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CODES

ICD10

F52.4 Premature ejaculation

N53.11 Retarded ejaculation

N53.14 Retrograde ejaculation

CLINICALPEARLS

If erectile dysfunction is contributing to ejaculatory difficulty, management of erectile dysfunction should precede attempted management of ejaculatory disorders.

Medications should always be thoroughly reviewed, as they may be the primary cause of ejaculatory disorders.

PE and DE generally have both psychogenic and physical causes, whereas AE and RE are due to organic neurogenic/autonomic dysfunction.

Amultidisciplinary approach, including the primary care physician, urologists, psychologists, and other appropriate health care professionals, is essential to the proper treatment of ejaculatory disorders.

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ELDER ABUSE

Nitin Budhwar, MD Kimberly Kone, MD

BASICS

DESCRIPTION

The National Center of Elder Abuse divides abuse into three categories (age >60) (1)[A]:

–Domestic: abuse from someone who has a special relationship with the elderly individual (spouse, child, friend, or in-home caregiver) that occurs in the home of the elderly or caregiver

–Institutional: occurs in the setting of a facility that is responsible for caring for the elderly, such as a nursing home or long-term care facility

–Self-neglect: The behavior of the elderly individual leads to harm.

Types of abuse in estimated order of occurrence:

–Self-neglect (estimated 50%). The most common form of abuse (2)[C].

–Financial

–Neglect

–Emotional

–Physical

–Sexual

–Taken advantage of: misinformation and unregulated online pharmaceutical, financial companies, and so forth, that specifically target the elderly leading to deleterious outcomes (3)[C]

EPIDEMIOLOGY

Incidence

Estimate is that as many as 1:10 have been victims of abuse, placing a conservative number at 50,000 cases per year. Majority of whom are believed to be women (4)[A].

Prevalence

Arecent national survey measuring prevalence of abuse in individuals of at least 60 years and older found that 11.9% of the surveyed population suffered some form of abuse:

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5.2% encountered financial mistreatment by family members.

5.1% suffered potential neglect.

4.6% encountered emotional mistreatment, mostly by humiliation or verbal abuse.

1.6% encountered physical mistreatment, mostly through battery.

0.6% sexually mistreated, mostly through forced intercourse.

ETIOLOGYAND PATHOPHYSIOLOGY

The etiology of elder abuse is a complex biopsychosocial combination of increased dependence on the caregiver by the victim in a suboptimal environment with poor behavioral coping methods, which is compounded by increased stress.

Genetics

Not contributory

RISK FACTORS

The victim:

–Advanced age

–Exploitable resources

–Prior history of abuse in life

–Dementia or other cognitive impairment

–Female gender

–Disability in caring for him/herself

–Depression

–Social isolation

–Stress: health, financial, or situational

The abuser:

–Mental illness

–Financial dependency

–Substance abuse

–History of violence

–Other antisocial behavior (5)[C]

GENERALPREVENTION

Improve patient’s social contact and support.

Identify and correct potential risk factors for elder abuse:

– Home visit to identify for potential risks of fall hazards and barriers to

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ambulation that could lead to fractures and functional decline that could leave the individual vulnerable to abuse

–Evaluate for assistive devices that help the patient independently complete his/her ADLs and prevent caregiver dependence.

–Screen for depression using validated tools like the Geriatric Depression Scale.

–Early identification and treatment of cognitive impairment

Identify caregiver stress and burden; refer to community programs that aid with emotional assistance.

Advance life directives planning, including identifying possible caregivers, choosing a medical power of attorney (MPOA), estate, and will planning, and so forth

COMMONLYASSOCIATED CONDITIONS

Most common associated conditions with elder abuse are also identified as risk factors: social isolation, increased dependence for ADL/IADLs, depression, cognitive impairment, and aggressive behavior (5)[C],(6)[B].

DIAGNOSIS

Ahigh index of suspicion when risk factors are present is important; types of abuse should be kept in mind as some types might not be obvious. It can be difficult to diagnose elder abuse in a single clinic visit, so it is important to get social services involved and to consider doing home visits, when abuse is suspected (5)[C].

HISTORY

It is important to take a detailed history with focus on the living arrangements, degree of functionality, who the caregivers are, and other risk factors listed above. Pay attention to clues such as withdrawal from normal activities or a sudden change in finances or abrupt changes to a will.

PHYSICALEXAM

It is important objectively to document positive and negative findings in your physical exam and to be very detailed because it can be admissible in court if abuse is suspected.

Vital signs: Check weight and assess for progressive loss in weight; BPand pulse rate can be an indicator of dehydration that could be secondary to

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neglect.

General overall appearance:

–Wasting or cachexia

–Poor hygiene, unkempt clothing

–If the patient is bedbound, it is important to assess the integrity of the mattress and sheets. Look for excessive skin flakes, hair, or urine-soiled

mattresses. Oral exam:

– Assess for poor dentition, oral ulcers, or abscesses. Skin exam:

–Most bruises from elder abuse are large (>5 cm) and located on the face, lateral arm, or back.

–Bite or burn marks

–It is important to check for pressure ulcers on the bony prominences of the patient: elbows, sacrum, heels, and scapula.

Mental/psychiatric:

– Withdrawn, anxious, fearful, blunted

Genital/rectal exam if sexual abuse is suspected (4)[A]

DIFFERENTIALDIAGNOSIS

Advanced dementia can present with individuals appearing withdrawn and they are often malnourished.

Elderly with advanced dementia of Alzheimer type or Lewy body dementia can present with delusions of persecution and aggression that can be confused for elder abuse.

Patients with Parkinson disease often fall and may exhibit fractures and bruises on a frequent basis that may mimic recurrent physical abuse.

Coagulopathy seen in patients in advanced malignancy with bone marrow suppression or invasion, and those on chronic antiplatelet therapy can appear with bruising that can be easily confused with elder abuse.

Wasting from malignancy, infections, chronic disease

Thyroid disorder can present with altered mental status (AMS), depression, or anxiety.

Chronic lung disease can present with decreased weight.

Delirium from acute electrolyte disturbances, infectious etiology, or cardiovascular compromise can all present similar to elder abuse. Impaired financial status can also be confused with self-neglect.

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DIAGNOSTIC TESTS & INTERPRETATION

The following workup is recommended:

Nutritional assessment: iron, vitamin B12, folate, thiamine, albumin,

prealbumin, CBC, LFTs, electrolytes

Malignancy workup, as per current guidelines

If bruising is noted, check for coagulopathies (e.g., platelets, bleeding times, PT/INR, and PTT).

If cognitive impairment is observed, check thyroid-stimulating hormone, vitamin B12 level; consider syphilis and HIV testing if indicated.

Assessment of infection: may include urinalysis and culture, chest radiograph, blood count, and cultures

Radiographic imaging of areas below soft tissue injury is indicated if there is evidence of infection (osteomyelitis) at a pressure ulcer site or bruising of a limb (fracture).

If physical abuse is suspected and cognitive impairment present, then cranial imaging to look for hemorrhage (e.g., subdural) is indicated using CT scan or MRI.

Diagnostic Procedures/Other

Pulse test: Check BPand pulse in presence and absence of suspected abuser. Elevation of either in the presence of the suspected abuser should raise suspicion. Useful in patients with dementia or other condition that makes history-taking difficult.

Folstein Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MOCA), or other validated tools to assess for cognitive impairment if suspected

Geriatric Depression Scale if suspected

Documentation: Practitioners may make statements of “suspected mistreatment” but should avoid making definitive diagnosis of abuse in their initial assessment, unless it is very obvious.

TREATMENT

Most states require all health care providers to report suspected elder abuse to a local agency such as the Adult Protective Services (http://www.nccafv.org/state_elder_abuse_hotlines.htm).

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MEDICATION

None

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Victims of elder abuse should be admitted to the hospital if there are no safe discharge alternatives.

Management of uncontrolled chronic conditions due to neglect (i.e., wound care from ulcers or infections)

Cases of suspected abuse must be reported to the state’s Adult Protective Services agency or a designated alternative (e.g., if patient resides in nursing home, then report to that state’s regulatory entity). Social services may help. If physical harm has occurred, consider reporting to local law enforcement for investigation.

Hospital security may need to be notified if restricted visitor access to a patient is required, and the patient’s name may be hidden from the public hospital census.

If the patient is a victim of elder abuse, he/she must be relocated to a safer alternative and may need admission for sequelae caused by the abuse. Victims should not be discharged to a potentially abusive environment. Alternatives to discharge to the unsafe environment may include:

–Friend or family member

–Nursing home

–Personal care home

–Assisted living facility

–Local victims’rescue or sheltering program if available

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Victims of abuse should not be discharged without adequate follow-up, including:

Primary care physician visit within 1 week

Follow-up with Adult Protective Services or other agency; a home visit should be scheduled prior to discharge if the patient is going back home.

Home Health Agency for assessment of safety (physical therapy)

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Follow-up with appropriate mental health care

Patient Monitoring

The patient should have frequent visits and be followed through the appropriate agencies to reduce continuation of abuse and to identify recurring abuse.

PATIENT EDUCATION

For Elder Abuse Resources in your state, you can go to the National Center of Elder Abuse at https://ncea.acl.gov

Or your local representative by calling 1-800-677-1166

PROGNOSIS

Elder abuse and self-neglect are associated with an overall increased risk in mortality (7)[B].

COMPLICATIONS

Complications of elder abuse can lead to worsening depression, increased mortality, and overall poor quality of life.

REFERENCES

1.National Center on Elder Abuse. Elder Abuse Prevalence and Incidence. Washington, DC: National Center on Elder Abuse; 2005.

2.Mosqueda L, Dong X. Elder abuse and self-neglect: “I don’t care anything about going to the doctor, to be honest. . .” JAMA. 2011;306(5):532–540.

3.Liang BA, Lovett KM, Mackey TK. Elder abuse. J Am Geriatr Soc. 2012;60(2):398–400.

4.Committee opinion no. 568: elder abuse and women’s health. Obstet Gynecol. 2013;122(1):187–191.

5.Halphen JM, Varas GM, Sadowsky JM. Recognizing and reporting elder abuse and neglect. Geriatrics. 2009;64(7):13–18.

6.Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health.

2010;100(2):292–297.

7.Dong X, Simon M, Mendes de Leon C, et al. Elder self-neglect and abuse and mortality risk in a community-dwelling population. JAMA. 2009;302(5):517– 526.

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ADDITIONALREADING

Burnett J, Dyer CB, Halphen JM, et al. Four subtypes of self-neglect in older adults: results of a latent class analysis. J Am Geriatr Soc. 2014;62(6):1127– 1132.

Cooper C, Katona C, Finne-Soveri H, et al. Indicators of elder abuse: a crossnational comparison of psychiatric morbidity and other determinants in the ad-hoc study. Am J Geriatr Psychiatry. 2006;14(6):489–497.

Lachs MS, Pillemer K. Elder abuse. Lancet. 2004;364(9441):1263–1272.

Lachs MS, Williams CS, O’Brien S, et al. Adult protective service use and nursing home placement. Gerontologist. 2002;42(6):734–739.

Lachs MS, Williams CS, O’Brien S, et al. The mortality of elder mistreatment. JAMA. 1998;280(5):428–432.

Widera E, Steenpass V, Marson D, et al. Finances in the older patient with cognitive impairment: “He didn’t want me to take over”. JAMA. 2011;305(7):698–706.

Wiglesworth A, Austin R, Corona M, et al. Bruising as a marker of physical elder abuse. J Am Geriatr Soc. 2009;57(7):1191–1196.

Wiglesworth A, Mosqueda L, Mulnard R, et al. Screening for abuse and neglect of people with dementia. J Am Geriatr Soc. 2010;58(3):493–500.

CODES

ICD10

T74.11XAAdult physical abuse, confirmed, initial encounter

T74.21XAAdult sexual abuse, confirmed, initial encounter T74.01XAAdult neglect or abandonment, confirmed, initial encounter

CLINICALPEARLS

Elder abuse, or elder mistreatment, is a condition in which the physical, psychological, or financial well-being of an older adult is infringed upon through intentional acts or lack of action, even if harm is not intended.

It is important to identify vulnerable individuals through proper evaluation of potential risk factors for abuse (social isolation, depression, cognitive impairment, disability requiring assistance, and financial dependence by the caregiver).

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Correction of risk factors is important to reduce the incidence of elder abuse

(strengthen the patients’social support, treat depression, provide the patient with assistive devices, screen for cognitive impairment with a trial of medication if possible, and identify caregiver burn out).

Clearly document your physical exam with only specific objective findings. Contact APS or your local resources if elder abuse is suspected; it is unlawful not to report suspected elder abuse.

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