ADVERTISEMENT
An Unexpected Case of Finger Autophagia in an 84-Year-Old Male
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. Despite these measures, the patient developed cellulitis of his left hand and was transferred to the skilled nursing unit for intravenous antibiotics and wound care prior to discharge.
----------
Discussion
Preliminary data suggest that SIB is highly prevalent (22%) in nursing home patients with dementia.1,2 The etiology is not completely understood, but developmental disability and psychiatric conditions may be predisposing factors.3-5 SIB is often associated with autism, mental retardation, and Lesch-Nyhan syndrome, and is described in all age groups.1 In older adults, it has been described in association with geriatric syndromes such as dementia, depression, and delirium.6 Chronic medical conditions and spousal loss may further predispose older patients to SIB.6,7 It is hypothesized that SIB in the elderly may be related to frustration and loss of the ability to communicate effectively with others.7
Autophagia, a subset of SIB, is associated with biting oneself and is considered an extreme form of onychophagia.3 Finger- and nail-biting have been observed in individuals with spinal cord injuries, mental retardation, psychiatric disorders, and those with congenital desensitivity syndromes.1,8,9 The incidence ranges from as low as 1% in individuals without clinical diagnosis to as high as 20% in adolescents with psychiatric disorders.10 This is likely to be underestimated since SIB often produces wounds that are self-treated, and so go unnoticed.
Etiology
Psychological, biological, and behavioral models have been proposed to describe the etiology of SIB. The Tension Reduction Model has been used to explain the etiology of behaviors associated with SIB, particularly onychophagia. According to the model, maladaptive behaviors are an attempt by the patients to reduce stress. Consequently, the more the behavior is repeated, the more the emotional stress is relieved.3,10
Other theories, such as the Deprivation Theory, also exist. The Deafferentiation Model, which has been studied extensively in tetraplegics, is one example.1 This assumes that organisms with reduced sensory input may seek stimuli to achieve optimal stimulation in order to compensate for their sensory deprivation. Clinically, this may manifest as preferences for high ventilator volumes and increased oral gratification or fluid intake.1 In patients who require substantial assistance with access to food, oral gratification needs may propagate SIB in an attempt to provide psychological or physiological stimulation to compensate for neurological or functional deficits.
Neuronal imbalances are another proposed mechanism for SIB.9 Exact mechanisms remain inconclusive, but researchers propose that serotonin, dopamine, and opiates all play a role in developing SIB.7,11,12 Low central nervous system levels of serotonin are associated with impulsive, self-mutilating behavior.12 Researchers have concluded that activation of dopamine receptors by agonists mediated SIB, while 5-hydroxytryptamine receptor agonists and dopamine receptor antagonists attenuated them.11 Others have postulated that while opioid levels may not result in SIB, increased opioid levels in cerebrospinal fluid may create an analgesic state that eliminates the motivation to terminate self-abuse.7
Treatment
Preliminary findings suggest that pharmacologic treatment for older persons with dementia may be effective.7,13 Consistent with the dopaminergic and serotonergic theories, selective serotonin reuptake inhibitors and neuroleptics have been observed to be effective, especially in cases with a compulsive or psychotic component.13
Topical preparations for autophagia have been successful in laboratory rats that demonstrated autophagia resulting from spinal or peripheral nerve injury.11,14 Evidence as to its usefulness in humans is lacking. Physical restraints are effective in adolescents but have demonstrated only modest effectiveness in older adults.15
Behavioral treatments including relaxation training and habit reversal have been described in adult onychophagia.16 These involve awareness training, teaching alternative behaviors, and social follow-up. The utility of these treatments depends on resources available to the patient and his/her ability to participate actively in such programs.
Conclusion
Emotional stressors and multiple environmental changes may have propelled the case patient into SIB, thus supporting the Tension Reduction Model. The drastic change in feeding schedule may also have contributed, thereby supporting the Deprivation Theory. From a clinical perspective, the patient had dementia and depression, predisposing geriatric syndromes.3,13 His admission diagnosis was UTI with hypoactive delirium, another risk factor. While psychosis was not evident on this patient’s initial exam, 30-38% of persons with Alzheimer’s disease have psychosis during the course of their dementia.17
Given the multifaceted approach to the case patient’s care, it is uncertain whether there was an actual response to the pharmacologic treatment. This would have given credence to the neuronal-based theories. Pica may be considered a part of the differential diagnosis but is not a valid theory for autophagia documented in the literature.
Patients who exhibit SIB cause great concern to their families and caregivers, and sequelae can complicate an already complex clinical picture. Treatment should be an individualized and possibly multifaceted approach. Recognition of potential triggers, behavior modification, and safety management are helpful. Caregivers and clinicians should be aware of this phenomenon and attempt to identify at-risk patients.
Important Points about Self-Injurious Behavior (SIB)
- SIB is highly prevalent in nursing home patients with dementia.
- Chronic medical conditions, geriatric syndromes, and communication barriers, as well as spousal loss, may predispose an older patient to SIB.
- Although the incidence of SIB is relatively low, the psychosocial and financial impact on patients and their caregivers can be immense.
- Treatment should be individualized to particular patients and, if necessary, involve an interdisciplinary and multifaceted approach.
- Increased awareness of this entity for those who work with at-risk populations will help increase identification of potential triggers.
Outcome of the Case Patient
No further episodes of SIB occurred in the case patient. He was transferred to the skilled nursing facility of the hospital for intravenous antibiotics and continued wound care. Although his cellulitis eventually resolved, his appetite and verbalization remained poor. He was discharged to the house call program and eventually transitioned to hospice care.
The authors report no relevant financial relationships.
Drs. Atai and Ahmed are Assistant Professors and Dr. Pearce is an Instructor in the Division of Geriatrics and Palliative Medicine, University of Texas Health Science Center - Medical School, Houston.
References
1. Frost FS, Mukkamala S, Covington E. Self-inflicted finger injury in individuals with spinal cord injury: An analysis of 5 Cases.J Spinal Cord Med 2008;31:109-116.
2. de Jonghe-Rouleau AP. Self-injurious behavior in nursing home residents with dementia. Int J Geriatr Psychiatry 2005;20:651-657.
3. Wells JH, Haines J, Williams CL. Severe morbid onychophagia: The classification as self-mutilation and a proposed model of maintenence. Aust N Z J Psychiatry 1998;32:534-545.
4. Claes L, Vandereycken W. Self-injurious behavior: Differential diagnosis and functional differentiation. Compr Psychiatry 2007;48:137-144. Published Online: January 2, 2007.
5. Rao KN, Sudarshan CY, Begum S. Self-injurious behavior: A clinical appraisal. Indian J Psychiatry 2008;50:288-297.
6. Warnock JK, Burkews J, Hueter C. Self injurious behavior in elderly patients with dementia: Four case reports. Am J Geriatr Psychiatry 1999;7:166-170.
7. Herman BH. Effects of opioid receptor antagonists in treatment of autism and self-injurious behavior. In: Ratey JJ, ed. Mental Retardation: Developing Pharmacotherapies. Washington, DC: American Psychiatric Press; 1991:107-137.
8. Anderson LT, Ernst M. Self-injury in Lesch-Nyhan disease. J Autism Dev Disord 1994;24:67-81.
9. Hellings JA, Warnock JK. Self-injurious behavior and serotonin in Prader-Willi syndrome. Pharmacol Bull 1994;30:245-250.
10. Winchel RM, Stanley M. Self-injurious behavior: A review of the behavior and biology of self-mutilative behavior. Am J Psychiatry 1991;148:306-314.
11. Mori T, Ito S, Kita T, Sawaguchi T. Effects of dopamine- and serotonin-related compounds on methamphetamine-induced self injurious behavior in mice. J Pharmacol Sci 2004;96:459-464. Published Online: December 10, 2004.
12. Turner C, Panksepp J, Bekkedal M, et al. Paradoxical effects of serotonin and opioids in pemoline-induced self-injurious behavior. Pharmacol Biochem Behav 1999;63:361-366.
13. Phillips KA, Taub SL. Skin picking as a symptom of body dysmorphic disorder. Psychopharmacol Bull 1995;31:279-288.
14. Zhang YP, Onifer SM, Burke DA, Shields CB. A topical mixture for preventing, abolishing, and treating autophagia and self-mutilation in laboratory rats. Contemp Top Lab Anim Sci 2001;40:35-36.
15. Luiselli JK. Contindent glove wearing for the treatment of self excoriating behavior in a sensory-impaired adolescent. Behav Modif 1989;13:65-73.
16. Twohig MP, Woods DW, Marcks BA, Teng EJ. Evaluating the efficacy of habit reversal: comparison with a placebo control. J Clin Psychiatry 2003;64:40-48.
Wragg RE, Jeste DV. Overview of depression and psychosis in Alzheimer's disease. Am J Psychiatry 1989;146:577-587.
