On-Call Geriatric Psychiatry by Ana Hategan James A. Bourgeois & Calvin H. Hirsch

Author:Ana Hategan, James A. Bourgeois & Calvin H. Hirsch
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

13.4 Case Vignettes

Case Vignette 1 – Neglect

The on-call psychiatrist was asked to assess the decisional capacity of Ms. R, a 78-year-old woman admitted 3 days earlier following recurrent falls, rule out syncope. This was her third fall-related emergency department (ED) visit in the past 2 months. Per the patient and niece, she lost her balance trying to open the passenger door of her niece’s car, falling backward and striking her head against the side walk. In the ED, she was alert and “oriented in four spheres (person, place, time, situation);” non-contrast computerized tomography of her head showed age-consistent atrophy but no evidence of intracranial bleeding or stroke. Her electrolytes and complete blood count were within normal limits except for a blood urea nitrogen of 26 mg/dL (9.3 mmol/L) and a creatinine of 1.3 mg/dL (114.9 μmol/L). Her electrocardiogram showed nonspecific ST-T wave changes. Per chart notes, on the admission physical examination, she appeared “well developed and well nourished,” but had greasy, unkempt hair, dirt-encrusted skin on her back and abdomen, and an “unwashed” body odor. She wore loose-fitting upper dentures and had poor lower dentition. She required one-person assistance to stand and was very unstable on her feet, with decreased vibratory sensation to the knees but normal proprioception. Several mycotic toenails were several centimeters long. Her B12 level was 550 pg/mL (400 pmol/L) and her serum albumin was 3.8 g/dL (38 g/L), both within normal limits. After 2 days of physical therapy, Ms. R was able to transfer and ambulate safely with a front-wheeled walker, but was caught several times by nurses ambulating to the bathroom without it. Telemetry demonstrated normal sinus rhythm with infrequent, short runs of supraventricular tachycardia. The primary medical team believed she was medically stable for discharge, but because of concern about self-neglect and a possible underlying NCD, wanted a formal determination of decisional capacity for self-management in the community. The patient did not want to leave her house of 40 years and lose her independence and refused placement in a board and care facility, where she feared she would lose her privacy. She indicated that her son, who lived on her “sun porch,” would take care of her. She did not know her son’s cell phone number. According to the discharge social worker, APS had opened and closed a case on her within the past year because of the son’s history of drug abuse, concluding that she was receiving adequate support.

On mental status evaluation, Ms. R scored 28/30 on the MoCA, missing the date and generating nine words in 1 min for the verbal fluency task (normal ≥11 words). Her clock draw was systematically and accurately executed, although the lines were shaky. When asked why she didn’t bathe, she replied that the bathroom sink was broken, and she was afraid to take a shower out of fear of falling. She planned to call a plumber when she returned home. She acknowledged that her son was unreliable and sometimes used drugs but that he needed a place to stay.

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