According to World Health Organization, elderly abuse is defined as “a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person”. This type of violence includes physical, sexual, psychological, and emotional abuse, neglect, and other various forms of abuse against people aged 60 years or older. It continues to be a serious public health issue that not only affects the victim and their loved ones but the entire society.^[1] Homicide-suicide as a criminal act is a distinct subcategory of homicide in which the assailant kills his wife and/or her children in a relationship that has been broken down.^[2] This type of crime can be committed by different methods, with shooting usually being the most common method, followed by applied blunt force or sharp force. Cases of suicide-homicide committed by different methods are uncommon and they are rare by frequency.

The present case is about the dyadic deaths of an 89-year-old man and an 82-year-old woman who were in a relationship as intimate partners (as husband and wife). In the early autumn of 2020, a report of an event was received in the Police District of Plovdiv about a woman who was found dead in her home. In the same building, they found the body of her husband next to hers. The victim seemed to be in a coma – breathing but unresponsive and passed away immediately before the arrival of the emergency crew. During the inspection of the crime scene by police officers and the coroner, the woman was found to have numerous injuries of various types in the area of the head, while her husband, during the primary physical examination, had no visible traumatic injuries but only watery fluids leaking from his mouth. A death note and a glass bottle containing 400 ml of a watery liquid with distinct alcohol smells were discovered in the house close to the corpse. When the crime scene was examined, the weapon of murder was not discovered. During the course of the case investigation, witnesses who were close to the family provided information about the husband’s prior history of repetitive domestic violence.

During the external examination of the woman’s corpse, nine lacerated wounds were found on her head(Fig. 1) . These wounds had different localizations, covering both halves of the head in different anatomic regions (frontal, temporal, parietal, and occipital regions), and were of different lengths and shapes. Some of them were linear and some had a stellate shape, all with irregular, ragged, and bruised margins and the presence of tissue bridges between the margins.

By making additional deep cuts through the soft tissues of the face during the external examination, the coroners discovered a blowout fracture of the right orbita. All lacerations on the head involved the entire thickness of the skin, with an imprint of the used weapon over the bone plate as a mosaic fracture (so-called ‘spider-web fracture’) in the right frontal to temporal region of the skull, involving both the frontal and temporal bones. Her right arm was also found to have numerous self-defense wounds, including bruises, lacerations, and abrasions of various sizes and shapes. All bruises on the corpse were bluish-red, and abrasions had a wet, reddish surface without the formation of a scab. All lacerations found on the right limb had similar wound characteristics as those seen on the head.

The internal examination of the woman, which included dissection of the soft tissues and bones of the cranium, showed depressed mosaic (spider-web type) fractures in the area of the frontal, temporal, and parietal bones on the right with tearing of the dura matter and the arachnoid with severe contusions and destruction of brain tissue, underlying the bone fracture.(Fig. 2). Ventricles were represented with blood collection inside. No other traumatic injuries were found during the internal examination. During the internal examination of organs and systems inside the thoracic and abdominal cavities, no pathologic or traumatic abnormalities were found. The additional toxicological examinations showed no evidence of alcohol or any drug in hazardous concentrations in the blood or urine of the corpse.

No traumatic injuries were found in the corpse of the man during the external examination. The internal examination of the man’s head revealed no signs of trauma aside from a small, reddish hemorrhage on the skin’s inner surface in the right occipital and temporal regions.

The internal examination of the man’s corpse showed the brain with severe edema and a few petechial hemorrhages inside the brain tissue. The lungs were heavy and congested. The weight and anatomical makeup of the heart were both normal. Pinpoint hemorrhages were discovered over the heart. In addition, dark, liquid blood was seen inside the major blood vessels in combination with severe congestion in the abdominal organs.

A blood sample was taken during the autopsy for additional routine toxicology analysis. The result of the test showed the presence of methyl alcohol in the blood (0.93‰ as determined by gas chromatography).

Homicide-suicide is a multifactor phenomenon, which refers to a murder of one or more individuals followed by a suicide of the perpetrator who in most of cases is male. This phenomenon is also known in the forensic literature as extended-suicide, murder-suicide, or dyadic death. Many authors report that the act of suicide usually occurs in the first 24 hours after the homicide.^[3]

Most statistical data show that perpetrators are primarily male, while victims are usually female^[4]. According to some authors, 76% of female victims knew their assailants and 44% of all female victims were killed by their spouses. The most common reasons for the homicide in these cases are either a quarrel, revenge, or loss of temper.^[2] In most cases, the couples are young (younger than 45 years in age), and only a small number of them are 60 years and over.

In great number of cases, the suicidal act is not necessarily premeditated. It is usually a result of an unrestrained anger that in some cases leads to homicide and then to the suicide of the assailant, when he/she realizes what he/she has done^[5], as in the present case.

Many risk factors are associated with this type of violence, including relationship dynamics and family situations, mental and personality disorders, history of previous criminal activity, and early childhood abuse.^[6–8]

In vast majority of cases, the most frequently used method is appliance of different firearm devices^[4], followed by non-gun associated methods, including different types of asphyxiation, sharp force, and poisoning.^[9] Beating with hands and feet are used in less than 10% of female deaths. The rates of female and male deaths caused by beating with an implement (9% and 12%, respectively) are roughly the same.^[10] Cases of homicide-suicide in combination of blunt force and poisoning are practically rare and statistically uncommon.

The elderly are one of the most vulnerable subgroups of intimate partner violence victims, largely because of their growing social isolation, lack of social support, and reliance on family members and caregivers. The aforementioned renders these individuals helpless to fend off the attack and, in some cases, unable to report it. In this age group, each physical harm could not only cause a negative feeling of pain, but could even lead to severe disability or even to increased mortality.^[11] Elder abuse is generally under-recognized by health providers and medical workers, because of the difficulty in differentiation and determination of injuries as a result of physical abuse from trauma having an accidental origin.

Therefore, better understanding of injury patterns, distinguishing accidental traumatic injuries from these injuries which were received by physical abuse, is necessary.‌^[12] Generation of new algorithms for assessment, examination, and reporting of cases that are suspicious of abuse, is also extremely necessary.

Physical, sexual abuse, and neglect are those types of elder abuse that result in visible traumatic injuries that could have a fatal outcome. In forensic examination, important practical point of view is to make an adequate assessment and to differentiate these changes on the skin caused by abuse from those injuries that are age-related skin changes.

Bruises on less noticeable body parts or on areas that are not frequently injured by falls are unlikely to be the result of accident and should raise suspicions of abuse.^[13] Patterned shape injuries greater than 5 cm in size, injuries at different healing stages, presence of parallel injuries, or patterned bruises such as “tram-line” bruises and signs of blunt trauma are the clues associated with elder abuse.^[14]

Abrasions as traumatic injuries are often seen in cases of elder abuse. In many cases, they are accidental by their origin, caused by little friction, because of the thickness of the skin and lack of elasticity, usually seen in elderly population. Abrasions could be seen in elder abuse, when elderly are pulled, or dragged across a rough surface. If the location of the abrasion is not typical, suspicion for elder abuse should be raised.^[15] Lacerations characterized by full-thickness splitting of the skin are a result of blunt forces. Their locations are also a clue for abuse – lacerations around the eye, nose, or mouth, or in various anatomic regions, and over less prominent body parts are also suspicious of abuse.^[11]

The most important action in each suspicious case of elder abuse or intimate partner violence is the timely reporting of the case to the responsible government and law enforcement agencies. It could save human lives and prevent the fatal outcome.

Physical abuse of the elderly in the context of intimate partner violence continues to be a major public health and social problem across the world, and it is getting worse due to the increasing aging of the world population. Elder abuse significantly increases morbidity and mortality rates at this age group, and homicide-suicide cases are those with the most violent domestic abuse outcomes.

Understanding the risk factors and distinguishing between accidents and elder abuse-related injuries are necessary if we are to stop this kind of violence. There are numerous strategies used to stop elder abuse, but there is currently no proof of their efficacy. In this circumstance, new assessment and reporting algorithms are urgently required for all suspected instances of applied abuse.