Choice of muscle relaxant in myasthenic crisis

 Image from microsoft.com image gallery, MP900178484. 

Available at: http://office.microsoft.com/en-us/images/results.aspx?ex=2&qu=drug#ai:MP900178484|mt:0|

We encountered a case of 38-year old Malay female with history of myasthenia gravis. She presented this time with the complaint of difficulty of getting up after praying. She also complained of episodes of vomiting and passing out loose stools for one day prior to her presentation. She has past history of hypokalemia and for this current admission, her potassium level from venous blood gas analysis was on the lower end of 3.2 mmol/l. The hypokalemia probably aggravates her proximal myopathy. However, about half an hour later, she complained of progressive breathing difficulty, and at one point she was cyanotic and gasping. We immediately put her through positive pressure ventilation by bag-valve-mask. We almost thought of intubating the patient. What would be the better choice of muscle relaxant in this case?

The more predictable choice would be a non-depolarizing agent although they may slightly slower compared to scoline. The reason being the post-synaptic receptors are now being occupied by the auto-antibodies and therefore, if you use scoline you would probably need a higher than usual dose. And  its duration of action may be last longer because of the higher dose! And that's why, scoline may be rather unpredictable. On the other hand, the non-depolarizing type could be displaced away after its action through competition. Reference: http://emedicine.medscape.com/article/793136-overview#aw2aab6c10

We almost wanted to intubate this patient but fortunately the patient had a rather quick recovery of its respiratory and diaphragm muscles following a dose of neostigmine, and thereby intubation was avoided. We gave her NIPPV too. Literature seems to suggest NIPPV helps.

Chaudhuri and Behan (2009) has written a rather interesting and informative review article on myasthenic crisis and it is worth to download this article which is available free at URL: http://qjmed.oxfordjournals.org/content/102/2/97.full.

According to Chaudhuri and Behan (2009), respiratory failure is a must in definition criteria of myasthenic crisis. Furthermore, in that article, it is also mentioned that the continuous use of anticholinesterase (such as IV pyridostigmine) (which this patient, fortunately, did not require) as a therapy for myasthenic crisis remains controversial, especially because of the risk of cardiac arrhythmias and myocardial infarction. As mentioned in the article, coronary vasospasm from excessive anticholinergic treatment is known to be an iatrogenic cause of myocardial infarction in myasthenia gravis.  Besides the risk of cardiac complication, large doses of anticholinesterases promote excessive salivary and gastric secretions, which may increase the risk of aspiration pneumonia.

In that article, Chaudhuri and Behan (2009) also listed a table with various differentiating features of other common causes that may mimic myasthenic crisis. Click here for the table.

A final thought: in any syndromic case, a syndrome is a syndrome; a clustering of signs and symptoms. It is important to treat the underlying cause(s). One of the common causes in many syndromes is offending drugs. In the case of myasthenic crisis, the various offending drugs include:
the various groups of antimicrobials such as the aminoglycosides, the macrolides, tetracycline group, the quinolones (ciprofloxacin, ofloxacin, norfloxacin); anticonvulsants such as phenytoin and carbamazepine; antipsychotics such as the neuroleptics; beta-blockers, calcium channel blockers, etc.


Reference:
1.    Chaudhuri A, Behan PO. Myasthenic crisis. QJM. 2009 Feb;102(2):97-107.

Estimating the volume of intracranial hematoma on CT

The commonly used formula for estimating the volume of intracranial bleed on CT is

ABC/2 

where

A is the maximal diameter of the hematoma by CT
B is the diameter 90° to A, and
C is the approximate number of CT slices with hemorrhage multiplied by the slice thickness

For a number of years, I could not really grasp why the formula is as such. I thought that the formula is derived from the formula of volume for a cylinder. The part of (C) in the formula I could understand as it involves the height of the cylinder. But what I could not grasp is that, if this formula is derived from the volume of a cylinder, the formula should entail the use of "pi" (π) which is taken to be 3.14 (up to 2 decimal points).  This is because the surface area of a circle is π * r *r; and therefore, the formula for volume of cylinder is π * r *r * h where h is the height of the cylinder.

Until I found this article Kothari et al (1996) which is helpful in explaining how this formula of ABC/2 comes about.

This formula is actually derived from the volume of an ellipsoid object and NOT of cylinder.

Figure 1

Image copyrighted to JoshDif licensed under under the Creative Commons Attribution-Share Alike 3.0 Unported license. Original site: Wikipedia

The volume for an ellipsoid object is

4/3 * π * a *b * c (a, b, and c as of Figure 1 above)

Applying this formula to the hematoma object on CT,
a and b are actually half of the two diameters mentioned on 2 dimension plane; and c is half of the height of the hematoma.

Therefore, the volume of the hematoma is

4/3 * π * (A/2) * (B/2) * (C/2)

where
A is the maximal diameter of the hematoma by CT
B is the diameter 90° to A, and
C is the approximate number of CT slices with hemorrhage multiplied by the slice thickness

assuming π ~ 3, therefore,

the volume of the hematoma is therefore,
4/3 * 3 * (A/2) * (B/2) * (C/2) = ABC/2

In an article by Freeman et al (2008), it is found that the ABC/2 method accurately estimates smaller ellipsoid hematoma volumes but inaccurately measures larger, irregularly shaped hematoma, or multicompartment hemorrhage such as intraventricular hemotoma and subdural hematoma. This article by Freeman et al (2008) has great pictures showing the ellipsoid shape of intracranial hematoma.

The importance of estimating the volume is that if the volume is large (~20 - 30 cc), it may be one of the indications for neurosurgical intervention, depending on the local neurosurgical management protocol of the center.

References:
1. Kothari RU, Brott T, Broderick JP, Barsan WG, Sauerbeck LR, Zuccarello M, Khoury J. The ABCs of measuring intracerebral hemorrhage volumes. Stroke. 1996 Aug;27(8):1304-5. Click here.

2. Freeman WD, Barrett KM, Bestic JM, Meschia JF, Broderick DF, Brott TG. Computer-assisted volumetric analysis compared with ABC/2 method for assessing warfarin-related intracranial hemorrhage volumes. Neurocrit Care. 2008;9(3):307-12. Click here.

The New WHO 2010 Severity Classification

WHO, in its recent dengue guidelines 2009, has alluded to the fact that its existing classification into dengue fever and dengue hemorrhagic fever (further divided into 4 grades) have a number of limitations due to the rigidity of its criteria.  Download also the Malaysian guidelines on dengue management.

For example,  in a number of cases, patients can present with dengue and shock but without fulfilling all the 4 criteria for DHF These patients would have been classified as dengue fever if the WHO criteria were strictly applied.

The requirement of 20% increase in HCT as one of the evidence of plasma leakage is difficult to fulfill due to several issues:

• Baseline hematocrit may not be easily available unless blood sampling for full blood count has been recently obtained in the same hospital or healthcare center where the patient presents himself to.
• Early fluid administration in a health clinic may have changed the hematocrit reading prior to referral to hospital.
• Bleeding itself will lower the HCT level

(* Previously, the following must ALL be present in order to classify the patients as having dengue hemorrhagic fever:

• Fever, or history of acute fever, lasting 2–7 days, occasionally biphasic.
• Haemorrhagic tendencies, evidenced by at least one of the following :

1. a positive tourniquet test
2. petechiae, ecchymoses or purpura
3. bleeding from the mucosa, gastrointestinal tract, injection sites or other locations
4. haematemesis or melaena.

• Thrombocytopenia (100,000 cells per mm3 or less).
• Evidence of plasma leakage due to increased vascular permeability, manifested by at least one of the following:

1. a rise in the HCT equal to or greater than 20% above average for age, sex and population
2. a drop in the HCT following volume-replacement treatment equal to or greater than 20% or baseline
3. signs of plasma leakage such as pleural effusion, ascites and hypoproteinaemia.)

As such, since 2009-2010, WHO and Malaysia has adopted a new classification that is more pragmatic. The whole idea is to capture early the group of patients that may potentially deteriorate due to the following pathogenetic processes:

Plasma leakage
Hemorrhage
Organ impairment

Under this classification, the patients would be classified into either

• Dengue fever (either probable or laboratory-confirmed)
• Dengue fever WITH warning signs
• Severe dengue (under which may have manifestations of severe plasma leakage, severe hemorrhage, severe organ impairment

For patients to be classified as dengue fever (probable), the pre-criteria is that any patients living in or travelling ENDEMIC AREA for dengue (including Malaysia) AND with FEVER and with 2 out of the following criteria:

• Nausea, vomiting
• Rash
• Aches and pains 
• Tourniquet test positive 
• Leukopenia 
• Any warning sign

These can be remembered with the following mnemonic:

AEEGYPTI (AEGYPTI)

A = Area endemic
E = Emesis
E = Exanthem (rash)
G = groan and ache
Y = yes to warning signs
P = Positive tourniquet test
T = total white cell low
I = increased temperature

Patients with dengue with warning signs need to be admitted.  These warning signs are:

Abdominal pain or tenderness 

Persistent vomiting

Clinical fluid accumulation 

Mucosal bleed

Lethargy, restlessness 

Liver enlargment >2 cm 

Laboratory: increase in HCT concurrent with rapid decrease in platelet count
The warning signs can be remembered by:
FLLLAVI (“Flavivirus”)

F = fluid accumulation
LLL = Liver, Lab, Lethargy
A = Abd pain
V = vomiting
I = “insignificant” bleed (“insignificant” does not mean “not important” but minor)

Other pointers in the diagnosis and management of dengue and severe dengue fever that should be kept in mind:

1. The earliest abnormality in the full blood count is a progressive decrease in total white cell count; not thrombocytopenia or increased hematocrit.

2. A relative bradycardia may be noted despite the fever, especially in the recovery phase. It is not always tachycardia in dengue.

3. Do not give acetylsalicylic acid (aspirin), ibuprofen or other non-steroidal anti-inflammatory agents (NSAIDs) as these drugs may aggravate the bleeding in dengue due to capillary fragility. Acetylsalicylic acid (aspirin) may be associated with Reye’s Syndrome.

4. Fresh whole blood or fresh red cells should be given whenever possible. This is because oxygen delivery at tissue level is optimal with high levels of 2,3 di-phosphoglycerate (2,3 DPG). Stored blood loses 2,3 DPG, low levels which may impede the oxygen-releasing capacity of hemoglobin.

5. If the haematocrit was low (<40% in children and adult females, <45% in adult males), this indicates bleeding and the need to cross- match and transfuse blood as soon as possible (see treatment for haemorrhagic complications).

The criteria in Surviving Sepsis Campaign Guideline for blood transfusion, i.e., hematocrit of <30% is not applicable to severe dengue. In fact, blood transfusion is life-saving and should be given as soon as severe bleeding is suspected or recognized. Do not wait for the haematocrit to drop too low before deciding on blood transfusion. This is because, in dengue, bleeding usually occurs AFTER a period of prolonged shock that is preceded by plasma leakage. During the plasma leakage the hematocrit IN FACT, increases to relatively high values before the onset of severe bleeding. As a result, when bleeding occurs in the later stage, hematocrit will then drop from this higher level; and therefore, it may not be as low as in the absence of plasma leakage.

6. A patient with normal SBP and normal mentation does not mean that he is not in shock. Patients in dengue shock often remain conscious and lucid. Look for narrowed pulse pressure despite normal SBP.

Once decompensation occurs, the BP may drop abruptly. Such prolonged hypotensive shock and hypoxia may in turn lead to multi-organ failure and an extremely difficult clinical course.

Differentiating chikungunya from dengue.
The key distinguishing feature for chikungunya is JOINT PAIN.

In fact, some clinicians came out with the aphorism “dengue + arthritis = chikungunya”!

The classical triad of clinical features for chikungunya infection are
•    fever,
•    arthralgia and
•    skin rash
(Ref: Robinson, M.C., 1955. An epidemic of virus disease in Southern Province, Tanganyika territory, in 1952-1953. Trans. R. Soc. Trop. Med. Hyg., 49 :28-32)
The arthralgia in chikungunya is usually symmetrical and involved more than one joint. The pain can be excruciating and involved fingers, wrist, elbows, toes, ankles and knees.

On the other hand, dengue presents with myalgia compared to chikungunya. The rash in chikungunya appears earlier (even in day 1 or 2 itself), as compared to dengue (around day 4). Furthermore, the rash in chikungunya starts with face and chest; those in dengue, the legs and trunks.

Legal Definition of a Child in Malaysia and the Definition of Statutory Rape

I made a mistake when discussing on the legal definition of a child in Malaysia and the definition of statutory, and so I thought it would be a good idea to revise on this topic.

I mistakenly thought that a child in Malaysia is defined as one aged 18 years old and below. I was wrong. According to the Malaysian Child Act 2001 or Act 611, a child is defined as

a person under the age of eighteen years or below 18 years old (NOT 18 years and below)

However, as Nadesan and Omar (2002) writes, the consenting age for sexual intercourse in Malaysia is 16 years old. As such, statutory rape is defined as sexual intercourse (regardless of whether WITH or WITHOUT consent) with a girl BELOW 16 years old (AND NOT with ANY child).

This definition is according to Section 376 of the Malaysian Penal Code (or Act 574).

Therefore, there exist a time period where a person under the age of 18 years old AND above the age of 16 years old, CAN consent to sexual intercourse, but cannot give consent to medical procedures and treatment (because she is below 18 years old).

The article written by Nadesan and Omar in 2002 is an excellent treatise of the current rape scenario in the Malaysian context. The article can be downloaded here.

The criteria of rape as per Section 375 of the Penal Code is as below:

1. Against her will
2. Without her consent
3. With her consent, when her consent has been obtained by putting her in fear of death or hurt to herself or any other person, or obtained under a misconception of fact and the man knows or has reason to believe that the consent was given in consequence of such misconception 
4. With her consent, when the man knows that he is not her husband, and her consent is given because she believes that he is another man to whom she is or believes herself to be lawfully married or to whom she would consent
5. With her consent, when, at the time of giving such consent, she is unable to understand the nature and consequences of that to which she gives consent
6. With or without her consent, when she is under sixteen years of age (statutory rape)

The word rape originates from the Latin word "rapere", which means "to snatch".  Often, to snatch something from someone would entail some amount of violence imposed. Furthermore, according to Section 375 of the Penal Code above, rape is defined when the sexual intercourse is done "against her will". As such, this places the burden on the victim and the prosecution team to establish the evidence of violence and "against her will". This can pose serious problems because, as Nadesan and Omar (2002) said:

".....the absence of injuries does not necessarily mean that the woman was a willing partner. Owing to many reasons, a victim may not resist the rapist and in that event the chances of a physical attack by the rapist is reduced. When victims are taken by surprise they may be too scared to resist. More importantly, in many instances the rapist is an immediate family member, a close relative or a friend. Several cases are actually incest and many more are statutory rapes where the victims are under the age of sixteen years."

In many countries, the burden of proof has been shifted to the defendant (alleged perpetrator) to prove that there was consent for sexual intercourse, but in Malaysia, the position still remains unchanged for the prosecution to establish that the woman did not consent.

Another thing I learned from the article by Nadesan and Omar (2002) is that amendment to the 1988 Section 146A of the Evidence Act (Act 56) states that no question in cross-examination shall be adduced or asked concerning the sexual activity of the complainant with any other person other than the accused. Previously, victims during cross-examinations were asked about their sexual encounters with persons other than the suspect in order to discredit their moral behavior.

Doctors and nurses working in the emergency departments should have a general knowledge of this important issue as these victims will be presented to the One Stop Crisis Center (OSCC) in emergency department. It is of utmost importance that such victims be accorded to utter privacy and confidentiality. No gossiping of the nature of the suffering inflicted upon the victim should be discussed among healthcare professionals!

My previous post on OSCC: click here.

Reference:

1. Nadesan K, Omar SZ. Rape--the Malaysian scenario. Malays J Pathol. 2002 Jun;24(1):9-14. [Click here to download the FREE full text in pdf]

Advanced ECG by Amal Mattu in Singapore

Attended the Advanced ECG workshop tomorrow conducted by Prof Amal Mattu in the Society for Emergency Medicine in Singapore 2012 Annual Scientific Conference (SEMS ASC).

A number of good streaming video ECG lectures by him in this website. Click here to assess.

Some highlights from the class:


 


Sgarbossa's criteria

The dictum that "in the presence of LBBB, one cannot diagnose myocardial infarction" is no longer true.

The three Sgarbossa criteria are the two concordances (elevation and depression) and one discordance (elevation). Discordance depression IS NOT part of Sgarbossa's criteria.

Discordance elevation requires an elevation of more than 5 mm as it obeys the rule of appropriate discordance.

Concordance depression is only for V1 - V3, but it is kind of a gestalt pattern recognition thing, because if you see, you should recognize it immediately.

Both concordances are more specific than the discordance elevation.

EMS123lead.com has a nice ECG on concordance elevation in this link (click here).

Sgarbossa's criteria also applies for patient with pacemakers.

Remember RBBB does NOT need special criteria such as Sgarbossa. For RBBB, interpret as straight forward STE as you would for any STEMI.

For Sgarbossa, only one abnormal lead is required.

On the other hand, once there is LBBB (as in Sgarbossa's), the significance of STE in aVR cannot be ascertained anymore.

2. Wellen's Syndrome

The problem is usually not with Wellen's Type 1 - it is rather easy to recognize Wellen's Type 1 with its typical deep symmetrical T inversion.

On the other hand, Wellen's Type 2 can be easily missed if we do not know what we are looking for.

The danger with Wellen's is that at the time of presentation, the patient may seem deceptively stable with a subsiding episode of chest pain. However, in reality, these ECG changes in Wellen's may represent a critical ischemia of LAD; medical therapy most probably may not work. The patient should be sent urgently to the cath lab. Although relatively asymptomatic, the patient should be subjected to a stress test, as the critical ischemia may trigger sudden collapse in these patients.

 Wellen's criteria is not dependent on ST changes, just the T inversion!

Note that young children and especially female up to 40 years, may have normal variant of T inversion (the juvenile pattern).

3. Posterior MI
Isolated posterior MI do occur in up to 5% of cases.
Do a posterior lead if unsure. An STE of even more than 0.5 mm is significant for posterior leads
I have previously written a detailed blog post on posterior MI.

4. STE in AVR
aVR is often called the forgotten lead. It is often ignored, often said to be of no use because of its position facing away from the normal direction of depolarization (rendering it to display negativity as reciprocal changes in most of the waveforms).

IN ACTUAL FACT,  ST ELEVATION IN AVR may SIGNIFY a LEFT MAIN CORONARY ARTERY (LMCA) STENOSIS with mortality up to 70%!!

Numerous articles have been written on this. It is coined as "a mostly ignored but very valuable lead in clinical electrocardiography", a "widow maker", etc.

STE in aVR itself of more than 1.5 mm carries a 75% specificity of LMCA  [in some articles, it is more than 1.0 mm. Check references in this article here.]
STE in aVR + avL -- 90% specificity
STE in aVR + V1 -- suggestive either prox LAD or LMCA occlusion but
STE in aVR > V1 -- more suggestive of LMCA

STE in aVR should be interpreted in conjunction with the symptoms presented; and also, its significance would be rendered dubious in the presence of BBB.

5. Brugada Syndrome
Any physician living in this part of south east Asia (SEA) should have Brugada in mind when its typical coved-shape STE jumps out in right sided leads.  Brugada syndrome is now thought of to be more widespread than just confined to SEA population. It is related to channelopathies (particularly sodium channel) and is associated with sudden cardiac arrest in young population.

Brugada syndrome may be confused with RBBB but RBBB would present with ST dep, NOT STE!

6. AF with underlying WPW
It is often difficult to suspect whether the AF is associated with underlying WPW.

However, WPW should be strongly suspected if the following features are seen in the AF:

• an irregularly irregular (with wide complexes) [by this virtue, AF should be suspected]
• a fast ventricular response up to 300 - 600/s
• a changing, (often bizzare) morphology

Anyway, delta wave in WPW might not be seen. However, short PR interval should be seen in almost all leads.

NEVER give ABCD drugs (Adenosine, B-Blocker, CCB, Dig) AND also should NOT give Amiodarone in WPW (although in many literature, including AHA guidelines, amiodarone is said to be safe in WPW. It is not! See an article on this here).

The drug that should or could be given in WPW is procainamide.
 
7. Prolonged QT interval
Technically prolonged QT interval is more than 400 ms; but for it to be dangerous of degenerating into Torsades, it often has to be more than 500 ms.

Grey-Turner Sign

Grey-Turner’s sign simply refers to the bluish discoloration of the flanks. The interesting thing about this sign is that whenever this sign is found, medical students are alerted to the fact that there is a possible underlying retroperitoneal bleeding going on.  Obviously, this sign could also indicate a possible intraperitoneal bleed besides the possibility of retroperitoneal bleed. The source of bleed could be traumatic or non-traumatic, as in hemorrhagic pancreatitis.

However, when British surgeon George Grey Turner (1877-1951) first described it in 1920, in the British Journal of Surgery, it was described as a sign of hemorrhagic pancreatitis.

Not many know about the pathophysiologic basis of this sign, however.  It is actually due to the action on the abdominal wall and skin of leaking extravasated pancreatic juice from the hemorrhagic or necrotizing pancreatitis tracked subcutaneously. It could also be the blood collection tracked subcutaneously from retroperitoneal organs in the flank region.

In this picture, CT scan was done; showing no evidence of retroperitoneal or intraperitoneal bleed. This patient had an intramuscular bleeding resulting in the bruise. Does this considered as a Grey Turner sign? But how do we know conclusively whether retroperitoneal bleed has actually occurred  without performing a CT scan? Isn't Grey-Turner sign a clinical sign?

Grey-Turner sign can be accompanied by another sign, the Cullen sign; also of similar pathophysiologic basis but at a different location. Grey-Turner refers to bruising at the flank; Cullen sign refers to bruising at the periumbilical region.

Grey-Turner vs Cullen: How to remember which is which?
The way I remember which is Grey-Turner and which is Cullen:

C = Cullen = Central abdomen (periumbilical)

Grey-Turner is the other one, then ("periphery", flank)

Elderly Abuse in Malaysia

The official visit by the undergraduate students and their lecturers from Tzu Chi University from Taiwan ended a week ago.
 
During that visit, I talked about elderly care and abuse, particularly within the Malaysian context because I feel this is one area which is not very much talked about, not easily detected, and in fact, what we know is probably the tip of the iceberg only. This forum would also provide a space for our students to interact with the Taiwanese students as Taiwan has a good legal provision for the elderly, although Professor Hanson Huang (extreme right in front row, pic) from this team of Tzu Chi university said that the problem still remains a concern as the issue is not the law, but the implementation of the law.

In Malaysia, elderly is defined as one who is “60 years and over”  (adapted from: United Nations World Assembly on Ageing, Vienna, 1982). Some would further divide them into the  “young old”, aged 55-75 years old, and the “old old”, aged above 75 years old.

Unfortunately, many of us as healthcare professionals have narrow perception on what health is. We often define health as an “absence of disease” as defined by Sidell (1995).

On the other hand, the World Health Organization (WHO) gives a more wholistic definition of health:

“the state of complete physical, mental and social well-being” (World Health Organization,1995)

The elderly population in Malaysia has increased from 5.9% in 1991 to 6.5% in 2000. And it is expected that the proportion of people age 60 years and above in 2020 would increase further to 9.5% (Sherina et al, 2005). The life expectancy of Malaysian men and women in 1957 was 55.8 years and 58.2 years respectively, but today, it is 71 for men and 74 for women.

Contrary to what many believe, elderly abuse is not only confined to physical abuse, but, may also be sexual, or emotional abuse or neglect

WHO defines elderly abuse as:

"a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person" (World Report on Violence and Health, World Health Organization, 2002)

As mentioned, elderly abuse can be:

• Physical abuse
• Sexual abuse
• Emotional and psychological abuse
• Financial exploitation
• Neglect
• Abandonment

Many believe that elderly abuse only occurs in nursing homes. But the truth is, more often than not, the abuser is a close relative – 80% being spouses and children of the victims or a close relative.
Another common myth is that elderly abuse would not happen in rich families although in actuality, elderly affects all ethnic groups and cuts across all socio-economic and religious lines. Those at risk are most likely to be female, widowed, frail, cognitively impaired, and chronically ill.

According to the 4th Malaysian Population and Family Survey, by the National Population and Family Development Board (LPPKN) 2011, one in three Malaysian elderly (33%) aged 60 and above are abandoned and do not receive financial support from their children. Click here and here to read further.

The main problem is that unlike child abuse (where there is the Malaysia Child Act 2001 to provide a protective legal environment for children), elderly abuse per se is not an offence in Malaysia as there is no law to explicitly deal with this. The only way is to charge any perpetrator under the Penal Code or Domestic Violence Act for physical abuse.

Under the Malaysian Domestic Violence Act 1994 (Act 521), domestic violence means the commission of any of the following acts:

willfully or knowingly placing, or attempting to place, the victim in fear of physical injury;

causing physical injury to the victim by such act which is known or ought to have been known would result in physical injury; 

compelling the victim by force or threat to engage in any conduct or act, sexual or otherwise, from which the victim has a right to abstain; 

confining or detaining the victim against the victim's will; or 

causing mischief or destruction or damage to property with intent to cause or knowing that it is likely to cause distress or annoyance to the victim

by a person against—

    his or her spouse;
    his or her former spouse;
    a child;
    an incapacitated adult
    any other member of the family. 

Under the domestic violence act 1994, the main issue of course is the fact that many of the more subtle forms of abuse such as emotional abuse, neglect and financial exploitation would be difficult to be legally charged.

Questions:
From your experience is elderly abuse? Why or why not?
What steps can you contribute to combat this society ill?


References:
Sidell, M. (1995) Health in Old Age: Myth, Mystery and Management, Buckingham: Open University Press.
Sherina M, Sidik Rampal L, Aini M, Norhidayati MH. The prevalence of depression among elderly in an urban area of Selangor, Malaysia. Int Med J. 2005;4(2):57-63.