Medicolegal evaluation of forensic cases aged 65 years and older who applied to Akdeniz University Hospital between 2014-2021

Nowadays, the development of medical science and the increase in preventive measures have prolonged the average life expectancy, thus increasing the population aged 65 years and older (1). With the increase in the elderly population, they are actively involved in social life, which leads to an increase in the risk of trauma exposure in individuals aged 65 years and over. Health Organization (WHO) divided the entire group over 65 years of age into three sub-groups as "young-elderly (65-74 years of age)", "mid-elderly (75-84 years of age)", and "advanced-elderly (85 years of age and over)" (3). The reasons for admission of elders as forensic cases to hospital emergency departments may include trauma-related causes such as traffic accidents, falls, burns, gunshot wounds, sharp object wounds, electrocution, physical abuse and non-traumatic causes such as poisoning and neglect. In this study, it was aimed to determine the frequency, demographic characteristics of forensic cases aged 65 years and older who had admitted to Akdeniz University Hospital between 2014 and 2021 and to compare the data in the light of the sources, in the medico-legal aspects. In our study, which was approved by the decision of Akdeniz University Faculty of Medicine Clinical Research Ethics Committee dated 04.04.2022 and numbered 70904504/192; 1925 (1.4%) of 132,591 patients aged 65 years and older who applied to Akdeniz University Hospital between 2014 and 2021 were included in the study as forensic cases. Among these cases, 1142 were admitted to the emergency department and 783 were admitted to other outpatient clinics. Of the cases admitted to the emergency department, 742 (65.0%) were male and 400 (35.0%) were female. The majority of these patients (64.5%) were between 65-74 years of age (young elderly). The most common reason for admission to the emergency department was traffic accidents (51.0%). Out-of-vehicle traffic accidents (26.3%) were followed by in-vehicle traffic accidents (22.0%) and the third most common cause was falls (19.6%). In 2.7% of the traffic accidents, due to the insufficient information, it was not possible to differentiate the cases whether in or out-vehicle nature of the accident. Traffic accidents (34.0%) were also the most common cause of admission in 783 cases admitted to outpatient clinics other than the emergency department. Of these 783 patients, 589 were admitted to the Department of Forensic Medicine. It was determined that patients aged 65 years and older most frequently applied to the Department of Forensic Medicine for evaluation of traffic accident (n=140, 23.7%), to determine whether they need a guardian appointment (n=131, 22.2%) and active psychopathology (n=18, 3.0%)/criminal capacity (n=94, 16.0%), respectively (n=112, 19.0%). According to hospital records, 43.1% of the 583 traffic accident cases were drivers/passengers in vehicular traffic accidents, 21.6% were pedestrians of out-of-vehicle traffic accidents, 3.4% were bicyclists, 2.4% were electric cyclist, and 16.0% were motorcyclists. Of the 96 cases resulting in death, 13 (13.6%) were pedestrians, 5 (5.2%) were drivers/passengers in vehicular traffic accidents, and 5 (5.2%) were motorcycle riders. As the elderly population increases year by year, the frequency of elderly people being involved in traffic accidents also increases. The risk of severe injury and death of elderly people is higher due to their comorbidities. Therefore, in order to protect the elderly from traffic accidents, safety measures related to infrastructure and landscaping should be emphasized and the education of the elderly and their relatives should be provided. Of the cases of cutting and stabbing injuries, 25.0% (n=16) were caused by a spiral machine, 20.3% (n=13) were caused by a knife, and 12.5% (n=8) were caused by a saw. 6.2% (n=4) with a tree cutting machine, 4.6% (n=3) with a glass, 4.6% (n=3) with a lawn mower, 4.6% (n=3) occurred with sawmills, 4.6% (n=3) occurred with iron pieces, and 1.5% (n=1) occurred with hoeing machines. Of the firearm injuries (n=19), 31.5% occurred with a mole gun, and 9 (47.3%) were accidents, 7 (36.8%) were homicides and 3 (15.7%) were suicides. Except from 3 sexual abuse cases, there wasn't any case of neglect or physical abuse in the patient files of the hospital automation system, Sexual abuse cases consist of 2 males and 1 female, it should be kept in mind that most sources stated that the real number of abuse cases is higher than the records. The total number of intoxication cases admitted to the emergency department was 58 and 23 (39.7%) of them were poisoned by drugs and 13 (22.4%) were poisoned by carbon monoxide. Drug intoxications are common in the elderly due to easy accessibility of drugs and uncontrolled drug use. Of the cases with traumatic findings (n=1031), 61.3% (n=632) had a single injury, 38.7% (n=399) had multiple injuries, the most common body parts of injury were head (31.5%), extremity (28.5%) and thorax (22.0%), and the least common was urogenital region (1.0%). It was recorded that 520 (45.5%) of the cases were hospitalized and 147 (28.2%) of these cases required intensive care. According to the hospital automation system records, 321 (28.0%) of the cases had multiple comorbidities, 273 (24.0%) had a single comorbidity, 513 (45.0%) had no recorded chronic disease at the time of the admission, and 35 (3.0%) had no recorded chronic disease. The most common comorbidities were hypertension (n=323 cases, %30.5) and diabetes mellitus (n=189 cases, %18.0). The prevalence of comorbidities increases with age and leads to an increase in the duration of hospitalization after trauma. It was recorded that, 406 (35.5%) of the cases admitted to the emergency department had life-threatening injury and the rest (n=736,64.5%) had not life-threatening injury. It was recorded that in 347 (30.3%) cases, injuries could be treated with simple medical treatment and in 795 (69.7%) cases, injuries couldn't be treated with simple medical treatment. It was determined that, 44.5% of the patients had bone fractures and the effect of bone fractures on life functions was mild in 1% (score:1) case, moderate in 53% (score:2-3) and severe in 43% (score:4-5-6). The most frequently fractured bones were upper extremity bones with 24.4% (n=197). This was followed by costal fractures with 20.9% (n=169), vertebral fractures with 15.9% (n=128), lower extremity bones with 15.0% (n=121), maxillofacial bones with 10.3% (n=83), pelvis fractures with 7.0% (n=57), and skull fractures with 6.2% (n=50). Two hundred ninety seven cases had multiple bone fractures. Among the 27 forensic cases aged 65 years and over who were admitted to the emergency department with serious injuries, 16 (59.2%) had a loss of function, 9 (33.4%) had a permanent impairment of function, and 2 (7.4%) had a disease that could not be cured. Of these cases, 10 had vertebral fractures requiring fusion surgery, 5 had fractures requiring prosthesis, 2 had injuries requiring supracondylar femur amputation, 3 had visual defects including 4/10 - 5/10 - 6/10 - 7/10 vision, 2 had 5-25 cm² bone defect in the skull, 1 had splenectomy, 1 had 2nd, 3rd and 4th finger amputation, 1 had amputation above ankle, 1 had paraplegia, 1 had organic brain syndrome. In the automation system of the hospital, the forensic report of 590 (51.7%) of the cases could be accessed, while the rest of 552 (48.3%) cases' reports didn't registered in the system. It is apparent that the forensic examination form is physically filled at the hospital emergency service and then scanned and transferred to the system. If the electronic system is used in the preparation of the form and the printout is physically approved, it will be possible to access the complete forensic examination form and forensic report of all cases. It is important to keep in consideration that traumatic and non-traumatic forensic events can be prevented to a significant extent when appropriate measures are taken in the elderly population, taking into account their physical capacities, functional status and comorbidities. It should be emphasized to develop systems where all elderly individuals can easily and safely meet their needs, support their opportunities to participate in social activities and receive regular and adequate medical care both in private living spaces, public and social spaces and in institutions where they receive care and support; care and rehabilitation opportunities should be provided where the individuality of the elderly is supported at the maximum level, and it should not be forgotten that old age is inevitable.