristics of
this age group (i.e., longer life expectancy of women, with
children being the next of kin). Supplementary Table 1
gives an overview of how some of the sociodemographic
characteristics mentioned here compare with correlates of
neglect in population-based studies. Most victims in this
review had medical/psychiatric disorders which require a
high degree of care, such as stroke, Parkinson’s disease or
dementia. In dementia, the situation can be exacerbated,
if the older adult living with dementia exhibits difficult
behaviors and provocative actions (e.g., aggression, being
unwilling or unable to uphold proper nutrition, hydration
and hygiene, not using appliances safely, and wandering).
In the majority of cases in this qualitative review adult
sons were involved as perpetrators. This is unexpected be-
cause it is generally assumed and borne out by a number
of quantitative studies, that daughters are at least equally
involved in the care of elderly parents. Most of the cases
are based on reports which came to the attention of the
Medical Examiner’s Office and may therefore be biased
towards reports with a fatal outcome, also affecting other
characteristics. There is limited empirical research into the
potential difficulties adult sons may encounter when caring
for elderly parents. According to a number of studies and
narrative accounts, intrinsic risk factors such as a mental
illness and contextual factors such as longstanding family
issues, the way a person was brought up as a child (e.g.,
tolerance toward negligence and violence against weaker
family members), not having a perspective in life, being un-
employed, having debts, and being financially dependent
on an elderly parent may lead to resentment and aggres-
sion. Parents may be seen as an economic resource, and vio-
lent interaction may follow noncompliance with the child’s
requests (Anetzberger, 1987; Bonnie & Wallace, 2003;
Dolan, 1999; Kahn, Goldscheider & García-Manglano,
2013; Kieselbach, 2013; Kosberg, 1983; Mighdoll, 2005;
Payne, 2000; Sengstock & Liang, 1982; Elder abuse by
adult children, n.d.).
Beyond the family relationship the case reports did not
yield much information on perpetrator characteristics.
Most perpetrators lived with the victim and emotional and/
or financial dependency on the victim was mentioned in
e461
five cases, such as the case of a 84-year-old woman whose
sons refused to treat her decubitus ulcers, left her in urine
soaked diapers and linen filthy with vomit in the basement
because they needed a place to live and were financially
dependent on the victim (Karch & Nunn, 2011, Table 1).
Contrasting this type of deliberate neglect is the case of a
daughter whose father presented to the emergency depart-
ment with malnutrition, decubitus ulcers and significantly
impaired physical and cognitive function (DeLiema et al.,
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2016, Table 1). After a home evaluation it became apparent
that the daughter was desperately (if unsuccessfully) trying
to care for her father at home. A hospice agency was found
and she was referred to respite and counselling services.
This case was not further investigated by law enforce-
ment. In 11 cases in this qualitative review statements to
the police and/or the outcome of legal proceedings indi-
cated that intentional neglect was involved, whereas in 6
cases mitigating circumstances indicated that neglect was
deemed either not serious or not willful.
In summary, dependency, rapid decline of cognitive or
physical health, social isolation, proximity to the perpe-
trator, cessation of medical appointments for the victim
and, mental health needs, abusive personality traits, al-
cohol- and substance use, financial and/or emotional de-
pendency on the victim and minimal social contact in the
perpetrator should raise alertness in clinicians, allied health
professionals, and investigative agencies about the potential
of neglect. Although not every individual in such situations
is a victim of neglect, a more thorough consideration of the
case as a whole is warranted. However, research on some of
the aforementioned risk factors has also yielded contradic-
tory results (Bonnie & Wallace, 2003). Neglect may occur
where these indicators are not apparent (Krug et al., 2002;
Supplementary Table 1).
Neglect can exacerbate age-related frailty, physical di-
sease, dementia, and loss of social contacts. When criminal
or civil litigation arises, the court has to make the deci-
sion whether neglect was intentional or unintentional and
whether it was a direct cause of death (e.g., sepsis) or indi-
rectly exacerbated other causes of death (e.g., dehydration
and malnutrition can decrease the likelihood to survive an
infection or heart condition).
Forensic medicine occupies itself with assisting law en-
forcement in finding and gathering evidence of the omis-
sion of relevant caring acts in the course of related duty.
Neglect may result in unexplained falls and injuries, ex-
cessive repeat prescriptions or under-usage of medication
(medical neglect), malnourishment or dehydration without
an illness-related cause, evidence of inadequate care or
poor standards of hygiene, or behavioral and emotional
indicators in the older adult such as a change in the eating
pattern or sleep problems (Krug et al., 2002). States of fear,
confusion or resignation with a newly identified passivity,
withdrawal or increasing depression in an older person may
have to be explained (Brnovich, n.d.). Helplessness, hope-
lessness, or anxiety may lead to contradictory statements
e462
or other ambivalence not resulting from mental confusion.
Other suspicious behavioral signs include the reluctance to
talk openly and the avoidance of physical, eye, or verbal
contact with the caregiver. The potential for a verbal or be-
havioral testimony for neglect may cause the tragic situ-
ation whereby the elderly person is being isolated. Other
causes for an older adult’s isolation include infantilization
and overprotection of the elderly person in the name of af-
fection, thereby reducing the necessary acceptance and as-
sumption of capacity on basis decisions (Krug et al., 2002).
Physical Indicators for Neglect
As the case reports illustrate, malnutrition, dehydration,
poor hygiene, untreated decubitus ulcers, hypothermia,
contractures, and an uncooperative caregiver are red flags
for neglect (Bonnie & Wallace, 2003; Collins, 2006; Di
Maio & Di Maio, 2001; Di Maio & Dana, 2007; Dyer
et al., 2003; Fox, 2012; Friedman et al., 2017; LoFaso &
Rosen, 2014). It is important to note that an older person
may be entirely dependent upon their family for provision
of physical and medical care. In some cases a diagnosis of
neglect may be complex. A key to interpreting physiolog-
ical indicators of neglect are characteristics such as extent,
location, severity, morphology, and multiplicity as well
as the context in which they occur. There are important
differences between intentional and unintentional neglect,
and disease-related symptoms which can mimic neglect
despite a caregiver’s best efforts. Additional challenges to
correctly classify the overlap among markers of disease
and neglect in older adults are posed by normal changes of
aging, multiple comorbidities, and medication effects.
Signs of malnutrition include weight loss, poor wound
healing, frequent infections, decreased total protein, al-
bumin and iron binding capacity. Age-related changes that
can mimic neglect include loss of taste and smell, changes in
the gastrointestinal system (e.g., decreased peristalsis), poor
dentition and dysphagia (all of which can result in loss of
appetite, decreased digestion and nutrient absorption) and
decreased adipose and muscular tissue. Certain organic
diseases (e.g., hypothyroidism; malabsorption syndromes;
inflammatory bowel syndrome), depression, dementia, and
certain medications may also contribute to weight loss and
malnutrition. Vascular disease, smoking, diabetes, infection,
and renal failure can lead to poor wound healing. However,
malnutrition is often a marker of neglect. More than 40%
loss of body weight can result in death. Caregivers may also
fail to maintain oral hygiene, which can lead to poor den-
tition and malnutrition (Boss & Seegmiller, 1981; Collins,
2006; Di Maio & Di Maio, 2001; Di Maio & Dana,
2007; Dyer et al., 2003; Fox, 2012; Friedman et al., 2017;
Hickson, 2006; Homeier, 2014; Quinn & Tomita, 1997).
Signs of dehydration can include dry mouth, rapid heart
rate, low blood pressure, tenting of skin, sunken eyes, dry
serosal surfaces, abnormal urine concentration and fecal
impaction. Dehydration is associated with electrolyte and
The Gerontologist, 2020, Vol. 60, No. 6
acid–base imbalances. Older adults, however, are more
prone to dehydration than younger people and dehydra-
tion may originate from causes other than caregiver ne-
glect. For example a well-meaning caregiver or the older
adult themselves may, in cases of incontinence, decide to
decrease water intake to prevent bed-wetting or the ne-
cessity of frequent clothes changes. Older adults may ex-
perience a reduced thirst sensation. Altered renal water
absorption, diuretic medication, diabetes, Addison’s di-
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sease and chronic renal disorders may also predispose to
dehydration (Besdine, n.d.; Billett, 1990; Boss & Seegmiller,
1981; Busher, 1990; Collins, 2006; Di Maio & Di Maio,
2001; Di Maio & Dana, 2007; Dyer et al., 2003; Fox,
2012; Hooper et al., 2016; LoFaso & Rosen, 2014; Quinn
& Tomita, 1997).
Advanced-stage or multiple decubitus ulcers with
signs of infection or poor care are evidence for medical
neglect. Insufficient hygienic conditions (such as lying in
feces and urine) promote skin lacerations and infection.
If sepsis contributes to a fatal outcome, detailed forensic
examinations may inform whether an untreated pres-
sure ulcer was the source of sepsis. Such an association
provides evidence of fatal neglect. On the other hand, de-
cubitus ulcers are not uncommon in older non ambulatory
adults. Immobilization and prolonged pressure over bony
prominences can lead to pressure ulcers. Conditions which
affect an older person’s mobility (e.g., stroke, Parkinson di-
sease, dementia), reduced sphincter pressure and bladder
capacity as well as age-related skin and metabolic changes
(e.g., decreased elasticity, poor perfusion, reduced absorp-
tion of nutrients, ready occurrence of senile purpure and
lacerations) may lead to pressure ulcers and may be mis-
taken for caregiver neglect. Certain diseases (e.g., neurolog-
ical disease, peripheral vascular disease, diabetes, anemia)
and poor nutritional status can also predispose an older
adult to decubitus ulcers. Documentation of pressure sores
should include measurements of size, depth, and location.
Multiple and advanced stage decubitus ulcers, omission
to adhere to the standard of care and failure to bring ne-
crotic ulcers to the attention of a physician indicate neglect
(Collins, 2006; Di Maio & Di Maio, 2002; Dyer et al.,
2003; Fox, 2012; Gibbs, 2014; LoFaso & Rosen, 2014;
Quinn & Tomita, 1997; Roy & Russell, 2006).
Fractures. In the case report by Ortmann et al. (2001) the
right tibia fractured at the site of an infected decubitus ulcer
and medical neglect (i.e., the caregiver did not seek medical
treatment or did not care for the older adults organic diseases)
was clearly evident. However, age and disease-related
changes can also predispose the older adult to fractures.
Medical conditions that affect bone integrity include oste-
openia and osteoporosis, which are frequently found in this
population. Spontaneous vertebral and hip fractures may
occur. A number of conditions (e.g., impaired balance, coor-
dination, strength and reaction time, stroke, hypotension, ar-
rhythmia and diabetic neuropathy) can make an older adult
prone to falls. Certain medications may weaken the bone as
The Gerontologist, 2020, Vol. 60, No. 6
well. Bisphosphonate therapy is associated with spontaneous
fractures of the infra-trochanteric femur. Documentation of
fractures and bruising should include a detailed descrip-
tion of size, color, extent, and location. Multiple fractures
of differing ages should raise the suspicion of maltreatment
(Boss & Seegmiller, 1981; Collins, 2006; Gibbs, 2014; Dyer
et al., 2003; Fox, 2012; Homeier, 2014).
Hypothermia and Hyperthermia. Fatal hypothermia was
listed as the cause of death in one case (Akaza et al., 2003).
Although older adults may be more vulnerable to hypo- or
hyperthermia due to diminished perception of temperature
changes and reduced internal temperature regulation, these
situations are preventable. Older adults may try to save
money on heating and electricity bills (Di Maio & Di Maio,
2001; Quinn & Tomita, 1997).
Contractures entail a stiffening of the joints resulting
in shortened muscles and potential paralysis or spasms.
Contractures result in many negative consequences such as
pain, increased fall risk, difficulties with hygiene, and other
activities of daily living. Mounting evidence from experi-
mental and clinical studies suggests that immobility or even
inactivity may lead to contractures. Contractures may there-
fore be an indicator of neglect (Offenbächer et al., 2014;
Payne, 2000; Saal et al., 2017; Wagner & Clevenger, 2010).
Although the aforementioned physiological markers
could be explained in the context of medical comorbidity
health professionals should be alerted to the potential of
intentional or unintentional neglect.
Lack of professional awareness and training and the
complexity of individual situations may contribute to
underreporting of neglect. Screening tools for elder abuse
(including items to identify neglect) have been developed
and are being trialed in a variety of health care settings
(Gallione et al., 2017; McCarthy, Campbell & Penhale,
2017). Educational programs for professional staff to im-
prove recognition have been trialled with promising results
(Alt, Nguyen, & Meurer, 2011). A number of recent policy
initiatives to respond to the abuse and neglect of older
adults have been implemented in a variety of countries for
which results are being awaited (Ormsby, 2019; Porter,
2019). The findings in this review highlight the importance
of detailed documentation as well as collaboration between
clinicians, allied health professionals, law enforcement and
medical forensic services to improve patient outcomes and
reduce the risk of further incidents.
Study Limitations
Many of the case reports in this review involved cases which
came to the attention of the justice system. They clearly
represent the extremes of neglect. Not all cases of neglect
have such severe outcomes. However, the identified phys-
ical indicators (malnutrition, dehydration, poor hygiene,
untreated decubitus ulcers, hypothermia, hyperthermia,
contractures, fractures) are also applicable for cases with
e463
a less severe outcome–—as judged from quantitative study
results, a large number of scientific publications and in-
formation on websites and other resources for elder abuse
(i.e., Bonnie & Wallace, 2003; Collins, 2006; Di Maio &
Di Maio, 2001; Di Maio & Dana, 2007; Dyer et al., 2003;
Fox, 2012; Friedman et al., 2017; LoFaso & Rosen, 2014).
The content of the review is limited by the content of the
case reports (mainly medical, psychiatric, and pathophys-
iological characteristics of the victim). Other search terms
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and a wider time frame may have resulted in additional
case reports and possibly additional or different victim/
perpetrator characteristics. Non-physical indicators of ne-
glect, as well as social and cultural aspects (such as so-
cial and cultural norms, where elder abuse and neglect is
tolerated; the influence of civil and criminal laws and the
criminal justice system, etc.) can play a profound role in
this context. Such factors were not often mentioned in the
case reports.
Conclusion
In conclusion, neglect is associated with poor physical, psy-
chological, and mental health. Neglect can be a direct cause
of death or contribute to a fatal outcome by exacerbating
existing conditions. From a medical, psychiatric, and fo-
rensic perspective evidence of neglect is not easy to obtain
due to age and disease-related changes.
Supplementary Material
Supplementary data are available at The Gerontologist online.
Conflict of interest
We have no conflict of interest to declare.
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