Elderly Abuse, Features and Treatment

Elderly Abuse Elder abuse affects 3% of the US elderly population. It continues to be under recognized and under reported. Clinical Features Elderly victims frequently live with their abuser who may be dependent on them financially, socially, or emotionally. They are often isolated from other family and friends. Abuse is strongly associated with personality problems of the caregiver who may have a history of mental illness, substance abuse, or personality disorder. Abused patients often have poor personal hygiene, inappropriate or soiled clothing, malnutrition, and worsening decubiti. They may abuse alcohol or drugs. Specific injuries suggestive of abuse include unexplained fractures or dislocations; unexplained lacerations, abrasions, and bruises; burns in unusual locations; and unexplained injuries to the head or face. Abused patients have been found to have significantly greater cognitive impairment than nonabused elderly patients. They often have a history of problematic behavior such as nocturnal shouting, incontinence, wandering, or paranoia. Diagnosis and Differential Most mistreatment of elderly patients occurs in residential settings and can be difficult to recognize. This difficulty is confounded by the fact that patients are often reluctant to disclose their abuse due to embarrassment or fear of abandonment, retaliation, or nursing home placement. The diagnosis should be considered in elderly patients with dementia, frequent falls, and dehydration or malnutrition.  The following findings are suggestive of an abusive relationship between the patient and the caretaker:  (a) the patient appears fearful of his or her companion, (b) there are conflicting accounts of the injury of illness between the patient and the caretaker,  (c) there is an absence of assistance toward the patient from the caretaker,  (d) the caretaker displays an attitude of anger or indifference toward the patient,  (e) the caretaker is overly concerned with the cost of treatment, and  (f) the caretaker denies the physician private interaction with the patient. Whenever suspected, the patient should be questioned directly about abuse. Emergency Department Care and Disposition Management of elder abuse involves treatment of medical conditions and immediate intervention. Admission is indicated when medically necessary or when the patient cannot be safely discharged back to the current living situation. A social services consultation should be obtained, and adult protective services should be notified. Forty-four states have mandatory reporting laws directed toward health care and social service workers, which require reporting of abuse despite the victim's wishes. When appropriate, caretakers should be provided with supportive services such as home health services, Meals on Wheels, transportation, and mental health services.

Child Abuse, Features and Treatment

Child Abuse The spectrum of child abuse includes physical abuse, sexual abuse, emotional abuse, parental substance abuse, neglect, and Munchhausen syndrome by proxy (MSBP). The physical stigmata of abuse may be characteristic or subtle. Recognition of abuse is aided by knowledge of normal child development. Clinical Features Child neglect in early infancy results in the syndrome of failure to thrive (FTT). Overall physical care and hygiene are frequently poor. These infants have little subcutaneous tissue, the ribs protrude prominently through the skin, and the skin over the buttocks hangs in loose folds. Muscle tone is usually increased but may be decreased. Behavioral characteristics include wariness, irritability, and avoidance of eye contact. Children older than 2 to 3 years with environmental neglect are termed psychosocial dwarfs. They manifest the classic triad of short stature, bizarre voracious appetite, and a disturbed home situation. They are frequently hyperactive with delayed speech. Several injury patterns should be recognized as suggestive of physical abuse. Bruises over multiple areas, especially the lower back, buttocks, thighs, cheeks, ears, neck, ankles, wrists, and mouth, should cause suspicion. Belt buckles, cords, or other blunt instruments produce well-demarcated bruises. Bites produce a characteristic oval pattern. Scald burns do not follow a typical splash configuration, but rather a "stocking and glove" distribution caused by immersion in hot water. Skeletal injuries may present with unexplained swelling of an extremity. Abused children with head injuries may appear well or may exhibit vomiting, irritability, apnea, or seizures. Injuries to the abdomen may present with vomiting, abdominal pain and distension, and diminished bowel sounds. Abused children may be overly affectionate with medical staff, may be submissive and compliant, and often do not resist painful medical procedures, such as blood draws. MSBP is an uncommon form of child abuse in which a caretaker fabricates illness in a child to secure prolonged contact with health care providers. These patients may present with bleeding, vomiting, seizures, altered mental status, apnea, or other symptoms as a result of the intentional administration of ipecac, warfarin, or other substances. Sexually abused children may have vaginal or urethral discharge, vaginal bleeding, or dysuria or may exhibit excessive masturbation, genital fondling, encopresis, nightmares, or sexually oriented or provocative behavior. Diagnosis and Differential A history that is inconsistent with the nature or extent of the injury, keeps changing as to the circumstances surrounding the injury, or develops a discrepancy between the story the child gives and the story the caretaker gives should raise the index of suspicion for abuse. Any serious injury or anogenital complaint should be examined carefully. All FTT infants should have weight, height, and head circumference measured and plotted on the appropriate growth chart. These infants typically will gain weight normally once admitted to the hospital, thus confirming the diagnosis. Children with suspected sexual abuse should have genital and rectal examinations performed. Careful examination of the perineum and hymen for tears and concavities can support or confirm the diagnosis. Swabs of the vagina, rectum, and oral cavity should be performed, with cultures for gonorrhea and chlamydia included. Erythema of the hymen and perineum suggests irritation and is not specific for abuse. It is important to note that a normal examination does not exclude the diagnosis of sexual abuse. Children with suspected physical abuse should have a complete blood cell count, coagulation studies, platelets, and a skeletal survey. Inflicted injuries are suggested by spiral fractures of a long bone, metaphyseal chip fractures, multiple fractures at different stages of healing, and unusual fracture sites. Infants and children with suspected head or abdominal trauma should be evaluated with computed tomography. Rarely, conditions such as leukemia, aplastic anemia, and osteogenesis imperfecta can mimic physical abuse. Emergency Department Care and Disposition Abused infants and children should be treated medically according to their injuries. Infants with FTT and MSBP should be admitted. A full social services assessment should be obtained in all cases of suspected neglect and physical and sexual abuse. All 50 states have mandatory reporting laws that require a verbal report be filed with law enforcement or a child protection agency. Failure to report may result in misdemeanor charges and lead to a fine or imprisonment. The child may be placed in temporary custody, with the final disposition dependent on a court hearing.

Sexual Abuse, Assault and Intimate Partner Sex Voilence

Introduction Sexual assault accounts for 1% of all violent crimes reported in the 2003 United States Uniform Crimes Report. Most episodes of sexual assault are committed by a person known to the victim. Until recently, male sexual assault was underrecognized and underreported. The incidence in men is estimated to be 10% of all sexual assaults. Intimate partner violence and abuse (IPVA) is defined as a pattern of assaultive behavior that may include physical injury, sexual assault, psychological abuse, stalking, deprivation, intimidation, and threats. IPVA occurs in every race, ethnicity, culture, geographic region, and religious affiliation and occurs in gay, lesbian, and heterosexual relationships.

Clinical Features A brief, tactfully obtained history should include the following elements: (a) who (whether the assailant was known and the number of attackers), (b) what happened (including physical assault and injuries), (c) when (time since assault), (d) where (actual or attempted vaginal, oral, or anal penetration and whether ejaculation occurred; use of condoms or foreign bodies), (e) whether the patient has showered, douched, or changed clothes since the attack, and (f) suspicion of drug-facilitated sexual assault (whether there is a period of amnesia, intoxication greater than expected for the amount of alcohol consumed, or history of waking in a different location with genital pain). Past medical history pertinent to the sexual assault victim should include last menstrual period, birth control method, and last consensual intercourse (this may affect laboratory analysis of evidence). Allergies and prior medical history should be obtained for sexually transmitted disease (STD) and pregnancy prophylaxes and prior sexual assault. The history for the IPVA victim can be more difficult to obtain. Between 4% and 15% of women are seen in emergency departments (EDs) because of symptoms related to IPVA. Risk factors for IPVA include female sex, age between 16 and 24 years, low socioeconomic status, separated relationship status, and children younger than 3 years in the home. When a victim reveals a history of IPVA, it should be documented in the patient's own words. Recent and remote abuse, including dates, locations, details of abuse, and witnesses, should be documented. Injuries inconsistent with the patient's history, multiple injuries in various stages of healing, delay in the time of injury occurrence and presentation, a visit for vague complaints without evidence of injury, or suicide attempts should trigger suspicions of IPVA. Patients also may complain initially of chronic pain syndromes, gynecologic or psychiatric difficulties, and alcohol and substance abuse. The victim of IPVA also may appear frightened when the partner is present. Physical Examination The examinations for sexual assault and IPVA should include a general medical examination, including general appearance and demeanor. Patients who present to the ED may request only a forensic examination for sexual assault; however, trauma is present in 45% to 67% of cases, with genital injury in 9% to 45%. Injuries should be described and documented, including photographs of injuries, if available. In the sexual assault victim, a pelvic examination should include documentation of vaginal discharge, abrasions, cervical abrasions, and lacerations. The rectum also should be examined for lacerations and abrasions. Anoscopy has proven to be a better tool for detection of trauma. Toluidine blue can detect small lacerations by staining the deeper dermis; it can be applied with gauze and removed with lubrication before the speculum examination. A colposcope also increases documentation of genital injuries, especially to the posterior fourchette. In the IPVA victim, characteristic injuries include fingernail scratches, bite marks, cigarette burns, rope burns, and forearm bruising or nightstick fractures, suggesting a defensive posture. Central injuries to the head, neck, face, and thorax should be identified and documented. Abdominal injuries are common in the pregnant IPVA patient. Evidence Examination Evidence collection in sexual assault is credible only within the first 72 hours after the assault. After 72 hours, a history, physical examination, and documentation of injuries should be provided with STD prophylaxis. The evidence should be labeled clearly with the victim's name, type and source of evidence, date and time, and name of the examiner collecting the evidence.

Diagnosis and Differential Sexual assault is a legal determination, not a medical diagnosis. The legal definition contains 3 elements: carnal knowledge, nonconsent, and compulsion or fear of harm. Because of the legal considerations, careful documentation and evidence collection are important. Informed consent should be obtained, and a system to preserve the "chain of evidence" should be maintained. A prepackaged sexual assault, or "rape," kit with directions for sample collection should be used. Diagrams for documentation of genital and physical injuries can be useful. If a sexual assault kit is not available, smears from the vagina and cervix are made, labeled, and air dried. A wet mount from the same areas should be microscopically examined for sperm. A vaginal aspirate using 5 to 10 mL normal saline may be obtained and tested for acid phosphatase. Premoistened rectal and buccal swabs should be obtained to check for the presence of sperm. An ultraviolet light with a peak output around 490 nm wavelength (eg, Bluemaxx BM 500) can be used to examine for areas of fluorescence where semen may be collected on the body. The output of the typical Wood lamp (360 nm) does not fluoresce semen. If anal penetration occurred, a rectal aspirate and rectal swab should be taken and slides made, labeled, and air dried in the same manner as for the vaginal swabs. Additional forensic laboratory evaluation may include glycoprotein p30 testing and genetic typing.

Emergency Department Care and Disposition for Sexual Assault  The health care provider initially should address life-threatening injuries and the psychological needs of the sexual assault patient. Pregnancy Prophylaxis  A pregnancy test should be obtained. Up to 5% of all sexual assault victims will become pregnant as a result of the assault.  Postcoital prophylaxis reduces the risk of pregnancy by 60–90% if adequate doses of estrogen are used.  Options include: levonorgestrel 0.75 mg (Plan B) 1 tablet initially followed by 1 tablet in 12 hrs ethinyl estradiol and levonorgestrel 50 mcg/0.25 mg (Preven) 2 tablets initially followed by 2 tablets in 12 hrs ethinyl estradiol and norgestrel 50 mcg/0.5 mg (Ovral) 2 tablets initially followed by 2 tablets in 12 hrs. STD Prophylaxis Gonorrhea: The 2002 CDC guidelines are a single dose of: ceftriaxone 125 mg IM,  cefixime 400 mg PO,  ciprofloxacin 500 mg PO, or  ofloxacin 400 mg PO.  Ceftriaxone 125 mg IM is recommended in pregnancy. Chlamydia: Recommended regimens for prophylaxis are:  a single dose of azithromycin 1 g PO, doxycycline 100 mg PO bid for 7 days, erythromycin base 500 mg PO qid for 7 days, or amoxicillin 500 mg PO tid for 7 days. Trichomoniasis and bacterial vaginosis:  Recommended regimens for prophylaxis are:  a single dose of metronidazole 2 g PO, metronidazole 250 mg PO tid for 7 days, or  clindamycin 300 mg PO bid for 7 days.  If pregnant and symptomatic, metronidazole 2 g PO may be used with close follow-up.  Hepatitis B: Recommended treatment regimens for prophylaxis are:  vaccination at the time of initial evaluation  follow-up doses at 1 to 2 mos and at 4 to 6 mos. Prophylaxis or Counseling for the Human Immunodeficiency Virus  Rates of HIV are 0.008% to 0.032% from receptive, unprotected anal intercourse and 0.005% to 0.0015% from vaginal intercourse with HIV-positive assailants.  Circumstances should guide treatment with known assailant positivity, high viral load exposures, vaginal trauma, and ejaculate on membranes, which represent a moderate to high risk for HIV seroconversion  Postexposure prophylaxis:  Also should consider expense and side effects of the medications and the need to arrange follow-up with a primary physician with experience in HIV treatment.  Per CDC guidelines, treatment is currently "recommended" for victims with "moderate" risk exposures.  Routine prophylaxis is not recommended, and counseling and follow-up should be provided. Follow-Up Care  The patient should be counseled by a social worker or sexual assault counselor at the time of the assault.  Follow-up medical care is needed to reexamine physical injuries and to examine the effectiveness of pregnancy and STD prophylaxes.

Emergency Department Care and Disposition for the IPVA Victim  The first goal of treatment should be to address any life-threatening injuries to the patient while simultaneously ensuring the safety of the victim and any children involved while they are in the ED.  IPVA experts (trained social workers or IPVA advocates) can assist with providing information about IPVA and assisting the victims with available options for their families.  Safety assessment:  Should identify indicators of a potentially lethal situation.  Risk indicators include:  increasing frequency or severity of violence  the threat or use of weapons  obsession with the victim  taking hostages  stalking  homicidal or suicidal threats  substance abuse by the assailant, especially with crack cocaine or amphetamines.  The most dangerous period for victims is during the time of abuse disclosure and during an attempt to leave the relationship.  Hospital admission is an option in high-risk situations if a safe location cannot be established before discharge.