A 70-year-old man was brought to the emergency room by paramedics after his daughter called 911 when she found him on the floor in his home without his caregiver. The emergency room doctor reported that the patient was dehydrated and confused; he could not provide his own medical history and did not know the date. You were the admitting physician; you were told that the patient had probably fallen at home. As you examined this patient’s injuries, you began to wonder if the injuries were consistent with a fall. When you met the patient, he was receiving a fluid bolus and was still confused. On review of his chart, you found that he had a history of macular degeneration, hypertension, coronary artery disease, severe arthritis, depression, incontinence, and mild Alzheimer disease. His medications included donepezil, aspirin, clopidogrel, hydrochlorothiazide, metoprolol, and sertraline. On examination, he had multiple bruises along his right shoulder, a large bruise on his left upper arm, and a large confluence of bruises scattered across his chest. There was also an unusual linear pattern bruise on the left side of his chest (Figs. 1 and 2). After seeing him and reviewing the chart, you considered the following questions: were these injuries consistent with the history of a fall? Where was the patient’s caregiver when he fell? Was the severity of the bruising caused by aspirin and clopidogrel? Could these injuries have been caused by physical abuse?

Table 1

Physiologic changes that occur with normal aging; considerations for elder abuse

Body Composition

From young adulthood to old age, the percentage of body fat increases from 15% to 30%. This increase is accompanied by a decrease in muscle mass, total body water, and bone mass. These changes are important when considering the metabolism of medications and are part of the reason that some medications (eg, benzodiazepines) are more dangerous in older adults than younger adults.

Skin

Skin is an important organ, which provides a protective, thermoregulatory, and sensory function. The effects of aging on the skin can be divided into intrinsic and extrinsic changes.2 The epidermal cells have a slower turnover rate, causing thinning of the epidermis. This thinner epidermis also has fewer melanocytes and Langerhans cells, decreasing the barrier and immune function of the skin and increasing risk for sunburn and cancer. In the dermis, there is a decrease in fibroblasts, collagen, and elastin, causing skin wrinkling and a loss of elasticity. A diminution of subdermal fat tissue in combination with capillary fragility leaves an elder more prone to bruising from seemingly minor trauma. In addition, several medications and conditions could increase an older adult’s risk for bruising. For example, aspirin, clopidogrel, and warfarin may increase bleeding time and propensity for bruising. Diseases such as cirrhosis or myelodysplasia could cause disruptions in the clotting mechanism and predispose to bruising or bleeding. Chronic sun exposure, the predominant extrinsic factor in age-related changes, contributes to wrinkling and loss of tone in the skin.

Bone

With aging, there are changes in the architecture of both trabecular and cortical bone, as well as changes in the bone marrow. There is a reduction in trabecular and cortical bone volume, caused by an imbalance between bone formation and resorption. There is also an increase in adiposity of the bone marrow.3 These changes...