CASE REPORT PATHOLOGY ⁄ BIOLOGY Roger W. Byard, 1,2 M.D. and John D. Gilbert, 2 F.R.A.C.P. Sleeping Accidents in the Elderly ABSTRACT: Two cases of dangerous sleeping environments in the elderly are reported to demonstrate similarities and differences of these ‘‘sleeping accidents’’ to similar episodes that occur in infants and children. Case reports: An 87-year-old wheelchair-bound man with a history of dementia was found in his nursing home room hanging off the side of the bed from a vertical metal bar, and an 87-year-old woman with epilepsy, ischemic heart disease, and insulin-dependent diabetes mellitus was found in hospital wedged between an inflatable mattress and the bars of her bed. These cases demonstrate that, as in the very young, relatively poor coordination and strength in the elderly often with limited comprehension and ability to deal with dangerous environments may predispose to sleeping accidents. Significant underlying organic disease may, however, make deter- mination of the precise lethal mechanisms difficult. Modification of beds should only be undertaken when safety issues have been carefully evaluated. KEYWORDS: forensic science, asphyxia, hanging, bed, nursing home, product safety Accidental asphyxia occurring in infants and young children in bed is not uncommon and may be due to a variety of circum- stances including wedging and hanging associated with defective cots and other hazards (1,2). The term ‘‘sleeping accident’’ has been used to describe such occurrences, although as victims are not nec- essarily asleep at the time of the fatal episode, the term is some- what of a misnomer. Lethal asphyxia in bed is less common in adults and is most often attributable to aspiration of gastric contents associated with underlying illness or intoxication or to positional asphyxia where respiration is compromised by abnormal position- ing of a body. Accidental hanging is very rarely encountered in the adult sleeping environment. The following cases are reported to compare and contrast the features of such cases at the extremes of life and to comment on safety issues involved. Case Reports Case 1 An 87-year-old man who was a nursing home resident was found deceased lying on the side of his bed, suspended by his neck from a metal pole that was designed to assist with getting out of bed (Fig. 1). His past history included dementia, hypertension, and peripheral and cerebrovascular disease. He had a history of falls from his bed and was mobile only in a wheelchair. A vertical metal pole was present on each side of the bed connected by a frame that had been inserted under the mattress. The poles were incorrectly positioned too close to the head of the bed. At autopsy, a linear red mark was present on the left side of his neck corresponding to the position of the bar, associated with underlying bruising of the left side of the thyroid gland. Eyelid and conjunctival petechiae were present. There was evidence of coincidental underlying atheroscle- rotic vascular disease and chronic obstructive airways disease. Toxicological evaluation of blood revealed therapeutic levels of paracetamol and subtherapeutic levels of frusemide. Death was attributable to low suspension hanging from a metal bar that had been intended to assist the victim in moving to and from his bed. Case 2 An 87-year-old woman who was in hospital following a success- ful surgical repair of a fractured right neck of femur was found deceased wedged between her inflatable mattress and the metal side railings of her bed. Her past history included ischemic heart dis- ease, chronic obstructive airways disease, congestive cardiac failure, hypertension, chronic renal failure, a right mastectomy for carci- noma, peripheral and cerebrovascular disease, hyperlipidemia, and insulin-dependent diabetes mellitus. At autopsy, two parallel, approximately horizontal indentations were identified consisting of a 230-mm-long groove across her lower chest and 20 cm caudally, a 20-mm area of blanching with adjacent hyperemia on the right side of her neck. These were not associated with underlying subcu- taneous or soft tissue bruising. The larynx was intact, and there were no facial or conjunctival petechiae. Significant underlying organic diseases that included marked coronary artery atherosclero- sis with myocardial scarring, chronic obstructive airways disease, previous cerebrovascular accidents, hypertensive cardiac and renal disease were observed. Toxiocology was unremarkable. There was no elevation of vitreous humor glucose or b-hydroxy butyrate. Examination of the bed railings showed vertical metal bars that were 20 cm apart, corresponding to the markings on the body. Death was therefore attributed to possible positional asphyxia complicating ischemic heart disease, chronic obstructive airways disease, and epilepsy. 1 Discipline of Pathology, The University of Adelaide, Frome Rd, Adela- ide, SA 5005, Australia. 2 Forensic Science SA, 21 Divett Place, Adelaide, SA 5000, Australia. Received 18 July 2010; and in revised form 13 Sept. 2010; accepted 3 Oct. 2010. J Forensic Sci, November 2011, Vol. 56, No. 6 doi: 10.1111/j.1556-4029.2011.01838.x Available online at: onlinelibrary.wiley.com Ó 2011 American Academy of Forensic Sciences 1645