Andrea Molinelli

Old age as an “alternative” to illness: gerontological and medico-legal aspects

The current trend toward an ever increasing aging population forces society to face the problem of how to care for elderly people who are exposed to the risk of so-called “elder abuse,” a phenomenon becoming increasingly widespread in Italy, as legislation does not provide a precise juridical definition of “elderly” nor does it provide for their specific protection. From a geriatric and medico-legal point of view, it is difficult to assess the cognitive performance of elderly individuals due to a number of factors, including the lack of evaluation tools with well-defined reference parameters for assessing decision-making capacities. Nonetheless, according to Italian penal code, abandoning a person incapable of self-support due to old age is considered a violation of the obligation of family assistance. Just as in the USA, which has instituted the Adult Protective Services, the Authors propose that the local health authorities provide help desks for the victims of elder abuse in Italy.

Elder abuse in Europe’s “most elderly” city: an assessment of the phenomenon and an analysis of the data from the Penal Court of Genoa from 2010 to 2015

IntroductionIn Italy, 5% of the elderly are estimated to have suffered abuse. While the Penal Code refers to generic types of abuse, such as physical and psychological maltreatment, abandonment and financial fraud, it does not specifically protect the elderly as a category.AimsTo assess the frequency and modalities of elder abuse in Genoa and its Province, and to compare these data with those reported in the literature, in order to provide a picture of the current situation that can be used by the authorities to combat this phenomenon.MethodsWe analysed the first-degree verdicts issued by the Court of Genoa regarding accusations of physical, psychological and moral abuse and maltreatment of elderly subjects (over 65 years) in the period 2010–2015.ResultsOnly 85 of the 4028 court verdicts analysed involved elderly persons: 19 cases of domestic maltreatment, 3 of abuse of the means of correction or discipline, 18 of personal injury, 5 of abandonment and 40 of circumvention (deceiving someone, especially an elderly or mentally impaired person, to obtain a profit).Discussion and conclusionsA gap was observed between the number of crimes reported to the judicial authorities (tip of the iceberg) and the estimated prevalence of the phenomenon in the literature. There is a need both to create a network of protection for the elderly involving medical and judicial specialists and to train healthcare professionals to better recognise and report cases of maltreatment.

A fatal case of iatrogenic aortic arch rupture occurred during a tracheostomy

The authors illustrate a rare case of aortic arch rupture in a 60-year-old woman, occurred during a tracheostomy performed using the Griggs method. The autopsy examination showed an aortic arch rupture in an intermediate position situated in the area between the brachiocephalic artery ostium and the left common carotid artery ostium, associated to a hemorrhage filling of the adjacent connective and muscular tissue. The death was therefore determined by cardiac arrest secondary to massive hemorrhagic hypovolemic shock caused by the aortic arch rupture. The lethal iatrogenic lesion was determined by the aortic arch traction caused by the dilatation. The surgeons incautious use of the Howard-Kelly forceps introduced in the mediastinum was therefore hypothesized.

Legal guardians and refusal of blood transfusion

A patient with k light chain multiple myeloma was sent by her General Practitioner to the Emergency Department because of severe anaemia (last haemoglobin 6.0 g/dL) and a fall to the ground that had caused trauma to the left knee and left periorbital ecchymosis. On entry to the Emergency Department the patient was found to have a haemoglobin concentration of 6.1 g/ dL. Being a Jehovah’s Witness, the patient refused a transfusion of red cell concentrates despite repeated discussion with the doctors in which the real and imminent risk of loss of consciousness and death was explained. Four days later, despite bone marrow stimulating treatment with high doses of erythropoietin (Eprex 10000 UI 3 times/week), there had been a progressive fall in the haemoglobin concentration (haemoglobin 4.4 g/dL). A person claiming to be the patient’s Guardian presented at the ward, giving the doctors an “application for the designation of temporary guardianship and emergency measures ex article 405 section 4 Civil Code” in order to safeguard, by confirming them, the wishes expressed by the patient who at that time was still conscious, lucid and demonstrated understanding of the risks related to her refusal of transfusions. Using the above case as a starting point, we, who were consulted about it in the quality of advisors for the University Hospital, analyse the medico-legal issues related to the powers of the new judicial figure introduced with Law 6/2004 of the Italian Civil Code.

Medico-legal aspects of deaths related to neglect and abandonment in the elderly

As life expectancy increases, the phenomenon of the neglect of elderly persons is becoming increasingly relevant in the fields of both medicine and social care. This work analyses the cases of two subjects whose deaths initially seemed to have been attributable to natural causes. The autopsy findings and the analysis of clinical data, however, were able to establish that neglect had played a determining role in their deaths. These cases highlight the need for healthcare workers to be more alert to the clinical signs of neglect. Finally, in cases of death, the forensic pathologist must conduct a meticulous post-mortem examination to detect the physical signs of neglect and to establish if abuse has been responsible for the death.