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In recent years, the num-ber of reports of elder abuse has risen as a result of greater family involvement in caregiving relation-ships with the elderly as well as the increase in the nu

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Elder abuse is a pervasive social and

medical problem that is suspected to

be a major source of morbidity and

mortality In recent years, the

num-ber of reports of elder abuse has

risen as a result of greater family

involvement in caregiving

relation-ships with the elderly as well as the

increase in the number of elderly

persons with chronic debilitating

diseases.1 Because of the increasing

public outcry about the widespread

public health problem of elder

abuse, all states now have abuse laws that are specific for older adults, and most states mandate reporting of elder abuse by health-care professionals However, physi-cians infrequently report elder abuse for a number of reasons, among them lack of familiarity with the reporting laws, fear of offending pa-tients or infringing on the autonomy

of competent individuals, concerns about time limitations and paper-work, or the belief that they do not

have the appropriate evaluation skills.2

Approximately 2.5 million cases

of elder abuse are reported

annual-ly, and as the population grows, this number will likely increase As this number represents only reported cases, it is undoubtedly an underes-timation of the actual incidence.3 A recent investigation reported the results of the first nationwide inci-dence study of abuse and neglect in noninstitutionalized elderly per-sons, estimating that 1% to 2% of older persons living in their homes are abused physically, emotionally, sexually, and/or financially, and that as many as five times more incidents go unreported.4 The exact magnitude of the problem is not easily quantifiable, although the most frequently cited estimate of community prevalence of elder abuse is 32 cases per 1,000 persons.3

Dr Chen is Resident, Department of Ortho-paedic Surgery, New York University–Hospital for Joint Diseases Orthopaedic Institute, New York, NY Dr Koval is Associate Professor and Chief, Fracture Service, Department of Orthopaedic Surgery, New York University– Hospital for Joint Diseases Orthopaedic Institute.

Reprint requests: Dr Koval, Hospital for Joint Diseases Orthopaedic Institute, 301 East 17th Street, New York, NY 10003.

Copyright 2002 by the American Academy of Orthopaedic Surgeons.

Abstract

Increased awareness of elder abuse has led to the recognition that mistreatment of

individuals over the age of 65 years is a widespread public health problem It is

estimated that the prevalence of elder abuse is 32 cases per 1,000 persons and is

increasing with the growing elderly population Elder abuse is suspected to be a

major source of morbidity and mortality, representing a high economic burden to

society The diagnosis of elder abuse is seldom straightforward due to social

issues, cognitive impairment, and comorbid conditions, and requires careful

cor-relation of historical and clinical findings Comprehensive evaluation, including

a detailed history, systematic physical examination, and appropriate laboratory

and radiographic assessment, is essential The orthopaedic surgeon consulted to

evaluate an elderly individual with musculoskeletal injuries must be cognizant

of the potential for elder abuse, especially when circumstances are suspect The

role of the orthopaedic surgeon is often fundamental to establishing whether

musculoskeletal injuries are consistent with the stated mechanism of injury.

Due to the variety of presentations, there are no fracture patterns considered

pathognomonic of elder abuse Rather, the nature and pattern of injury must be

viewed in the context of the general health and psychosocial environment of the

patient to determine whether abuse has occurred Once the diagnosis of elder

abuse has been made, a comprehensive, multidisciplinary long-term care plan

must be formulated to ensure patient safety while respecting the autonomy of a

competent individual Physicians have an ethical and legal responsibility to

pro-tect patients from suspected abuse, and most states mandate reporting by

health-care personnel.

J Am Acad Orthop Surg 2002;10:25-31

Surgeon in Diagnosis and Management

Andrew L Chen, MD, MS, and Kenneth J Koval, MD

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The difficulty of collecting more

accurate statistics is likely related to

underrecognition or denial of abuse

by community members and health

professionals This is compounded

by a poor understanding of the signs

and symptoms associated with elder

abuse, which may be mistaken for

age-related changes or signs of

dis-ease.5 Elderly persons may be

reluc-tant to report abuse because of fear

of family embarrassment, fear of

iso-lation from caregivers, or stoicism.6

Furthermore, negative stereotyping

of the elderly and age-related

dis-crimination may result in the

unjus-tified labeling of elderly persons as

demented, thus diminishing the

credibility of abuse reports

Definition of Abuse

The precise definition varies by

state agency, but in general the

term “elder abuse” refers to the

in-fliction of physical pain, injury,

mental anguish, or deprivation by a

caretaker who performs services

necessary for the physical and

men-tal well-being of an individual over

the age of 65 years Elder

mistreat-ment may occur as a result of

abu-sive behavior, in which purposeful

acts of harm or injury are inflicted

by the abuser, or neglectful

behav-ior, in which attention to specific

needs is withheld or delayed

Ac-tive neglect occurs when the

re-sponsible party is cognizant of his

or her neglectful actions Passive

neglect implies a lack of awareness

of the mistreatment and what

spe-cific needs are not being met.5 For

example, the intentional

withhold-ing of necessary medications from

an elderly individual constitutes

active neglect, but unintentional

failure to provide adequate

nutri-tion to an elderly individual may

constitute passive neglect

Abuse extends to any violation of

the individual’s sphere of well-being

and includes physical,

psychologi-cal, financial, and material forms

Physical abuse refers to any unwanted physical contact, including the inflic-tion of bodily injury, physical pain,

or unsolicited sexual contact Psy-chological abuse refers to the inflic-tion of mental or emoinflic-tional anguish

Financial or material abuse involves the exploitation of an individual for financial or material gain.7

Abuse that occurs in a medical, long-term care, or board-and-care facility is referred to as “institutional abuse.” Although a minority of physicians provide care in that set-ting, patients living in such facilities may be encountered in outpatient offices, inpatient facilities, or emer-gency settings, thus providing op-portunities for physicians to recog-nize sequelae of abuse Abuse in the institutional setting may be perpe-trated by visitors, other residents of the institution, or members of the staff In a random-sample survey of nursing home staff members, 10% of nurses’ aides reported that they had committed at least one act of physi-cal abuse in the preceding year, and 40% reported at least one act of psy-chological abuse.8 Institutional abuse may also include unreason-able restraint, isolation from other re-sidents, failure to respect the wishes

of a competent individual, and fail-ure to devise or implement a goal-oriented extended-care plan.9

Risk Factors for Abuse

Approximately 1% to 2% of elderly persons living in their own homes are abused.10 The term “victim char-acteristics” refers to a constellation of psychosocial traits, conditions, and behaviors that may increase the risk

of abuse These include dementia, poor physical and emotional health, disruptive or aggressive behavior, social dysfunction, and prior vio-lence or abusive acts by the victim toward the abuser.11 Other risk fac-tors are listed in Table 1 Gender has

not been identified as an indepen-dent risk factor Pooled logistic regression analysis has identified increasing age, race, poverty, func-tional disability, and cognitive im-pairment as additional risk factors for elder mistreatment.10 A strong association between reported child abuse and reported elder abuse

with-in a regional population has been reported, suggesting a correlation between geographic demographics and risk of elder abuse.12

Abusers are predominantly adult children, spouses, and other rela-tives, and are often financially de-pendent on the abused person.10 A caregiver history of psychiatric ill-ness, including depression, person-ality disorder, social dysfunction, or alcohol abuse, may increase the risk

of elder abuse The “caregiver stress hypothesis,” which maintains that elder abuse is the result of resent-ment and frustration engendered by the long-term responsibility for care

of dependent elders, is controver-sial.2,9 Stress for the caregiver arises from social isolation, especially when the elderly person needs full-time care; the frustration of dealing with declining health or terminal ill-ness; the possible strain of financial resources; and a lack of understand-ing of the patient’s needs This may

be compounded by the lack of in-volvement of other family members

or by a sense of ingratitude Among institutional caregivers, risk factors for abuse include a history of previ-ous abuse, job dissatisfaction, de-pression, burnout, a tendency to in-fantilize the elderly, and a stressful personal life

History and Clinical Features

A detailed history is essential when elder abuse is suspected The pa-tient, caregiver, and any other rele-vant persons should all be inter-viewed individually Any conflicting

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information should be noted and

investigated Patients typically are

reluctant to discuss the abuses they

have received because of a fear of

reprisal, a sense of being thought ungrateful, or unwillingness to im-plicate a friend or relative The in-terview must, therefore, be

comfort-able and psychologically supportive;

an accusatory or probing tone may result in disinclination on the pa-tient’s part to reveal any abuse that has occurred

The interview should be initiated with general questions concerning the patient’s perceptions about his

or her own care within the house (or institution) and should progress

to more specific questions about feelings of safety, disagreements, delayed meals or medication, and any aggressive behavior or unso-licited contact on the part of anyone toward the patient Early con-frontation is likely to be counter-productive in terms of disclosure of information; a nonaggressive, im-partial approach that is cognizant of the suspected abuser’s feelings and stresses is more conducive to an effective informational interview.5

Elderly persons suffer a variety

of chronic diseases that can mimic the signs and symptoms of abuse Dramatic cases of abuse are typically not difficult to diagnose, but subtle

or contradictory physical and psy-chological signs and symptoms may require high-level clinical investiga-tion or diagnostic testing Common physical findings consistent with abuse include bodily injury without reasonable cause or explanation and multiple wound sites in various stages of healing Evidence of dehy-dration, long-standing malnutrition, poor hygiene, and unmet medical needs are pertinent findings if they are inconsistent with the patient’s standard of living Finally, with-drawal, refusal to make eye contact, and wariness of contact with the suspected abuser are also warning signs Other presentations that are suggestive of abuse or neglect are listed in Table 2

Physical Examination

When elder abuse is suspected, a de-tailed, systematic, multidisciplinary

Table 1

Risk Factors for Abuse of the Elderly *

Poor health and functional - Disability reduces the elderly

impairment person’s ability to seek help

and defend himself or herself

Cognitive impairment Aggression toward the caregiver

and disruptive behavior resulting from dementia may precipitate abuse Higher rates of abuse have been found among patients with dementia

Substance abuse or mental illness on Abusers are likely to abuse alcohol

the part of the abuser or drugs and to have serious mental

illness, which in turn leads to abusive behavior

Dependence of the abuser on the Abusers are very likely to depend on

victim the victim financially, for housing,

and in other areas Abuse results from attempts by a relative (espe-cially an adult child) to obtain resources from the elderly person

Shared living arrangements Abuse is much less likely among

elderly people living alone A shared living situation provides greater opportunities for tension and conflict, which generally pre-cede incidents of abuse

External factors causing stress Stressful life events and continuing

financial strain decrease the family’s resistance and increase the likeli-hood of abuse

Social isolation Elderly people with fewer social

con-tacts are more likely to be victims

Isolation reduces the likelihood that abuse will be detected and stopped In addition, social support can buffer the effects of stress

History of violence Particularly among spouses, a history

of violence in the relationship may predict abuse in later life

* Reprinted with permission from Lachs MS, Pillemer K: Abuse and neglect of elderly

persons N Engl J Med 1995;332:437-443 Copyright 1995 by the Massachusetts

Medical Society All rights reserved.

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evaluation is required (Table 3) An

informal mental status examination

should be performed initially, and

risk factors for abuse, such as

cogni-tive impairment, noted A

compre-hensive physical examination should

also be performed, with close

atten-tion paid to the interacatten-tion of the

patient with the suspected abuser

The general appearance of the patient

should be noted, including the

man-ner in which the patient is dressed

and the level of cleanliness The skin

should be scrutinized for evidence of old injuries The head and scalp should be examined for evidence of trauma, lacerations, or alopecia, which may be suggestive of hair-pulling The oral cavity and nares should be carefully examined for evi-dence of dental or mucosal injury that may otherwise go unrecognized

on an external examination.13

Frequent manifestations of phy-sical abuse include bruises, sprains, abrasions, lacerations (particularly

evidence of old lacerations that healed by secondary intention), head injuries, burns, and unexplained frac-tures.9 With musculoskeletal inju-ries, the role of the orthopaedist is to determine the age and nature of the injury, whether the injury is associ-ated with other injuries that may be suggestive of abuse, and whether there are other fractures in various stages of healing or healed but mal-aligned Musculoskeletal injuries must be carefully evaluated, with correlation of soft-tissue and overly-ing skin injuries (e.g., lacerations, contusions, ecchymoses) Cogni-tively impaired patients require examination and palpation of all extremities The orthopaedist must decide whether the injury is consis-tent with the mechanism of injury, and must remain cognizant of the possibility of an underlying disorder, such as a malignant condition, that may explain a fracture after seem-ingly minor trauma

Diagnostic Evaluation

Laboratory tests may be indicated, depending on the index of suspicion

of abuse and the results of the physi-cal examination Laboratory tests should include (1) a complete blood cell count with platelet count; (2) serum electrolyte, blood urea nitro-gen, and serum creatinine levels (to assess dehydration and diabetic control); (3) prothrombin and partial thromboplastin times (to rule out coagulopathy); (4) liver function tests (to identify alcohol abuse and other metabolic problems); (5) serum albu-min level (to assess nutritional sta-tus); (6) thyroid function tests (to rule out hyperthyroidism as a cause of weight loss); and (7) urinalysis (to assess the source of fever) Toxico-logic screening may be used to demonstrate the presence of drugs or other substances that were not pre-scribed for the patient or that were prescribed at a subtherapeutic level

Table 2

Presentations That Suggest Abuse or Neglect of an Elderly Patient *

Delays between an injury or illness Lacerations healing by secondary

and the seeking of medical atten- intention, radiographic evidence of

tion healed but misaligned fractures,

presentation in extremis with decompensated chronic disease when caregiver has been monitor-ing patient

Disparity in histories from the Different mechanisms of injury

patient and the suspected abuser offered, different chronology of

or a history that is given solely injuries

by the caregiver

Implausible or vague explanations Fractures that are not explained by

provided by either party the purported mechanisms of

injury Frequent visits to the emergency Exacerbations of chronic obstructive

room for exacerbations of chronic pulmonary disease or congestive

disease despite a plan for medical heart failure due to lack or

misad-care and adequate resources ministration of medicines

Presentation of a functionally im- Patient with advanced dementia

paired patient without his or her who presents to the emergency

designated caregiver room alone

Laboratory findings that are incon- Subtherapeutic levels of drugs (e.g.,

sistent with the history provided digoxin) despite compliance

reported by caregiver, toxicologic evidence of psychotropic agents that have not been prescribed

* Adapted with permission from Lachs MS, Pillemer K: Abuse and neglect of elderly

persons N Engl J Med 1995;332:437-443 Copyright 1995 by the Massachusetts

Medical Society All rights reserved.

† The indicators of possible abuse or neglect are derived from Jones JS: Geriatric abuse

and neglect, in Bosker G, Schwartz GR, Jones JS, Sequeira M (eds): Geriatric Emergency

Medicine St Louis: CV Mosby, 1990, pp 533-542.

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Table 3

Clinical Procedures for the Detection of Abuse of an Elderly Patient *

Focus Procedure or Item to Be Noted

History Interview the patient and the suspected abuser separately and alone

Make direct inquiries about physical violence, restraints, or neglect

Request precise details about nature, frequency, and severity of events

Assess the patient’s functional status (independence, activities of daily living)

Inquire who is the designated caregiver if impairment in activities of daily living is present Assess recent psychosocial factors (e.g., bereavement, financial stress)

Elicit caregiver’s understanding of patient’s illness (e.g., care needs, prognosis)

Behavioral observation Withdrawal

Infantilizing of patient by caregiver Caregiver who insists on providing the history General appearance Hygiene

Cleanliness and appropriateness of dress Skin and mucous Skin turgor, other signs of dehydration

membranes Multiple skin lesions in various stages of evolution

Bruises, decubitus ulcers Evaluate care of skin lesions Head and neck Traumatic alopecia (distinguishable from male-pattern alopecia on the basis of distribution)

Scalp hematomas Lacerations, abrasions Trunk Bruises, welts (the shape may suggest an implement, such as an iron or belt)

Genitourinary tract Rectal bleeding

Vaginal bleeding Decubitus ulcers, infestations Extremities Wrist or ankle lesions suggesting the use of restraints or an immersion burn

(stocking-glove distribution) Musculoskeletal system Examine for occult fracture, pain

Observe gait Neurologic-psychiatric status Conduct a thorough evaluation to assess focality

Depressive symptoms, anxiety Other psychiatric symptoms, including delusions and hallucinations Formal mental-status testing

Cognitive impairment suggesting delirium or dementia has a role in assessing decision-making capacity

Imaging and laboratory tests As indicated from the clinical evaluation (serum albumin, blood urea nitrogen, and serum

creatinine levels, toxicologic screening [assess caregiver’s compliance with medical regimen]) Social and financial resources Inquire about other members of the social network available to assist the elderly person

and about financial resources (this information is crucial in considering interventions that include alternative living arrangements and home services)

*Adapted with permission from Lachs MS, Pillemer K: Abuse and neglect of elderly persons N Engl J Med 1995;332:437-443.

Copyright 1995 by the Massachusetts Medical Society All rights reserved.

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Radiographic evaluation should

include plain films of the chest, as

well as any area in which a suspected

injury was noted during the

phy-sical examination If there is

evi-dence of fracture, one should assess

whether the stated history of injury

is consistent with the radiographic

picture The presence of multiple

healed fractures, especially if

mal-aligned, should raise suspicion of

abuse in the absence of a plausible

explanation, such as severe

osteope-nia A skeletal survey may be

indi-cated if the patient has multiple

sites of injury or a severe cognitive

impairment and the examiner has a

strong suspicion of abuse The

pos-sibility of pathologic fracture (e.g.,

due to malignancy or osteomalacia)

must be ruled out with further

eval-uation if the radiographic

presen-tation is suggestive of underlying

disease

If cognitive problems that are

new, unexplained, or correlated

with head injury are identified

dur-ing mental status testdur-ing, computed

tomography of the head may be

indicated If a significant weight

loss cannot be attributed to stress,

drug use, or abuse, a metastatic

workup should be initiated

Appro-priate consultation should be sought

as dictated by the results of

evalu-ation

Differential Diagnosis

The presentation of elder abuse is

extremely variable Acute and

chronic disease states that may

mimic elder abuse include delirium,

dementia, clotting disorder (which

may be manifested by bruises),

depression (malnourishment, poor

hygiene, apathy), alcoholism (falls,

bruises, malnourishment), anorexia,

malignancy (cachexia,

malnourish-ment, fractures), and gait disorders

(falls) An increased propensity

toward fractures may reflect a

dis-ruption of normal bone

homeosta-sis, such as may occur with osteo-porosis, osteomalacia, renal disor-ders, or a malignant condition

Various reports have demonstrated that prolonged bed rest, malnour-ishment, and lack of exposure to sunlight may result in “sponta-neous” long-bone fractures in the absence of obvious trauma.14-16 This emphasizes the need for thorough evaluation and consultation, if nec-essary, before interpretation of a case of suspected elder abuse

Management

After appropriate treatment of injuries, the safety of the patient must be ensured This requires a multidisciplinary approach, with coordination between the treating medical personnel and social work-ers The patient’s autonomy must

be respected during this process of establishing a secure environment

Some patients lack decision-making ability, and others will not permit

an intervention on their behalf In either case, if the physician suspects abuse and perceives that the indi-vidual is in continued danger, every alternative must be explored to maximize the safety of the patient, including removal from the care of the suspected abuser or the abusive environment The reluctance to remove an elderly person from a functional living arrangement, par-ticularly from a family member’s home, must be superseded by the ensured safety of the individual

The physician’s authority to pre-scribe hospitalization can be upheld

on the basis of documented injury

or continuing medical problems.17

The wishes of a competent

elder-ly individual who refuses to leave a confirmed abusive environment must be respected Physicians must detail all possible options of inter-vention to maximize acceptance of a positive treatment plan and empha-size to the patient that the current

situation can be improved Every effort must be made to ensure a safe environment while preserving pa-tient autonomy A court-appointed guardian or conservator may be required for patients without deci-sion-making capacity A thorough evaluation is necessary to optimize living arrangements to ensure a safe environment.5

Reporting Requirements

The Omnibus Budget Reconciliation Act of 1987 established standards for the quality of nursing home care The Older Americans Act of 1976 requires that access to nursing home ombudsmen must be provided for residents and that physicians must report elder abuse to the state om-budsman As a result, most states have laws that require health-care workers to report suspected cases of elder abuse to government or offi-cial state agencies, such as the Department of Adult Protective Ser-vices Each state, however, has de-veloped its own definition of abuse and neglect as well as mandatory-reporting regulations According to

a recent US Government Account-ing Office study, the interstate vari-ability of abuse definition and re-porting requirements obfuscates meaningful analysis and compari-son of state reporting data, although enhanced public awareness of abuse

of the elderly was likely a signifi-cant factor in the disclosure of new elderly abuse cases.14

In most states, suspicion of elder abuse by the physician is sufficient cause to initiate an information-gathering inquiry without absolute proof Many states offer immunity and anonymity to physicians who file reports of suspected abuse If evidence of abuse is established, however, the physician has a moral and legal obligation to ensure the safety of the abused individual and

to solicit permission from the

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pa-tient for family or professional

inter-vention

Summary

Abuse of individuals over the age of

65 years is a widespread public

health problem that appears to be

increasing with the growing elderly

population Although elder abuse is

suspected to be a major source of morbidity and mortality, the diagno-sis of elder abuse is seldom straight-forward The orthopaedist is fre-quently consulted to manage mus-culoskeletal injuries sustained dur-ing such abuse, and therefore must

be cognizant of the potential for elder abuse, especially when circum-stances are suspect Although there are no fracture patterns considered

pathognomonic of elder abuse, the nature and pattern of injury must be considered in the context of the gen-eral health and psychosocial envi-ronment of the patient Once elder abuse has been established and appropriate treatment rendered, a long-term care plan must be formu-lated to ensure continued patient safety while respecting the

autono-my of a competent individual

References

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by adult children: An applied

ecologi-cal framework for understanding

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intergener-ational character of quality of life Int J

Aging Hum Dev 2000;50:329-359.

2 Kleinschmidt KC: Elder abuse: A

re-view Ann Emerg Med 1997;30:463-472.

3 Pillemer K, Finkelhor D: The

preva-lence of elder abuse: A random sample

survey Gerontologist 1988;28:51-57.

4 Dolan VF: Risk factors for elder abuse.

J Insur Med 1999;31:13-20.

5 Koval KJ: Elder abuse Arch Am Acad

Orthop Surg 1998;2:45-51.

6 Otiniano ME, Herrera CR: Abuse of

Hispanic elders Tex Med 1999;95:

68-71.

7 Marshall CE, Benton D, Brazier JM:

Elder abuse: Using clinical tools to

iden-tify clues of mistreatment Geriatrics

2000;55:42-44, 47-50, 53.

8 Pillemer K, Moore DW: Abuse of pa-tients in nursing homes: Findings from

a survey of staff Gerontologist 1989;29:

314-320.

9 Lachs MS, Pillemer K: Abuse and

ne-glect of elderly persons N Engl J Med

1995;332:437-443.

10 Lachs MS, Williams C, O’Brien S, Hurst L, Horwitz R: Risk factors for reported elder abuse and neglect: A nine-year observational cohort study.

Gerontologist 1997;37:469-474.

11 Anetzberger GJ, Palmisano BR, San-ders M, et al: A model intervention

for elder abuse and dementia Geron-tologist 2000;40:492-497.

12 Jogerst GJ, Dawson JD, Hartz AJ, Ely

JW, Schweitzer LA: Community

char-acteristics associated with elder abuse.

J Am Geriatr Soc 2000;48:513-518.

13 Fenton SJ, Bouquot JE, Unkel JH: Oro-facial considerations for pediatric, adult,

and elderly victims of abuse Emerg Med Clin North Am 2000;18:601-617.

14 Kane RS, Goodwin JS: Spontaneous fractures of the long bones in nursing

home patients Am J Med 1991;90:263-266.

15 Horiuchi T, Igarashi M, Karube S, et al: Spontaneous fractures of the hip in the

elderly Orthopedics 1988;11:1277-1280.

16 Lourie H: Spontaneous osteoporotic fracture of the sacrum: An

unrecog-nized syndrome of the elderly JAMA

1982;248:715-717.

17 Clarke ME, Pierson W: Management

of elder abuse in the emergency

de-partment Emerg Med Clin North Am

1999;17:631-644.

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