Elderly victims of NAT are less likely to have fractures than victims of accidental trauma.⁶ However, research has indicated that certain types of fractures are more likely to occur in victims of NAT. Skull, face, and rib fractures are more often a result of NAT than of falls. Victims of elder abuse are also more likely to have multiple fractures.⁹ 

Reporting

Reporting requirements for elder abuse vary among jurisdictions. In most states, Adult Protective Services receives and investigates reports of elder abuse and neglect. It is important to know the reporting requirements and procedures for the jurisdictions in which you practice. Hospital social workers or clinical forensic examiners may be able to assist with reporting.

Case Conclusion

On further examination, the patient is found to have bruising on her back. A CT scan of the head does not show any acute traumatic injury. Given your concern for nonaccidental injury, you consult the forensic examiner’s team for assistance. Photos are taken for the medical record, and the case is reported to Adult Protective Services. The patient is discharged in the care of her daughter pending an investigation.

Dr. Rozzi is an emergency physician, medical director of the Forensic Examiner Team at WellSpan York Hospital in York, Pennsylvania, and secretary of ACEP’s Forensic Section.

Dr. Riviello is chair of emergency medicine at Crozer-Keystone Health System and medical director of the Philadelphia Sexual Assault Response Center.

References

1. Centers for Disease Control and Prevention. About Abuse of Older Persons. 2025. https://www.cdc.gov/elder-abuse/about/index.html. Accessed September 11, 2025.
2. Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and Correlates of Emotional, Physical, Sexual, and Financial Abuse and Potential Neglect in the United States: The National Elder Mistreatment Study. Am J Public Health 2010;Feb;100(2):292-297.
3. Acierno R, Hernandez-Tejada M, Muzzy W, Steve K. The National Elder Mistreatment Study. U.S. Department of Justice. 2009. Document 226456. https://www.ojp.gov/pdffiles1/nij/grants/226456.pdf.
4. Lifespan of Greater Rochester, Inc., Weill Cornell Medical Center of Cornell University and the New York City Department for the Aging. 2011. Under the Radar: New York State Elder Abuse Prevalence Study. https://ocfs.ny.gov/reports/aps/Under-the-Radar-2011May12.pdf. 
5. Wiglesworth, A, Austin, R, Corona, M, et al. Bruising as a Marker of Physical Elder Abuse. J Am Geriatr Soci 2009;57:1191-1196.
6. Rosen T, LoFaso VM, Bloemen EM, et al. Identifying Injury Patterns Associated With Physical Elder Abuse: Analysis of Legally Adjudicated Cases. Ann Emerg Med 2020; 76(3):266-276.
7. van Houten ME, Vloet LCM, Pelgrim T, et al. Types, characteristics and anatomic location of physical signs in elder abuse: A systematic review: Awareness and recognition of injury patterns. Eur Geriatr Med 2022;13(1):53-85.
8. Ziminski, CE, Wiglesworth, A, Austin, R, et al. Injury patterns and causal mechanisms of bruising in physical elder abuse. JForensic Nurs 2013; 9(2):84-91.
9. Gardezi M, Moore HG, Rubin LE, Grauer JN. Predictors of Physical Abuse in Elder Patients with Fracture. J Am Acad Orthop Surg Glob Res Rev 2022; 12;6(7):e22.00144.