An 81-year-old woman comes to the office for follow-up of type 2 diabetes mellitus, which has been well controlled on a stable medication regimen for several years. Medical history is notable for hypertension and osteoporosis. Six months ago, she suffered a nondisplaced orbital fracture. She is widowed and has lived with her daughter and son-in-law for the last year. She claims that she is independent and "takes care" of herself. Blood pressure is 176/102 mm Hg and pulse is 84/min. Examination shows bruising at the right forearm and right flank. No cardiac murmurs are heard. Abdominal examination is unremarkable. Gait is steady and the patient does well on the Timed Up and Go test. Laboratory results show a fasting glucose of 220 mg/dL and hemoglobin A1c of 9%. Four months ago, glucose was 105 mg/dL and hemoglobin A1c was 7.2%. On further discussion, the patient says, "The pharmacy charges me too much these days. I just can't afford my medication anymore." Which of the following is the most likely explanation for this patient's clinical findings?

Question

An 81-year-old woman comes to the office for follow-up of type 2 diabetes mellitus, which has been well controlled on a stable medication regimen for several years.  Medical history is notable for hypertension and osteoporosis.  Six months ago, she suffered a nondisplaced orbital fracture.  She is widowed and has lived with her daughter and son-in-law for the last year.  She claims that she is independent and "takes care" of herself.  Blood pressure is 176/102 mm Hg and pulse is 84/min.  Examination shows bruising at the right forearm and right flank.  No cardiac murmurs are heard.  Abdominal examination is unremarkable.  Gait is steady and the patient does well on the Timed Up and Go test.  Laboratory results show a fasting glucose of 220 mg/dL and hemoglobin A1c of 9%.  Four months ago, glucose was 105 mg/dL and hemoglobin A1c was 7.2%.  On further discussion, the patient says, "The pharmacy charges me too much these days.  I just can't afford my medication anymore."  Which of the following is the most likely explanation for this patient's clinical findings?

Quizplus · Accepted Answer

11ec25c8_d233_7fde_bc81_afdc4edf404a_MD0003_00 This patient has findings that raise concern for elder abuse, including multiple injuries and an acute change in financial status (ie, discontinuing longstanding medications due to cost), possibly due to diversion of finances by family members. Abuse is most common in older women, especially those who are socially isolated or have a shared living environment (ie, live with multiple nonspousal others). Dementia and chronic mental illness also increase the risk. Manifestations of physical abuse in the elderly are similar to those in younger patients, and may include unexplained pain, injuries in multiple stages of healing, or injuries in unusual locations. Although osteoporosis increases the risk of fracture with minor trauma, orbital fractures (as in this patient) are atypical. Elderly individuals are also at risk for financial exploitation, psychological abuse, sexual abuse, and neglect. Most jurisdictions require that suspected abuse be reported to adult protective services or other governmental agency. (Choice A) Late-onset alcohol abuse is more common in elders who live alone. Living with multiple family members increases the risk for elder abuse. Elder abuse is also more likely to explain this patient's injury pattern (orbital fracture, multiple bruises in unusual locations). (Choices B, D, and F) Dementia, affective disorders, and psychotic disorders are common in elderly patients and can lead to nonadherence to medical therapy. However, this patient has experienced multiple injuries that suggest abuse. (Choice E) Nutritional deficiencies are usually seen in elders who live alone and do not have outside nutritional support. Although a variety of vitamin deficiencies can cause bruising, this patient's orbital fracture is more suspicious for abuse. Educational objective: Manifestations of physical abuse in the elderly may include unexplained pain, injuries in multiple stages of healing, or injuries in unusual locations. Elderly individuals are also at risk for financial exploitation, psychological abuse, sexual abuse, and neglect. References: Elder abuse. (http://www.ncbi.nlm.nih.gov/pubmed/26559573)

An 81-Year-Old Woman Comes to the Office for Follow-Up of Type