How to manage bruises in an older person?

Management of Bruises in Older Adults

The management of bruises in older adults should focus on local application of cold, compression, and elevation of the injured area as the primary treatment approach, with careful assessment for potential signs of abuse when bruising patterns are concerning. 1

Assessment of Bruises in Older Adults

Location and Pattern Assessment

• Nearly 90% of accidental bruises in older adults occur on the extremities 2
• Bruises that may indicate potential abuse are often:
  • Larger (>5 cm)
  • Located on the face, lateral aspect of the right arm, or posterior torso
  • Multiple in number without clear explanation 3
• Accidental bruises typically do not appear on:
  • Neck, ears, genitalia, buttocks, or soles of feet 2

History Taking

• Determine if the older person knows the cause of the bruise
  • 89.6% of abuse victims can recall the cause versus only 23.5% of those with accidental bruises 3
• Ask about falls history, as this is a common cause of accidental bruising
• Document medication use, particularly:
  • Anticoagulants (warfarin, DOACs)
  • Antiplatelet agents (aspirin, clopidogrel)
  • These medications increase bruising tendency 4

Treatment Approach

Immediate Management

• Apply cold compresses to the bruised area as soon as possible
• Elevate the affected area if possible
• Apply gentle compression if appropriate 1
• For painful bruises, consider:
  • Topical clobetasone butyrate for short-term relief 4
  • Topical menthol preparations may provide symptomatic relief 4

Medication Considerations

• Assess medication history for drugs that may increase bleeding risk
• For patients on vitamin K antagonists (e.g., warfarin):
  • Check INR if bruising is extensive or concerning
  • Consider reversal protocol only if life-threatening bleeding is present 4
• For patients on DOACs:
  • Early assessment of coagulation tests may be needed if extensive bruising 4
  • Reversal agents should only be considered in critical situations 4

Skin Care for Elderly

• Recommend regular use of emollients with high lipid content 5
• Apply moisturizers immediately after bathing when skin is still slightly damp 5
• Avoid harsh soaps and consider using cream soap substitutes 5

Special Considerations

When to Suspect Abuse

• Multiple bruises without adequate explanation
• Bruises in unusual locations (face, posterior torso)
• Large bruises (>5 cm)
• Patient unable to explain bruise origin or shows fear when asked 3

Age Determination of Bruises

• Color changes in bruises are not reliable indicators of age
  • Yellow coloration can appear within 24 hours in some bruises 2
  • Only conclusion possible is that yellow coloration indicates a bruise is >18 hours old 6
• Spatial inhomogeneity (red-blue core with yellow surrounding area) may provide more accurate age estimation but requires specialized imaging 7

Prevention Strategies

• For recurrent bruising, consider:
  • Home safety assessment to reduce fall risk
  • Review of medications that may contribute to bruising
  • Protective padding for frequently bruised areas
  • Multifactorial falls prevention interventions for those at high risk 4

When to Refer

• Extensive bruising without clear cause
• Suspicion of elder abuse
• Bruising associated with significant pain or functional limitation
• Bruising in patients on anticoagulation therapy that appears excessive
• Bruising accompanied by other concerning symptoms (e.g., unexplained weight loss, fatigue)

Remember that bruising in older adults is common due to age-related skin changes and increased capillary fragility, but unusual patterns or unexplained bruising should always prompt further investigation.