Detecting Abuse in Elderly Patients

(Great Britain—The Practitioner, March 1999, p. 164) Although elder abuse has only recently received recognition, it is estimated that a typical British family practice may have as many as 20 elderly patients who are victims of abuse. Definitions of elder abuse vary, but all incorporate a range of harmful psychologic, physical and economic activities that may be active, such as the direct physical harming of an elderly person, or passive, as in neglect or withholding of assistance. Potential victims are characterized by frailty, communication problems, variability in function and prolonged decline in health, and may have preexisting personality problems or a history of conflicts with family members. Characteristics of potential abusers include poor mental or physical health, alcohol dependence, social isolation, financial difficulties and resentment of the elderly person whom they abuse. Paradoxically, victims may protect the abuser or impede actions to confront the situation because of family loyalties or fear that alternative living arrangements may be worse than the current situation. Abusers are ashamed of their actions but are often relieved when the situation is discovered and collaborate in constructive change. Physicians should be alert for physical and psychologic signs and symptoms of abuse in the elderly, such as bruises in unusual sites, signs of neglect, and findings that are inconsistent with the history. Other indications of abuse include overuse of medical services or significant underuse of services and difficulty in contacting elderly patients.

Ocular Ischemic Syndrome

(Canada—Canadian Family Physician, April 1999, p. 901.) Because the ophthalmic artery is a branch of the internal carotid artery, obstruction of the internal carotid can cause ocular ischemic syndrome. In over 90 percent of cases, patients complain of gradual vision loss, but sudden blindness can occur. Some patients with ocular ischemic syndrome experience eye pain, caused by ischemia or glaucoma due to new vessel formation in the anterior chamber angle. Ocular ischemic syndrome results in dilated retinal veins with hemorrhages, new vessel formation and soft exudates. The new vessels and microaneurysms are often very friable, resulting in hemorrhage. Laser photocoagulation can prevent hemorrhage from new vessels. The cause and location of carotid stenosis should be identified and rectified if possible. Ocular ischemic syndrome indicates arterial disease, and the five-year mortality rate is 40 percent; the leading causes of death are cardiac disease, stroke and other arterial complications.

Otitis Externa

(Australia—Australian Family Physician, March 1999, p. 217.) Trauma and exposure to water predispose the epithelium of the ear canal to otitis externa. The initial inflammation leads to accumulation of debris that exacerbates edema and narrowing of the canal. Pain (intensified by chewing or movement of the ear), hearing loss, lymphadenopathy, and signs of superficial cellulitis and systemic upset generally develop. Early or mild cases of otitis externa may be treated with removal of debris by dry mopping and instillation of 3 percent hydrogen peroxide solution, followed by application of an antipseudomonal ototopical agent. More severe cases may require treatment with analgesics, oral antibiotics or topical preparations containing steroids. In patients who have diabetes or are immunocompromised, malignant otitis externa may develop. This progressive, necrotizing pseudomonal infection requires urgent treatment. The risk of otitis externa can be reduced by wearing ear plugs in the water, drying well after swimming or showering, and using acetic acid and alcohol ear drops.

Surgery for Parkinson's Disease

(China—Hong Kong Practitioner, March 1999, p. 106.) Surgery may provide control of specific symptoms in Parkinson's disease and is increasingly used to complement medical therapy in selected patients. Thalamotomy—destruction of the ventralis intermedius nucleus of the ventrolateral thalamus—improves tremor in 86 percent of patients but has little effect on rigidity and bradykinesia. Pallidotomy mainly improves bradykinesia and rigidity but is also effective for tremor in 81 percent of patients. Ablative surgery may be perfomed using conventional craniotomy techniques or stereotactic radiosurgery using the gamma-knife. Current trials include stimulation procedures in which probes are left in selected areas of the brain such as the globus pallidus, thalamus and subthalamic nuclei. Cell transplantation, including use of fetal tissue, has been studied but raises important ethical issues.