Elderly people are expected to die, but old age can be used as a cover for negligent or deliberate deaths, prosecutors and elder advocates are starting to realize.

Older people with complex medical problems can die and be buried without an autopsy or a close look at the circumstances of their death, says a growing chorus of warnings.

Cancer can leave an elderly body emaciated but so can malnutrition. Bumps can easily cause bruises but fists do too. Falls can break bones but broken bones also can come from being thrown down.

Social workers aren't prepared to conduct criminal investigations. Law enforcement is often poorly trained to differentiate between age-related health problems and physical abuse. And, prosecutors find it difficult to build a case due to a lack of evidence or witnesses.

"When you combine all those things together, it's a scary picture," said Lori Stiegel, a national expert with the American Bar Association Commission On Law and Aging. She said the extent of the problem is unknown because there is little research done on elder abuse deaths.

However, new scrutiny is coming from a handful of new programs including the Sacramento County Elder Death Review Team.

In Little Rock, Ark., reviews and some exhumations of about 100 nursing home patients raised enough questions to change state law for closer scrutiny.

The last body exhumed was an elderly man who reportedly died from natural causes but an exhumation determined that he had been caught in a bedrail and died from accidental asphyxiation, possibly caused by negligence. "No one would have known, no one would have cared," said Pulaski County Coroner Mark Malcolm. "Everyone would have gone to the funeral home, a cemetery and the family would have been none the wiser."

Malcolm estimated that poor care contributed to 4 percent to 5 percent of the 900 deaths a year his staff has scrutinized since a 1999 amendment to the state's Elder Abuse Reporting Act.

All deaths in nursing homes now are reported to county coroners, said Malcolm.

Praised by the National Center on Elder Abuse, the Little Rock coroner found patients who suffered from medication errors, malnutrition and neglect that may have contributed to their early deaths.

In the last three years, he said, four cases were referred to prosecutors for criminal charges; federal officials shut down one home for chronic problems and state health licensing violations, and Medicaid officials acted on other findings.

Sacramento County broke new ground as one of the first counties in the United States to establish a team of experts to examine suspicious deaths of seniors. Only four or five others exist nationwide.

The team's creation grew out of concern over the 1998 death of Martha Merritt, an 88-year-old with Alzheimer's disease, who died from a subdural hematoma. District Attorney Jan Scully declined to prosecute, citing no evidence of a criminal offense.

But the complex issues raised by the case led to the team's creation.

"If you write everything off to old age, you've just closed your mind and eyes to the potential for abuse and neglect," said Jeff Rose, assistant chief deputy for the Sacramento County District Attorney's Office. "It's too easy to say a person who is 80 or 90 just died because they're old."

Scully remembers when she started working in the prosecutor's office and nobody wanted to handle the elder abuse cases.

"We always viewed elder abuse as kind of like ten years behind child abuse, that slow in getting the focused attention that it deserves," said Scully.

The pioneering efforts under way now are laying the groundwork in the fledging field of "forensic geriatrics." But without years of research and scientific work to back up their programs, it's been slow going.

Sacramento County wanted to establish its team in late 1999 but first a state law had to be passed to waive the confidentiality restrictions so the team members could talk with each other about their cases.

Once a month, the team -- made up of prosecutors, law enforcement, Adult Protective Services, pathologists, geriatricians and aging experts -- meets to discuss deaths that it thinks warrant review.

California state law has allowed counties the discretion to set up such teams since January 2002. Other teams are getting under way in Yolo, San Diego and Orange counties.

Paul Greenwood, head of the Elder Abuse Prosecution unit in the San Diego District Attorney's Office, said the need for the team surfaced three years ago when the body of Alfred Christian Polchow, 84, of Oceanside was stopped from cremation for a last-minute autopsy.

Polchow had been found dead, presumably from natural causes, in his living room. His family later called to report use of his credit card. A court later convicted Yolanda Faye Harden, 24, of strangling and robbing him. Authorities say she had knocked on the door to use the phone.

"It takes a shocking case to raise the eyebrows," said Greenwood.

Sacramento has reviewed about 24 elder death cases in the last two years and Yolo County's team has looked at about a dozen cases. Placer County recently has established a protocol for reviewing all suspicious deaths including children, older people and domestic violence victims. The findings of the review teams are all confidential.

Suzanna Mak, a deputy district attorney in Yolo County, said the successful prosecution of Viola Virginia Journey last year on charges of murder and elder abuse was aided by the team's collaboration.

Journey was convicted in the shooting death of her 79-year-old husband whom the prosecution alleged she was tired of caring for.

Mak said only about 15 percent of elder abuse cases nationally are ever reported to authorities and autopsies are performed in less than 1 percent of senior deaths.

In May, the country's first Elder Abuse Forensic Center opened in Santa Ana to bring the expertise of experts with 10 public and private organizations who meet twice a week to discuss their elder abuse cases.

Dr. Laura Mosqueda, the center's director and head of geriatrics at UC Irvine's medical center, said many frail elderly are secluded with their caregivers.

"Nobody knows that somebody is keeping them isolated, threatening them and having them sign over their wills," said Mosqueda. "The last thing a police officer wants to do is sit down with a woman who has early Alzheimer's and take a history."

Death review teams often take a two-prong approach to elder abuse. Prosecuting people for deaths related to abuse and neglect is one goal. The other is looking for gaps in the social system to prevent abuse.

Mosqueda said one case under review now involves an elderly woman who was "neglected to death" despite having been seen by social workers and emergency room doctors.

"There were all kinds of times this lady was somehow involved in the system," said Mosqueda. "She died with a lot of wounds."

Sacramento County officials also are bumping into the lack of scientifically based research and standards to use in evaluating elder deaths.

"There's a huge question mark as to what's natural, what's neglect, what criminal means," said Sacramento County Deputy District Attorney Rose. "Is this a crime? Is this neglect? Who's involved? Who's responsible if anyone? There are lots of gray areas."

Help may be on the way with a proposed federal law before Congress called "The Elder Justice Act."

The act would spotlight national attention on elder abuse, increase money for research and to help law enforcement improve their forensic abilities, fund adult protective services in states and institute other reforms.

Rose said Sacramento's death team is working on increasing the number of cases it reviews but with caution.

"We have a long way to go," said Rose. "We're still on baby steps."