Annals of Long Term Care

Introduction
A frail 84-year-old male demonstrated finger autophagia during acute hospitalization for an uncomplicated urinary tract infection (UTI). Although he had demonstrated severe disability and failure to thrive for over a year, the unexpected self-mutilation that ensued further complicated his hospital course, causing anxiety and distrust between his family and the healthcare team, as well as prolonging his hospitalization. Although the incidence of self-injurious behavior (SIB) is relatively low, the psychosocial and financial impact on patients and their caregivers can be immense. Increased awareness of this entity for at-risk populations will help increase the identification of potential triggers and broaden routine screening measures to include SIB. This case report aims to present an evidence-based review of the etiology and treatment of SIB in frail older persons.

Case Presentation
An 84-year-old male with a history of dementia, depression, prostate cancer, and failure to thrive was admitted with a five-day history of reduced appetite and speech. His wife had also noticed three new pressure ulcers shortly after his airbed deflated following a power outage.

The patient’s initial admission a year prior documented that he was at the time ambulating with a walker and feeding himself. He had since been hospitalized multiple times for mental status changes and UTIs. He progressively declined cognitively and functionally, becoming minimally verbal and totally dependent. However, he maintained a good appetite on a soft mechanical diet five times daily fed by his wife.

Examination revealed a thin older male lying with eyes closed, who opened his eyes momentarily and muttered incomprehensibly in response to voice. Vital signs included temperature 96.6 degrees F, pulse 99-114 bpm, blood pressure 110/56 mm Hg, respiratory rate 20 breaths per minute, and SP02 at 96% on room air. Pupils were equal, round, and reactive. The patient had wasted bilateral lower extremities and flexion contractures in all four extremities. He withdrew lower extremities to tactile stimuli. There were stage 2 pressure ulcers on bilateral hips and sacrum.

Initial tests showed a creatinine kinase of 2877 U/L and a white cell count 14.9x10³/µL with 70.6% neutrophils. Blood urea nitrogen was 33 mg/dL, creatinine was 0.6 mg/dL, and cardiac enzymes were negative. Urinalysis showed moderate leukocyte esterase with 50-100 white cells per high power field. An electrocardiogram revealed no acute changes. A head scan and chest films showed no acute changes.

The patient was started on ceftriaxone, intravenous hydration, and wound care. A precautionary swallow study was ordered, which the patient failed, but he was allowed to eat if assisted by family at their request. Forty-eight hours into admission, he was found by the night staff to have chewed his distal palmar left index and middle fingers, exposing the digitorum profundus tendon in the former.

X-rays demonstrated only soft-tissue injury. Amoxicillin-clavulanate and daily dressings were instituted. Psychiatry was consulted and recommended evaluating him for pica and treating with risperidone for presumed delirium. Mittens were utilized to prevent further occurrences. Pain as evidenced by episodes of sweating, groaning, grimacing, and tachycardia was managed with scheduled acetaminophen and morphine as needed.