Dementia

1. John R. Martinelli, MSIII SGUSOM
Case #5: Dementia
01/28/14
Identifying Information
Ms. E.M. is a non-English speaking 91-year-old Latino lady who was admitted to SBMC
via the ED on January 21, 2014.
Chief Complaint
Daughter states Ms. E.M.’s confusion and mental state has rapidly worsened over the
preceding several weeks.
History of Present Illness
Ms. E.M. is a 91-year-old lady who was last examined on December 2, 2013 by the
SBMC IMFP service with a history of slowly progressive unspecified dementia
beginning approximately 2 years prior. She was taken to IMFP after her daughter became
concerned with the inability of her mother to recall the time of day, as well as noncompliance with her medication. At that time it was determined her dementia was
“progressing as expected”, however, she was also given a depression screen indicating
this also being a possible factor. Ms. E.M.’s physical exam and laboratory investigations
were non-contributory and relatively unchanged from previous visits; therefore, the
daughter was reassured and educated with respect to dementia as well as social services if
needed.
Regarding her current admission, approximately 3 hours prior to presenting to the SBMC
ED and shortly after her dinner, Ms. E.M. began to experience paranoid-type delusions.
According to her daughter, she began screaming that animals were in the room and were
“going to get her”. She continuously attempted to force her hand down her throat
believing she could remove them, and also threatened to drink boiling water to kill them.
The daughter immediately called 911 and requested an ambulance to transport her mother
to the ED where she was admitted for further evaluation.
At the time of her admission, Ms. E.M. was found to be slightly dehydrated and
hypotensive for which she was given adequate IV fluids with lower dosing of her antihypertensive medication (amlodipine). Her previous dementia/anti-psychotic medication
(quetiapine) was also discontinued and substituted with risperidone. He daughter denied
suspecting nausea, vomiting, diarrhea, chest pain, or shortness of breath. Laboratory
findings including BMP were consistent with slight dehydration. She has been afebrile
with a normal CBC and WBC count. Non-contrast CT of the brain revealed only normal
changes for age without evidence of acute vascular events, progressive encephalopathy,
normal pressure hydrocephalus, or masses. Ms. E.M. has responded quite nicely to this
current treatment regimen with daily improvement in her overall affect and awareness,

2. including resolution of her paranoid delusions. Additionally, her BMP returned to
baseline and her blood pressure is now in a normal range. To date, she continues to be
monitored in-patient and is awaiting placement in a skilled nursing facility.
Past Medical History
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9.
UTI (2014, resolved)
Dementia (2011 – current)
Osteopenia (2011 – current)
Atrial Fibrillation (2011)
Hypertension (? years)
Diabetes Mellitus Type II (diet control, ?years)
Hyperlipidemia (diet control, ?years)
Hypothyroidism (? years)
Chronic Kidney Disease (? years)
Past Surgical/Procedural History
Myocardial Nuclear Stress Imaging/Tc-99 (2012, 2011)
Normal
Echocardiogram (2011)
Normal, EF: 74%
DEXA Scan (2011)
Osteopenia
Mammogram (2011)
Normal
Medication (In-Patient)
Dehydration
NS Flush 3ml, IV Push, PRN
Dementia
Risperidone 0.25mg, PO, BID
Atrial Fibrillation
Dabigatran 75mg, PO, BID
Hypertension
Amlodipine 2.5mg, PO, QD
Hypothyroidism
Levothyroxine 25mcg, PO, QD
GI Prophylaxis
Omeprazole 10mg, PO, QD
Nausea/Vomiting
Ondansetron 4mg, IV Push, Q6H, PRN
Bacterial Conjunctivitis
Levofloxacin, 1gtt TID OU x 5 days, Lid Scrubs/Hygiene
2

3. Allergies
NKA/NKDA
Social History
Lives with daughter and son-in-law in a smoke-free and pet-free home. No history of
alcohol or tobacco use. Diet has been good per daughter without prior need for assistance.
Family History
Father:
Mother:
Unknown
Unknown
Review of Systems (on Admission)
Constitutional:
Eye:
Ear/Nose/Mouth/Throat:
Respiratory:
Cardiovascular:
Gastrointestinal:
Genitourinary:
Hematologic/Lymphatic:
Endocrine:
Immunologic:
Musculoskeletal:
Integumentary:
Neurologic:
Psychiatric:
Mild weakness, Ambulating with minimal assistance.
Cataract OD, Cataract surgery OS, No visual complaints.
Hearing adequate, No nasal congestion, No sore throat.
No shortness of breath, No cough, No wheezing.
No chest pain or palpitations.
No vomiting, diarrhea, constipation, (+) Abdominal pain.
No dysuria.
No complaints or suggestion of lymphadenopathy.
Hypothyroidism.
No indication of autoimmune disease.
Mild extremity weakness, No pain.
No rash.
Altered Mental Status.
Altered Mental Status.
Physical Examination (on Admission)
General Appearance:
Vital Signs:
Severe distress – attempting to force hand in mouth.
Tp
BP
PR
RR
O2
Integument:
Lymphatics:
HEENT:
98.7
120/52
66
20
99% (Room Air)
Normal Tp to touch, dry, no pallor, scars, rash, or masses.
No lymphadenopathy.
Normocephalic. No gross neuro-ophthalmic deficits.
Mucopurulent conjunctival discharge OU. Unremarkable
3

4. Neck:
Thorax & Lungs:
Cardiovascular:
Abdomen:
Genital/Pelvic:
Rectal/Prostate:
Musculoskeletal:
Neurologic:
ears, nares, oropharynx.
Supple, no edema, masses, or lymphadenopathy.
Clear to auscultation bilaterally. No crackles.
RRR, no murmur, no tachyarrhythmia, equal pulses at
extremities, no peripheral edema.
Soft, non-distended, no masses, bowel sounds present.
Slight tenderness to touch in epigastric and suprapubic
regions.
Deferred, N/A.
Deferred, N/A.
All extremities 3+ power, DTR? (poor cooperation)
Altered Mental Status. No evidence of focal deficits.
Diagnostic & Laboratory Testing
CT Brain (non-contrast): Normal changes for age without evidence of acute vascular
events, progressive encephalopathy, normal pressure hydrocephalus, or masses.
MRI: Attempted but could not perform due to poor patient cooperation.
EKG: Normal Sinus Rhythm. No evidence of atrial fibrillation or tachyarrhythmia.
Admission:
WBC: 4.6
Hgb: 13.4
Hct: 39.5
Platelets: 244
Na: 146
K: 4.2
Cl: 108
HCO3: 24
BUN: 21
Cr: 1.14
Glu: 140
BUN: 20
Cr: 0.85
Glu: 79
UA & Ucx: Negative
Day 7 of Admission:
WBC: 3.6
Hgb: 13.1
Hct: 39.6
Platelets: 196
Na: 135
K: 4.5
Cl: 102
HCO3: 26
Vitals:
Tp
BP
PR
RR
O2
97.4
127/73
78
20
97% (Room Air)
4

5. Summary
This is a 91-year-old lady with an approximate 2-year history of declining mentation who
was admitted to SBMC after her daughter witnessed her experiencing paranoid delusions.
Upon admission, she was found to be in severe mental distress with continuation of these
beliefs. After being found slightly dehydrated and hypotensive, she was given IV
hydration with a dosage reduction in her hypertensive medication. In addition, her
previous anti-psychotic was discontinued and she was placed on a newer generation
atypical anti-psychotic. Her in-patient course shows daily and continued improvement
with respect to her mental status including complete resolution of her delusional beliefs.
She is currently awaiting discharge to a skilled nursing facility.
Assessment
1. Dementia, unspecified. Possible rapid progression during preceding 6 weeks prior
to admission culminating in paranoid psychoses. Clinical evidence of
improvement. Differentials for reversible rapid progression in this patient include
pharmacologic efficacy and/or compliance as well as dehydration and/or
nutritional basis.
2. Osteopenia.
3. Atrial Fibrillation.
4. Hypertension.
5. Diabetes Mellitus Type II.
6. Hyperlipidemia.
7. Hypothyroidism.
8. Chronic Kidney Disease.
9. Bacterial Conjunctivitis OU
Action Plan
1. Continue risperidone. Stressed proper diet and fluid intake. Will be discharged to
skilled nursing facility pending availability. Follow-up appointment made with
geriatric specialist for continued treatment and monitoring.
2. Vitamin D and Ca supplementation. Physical Therapy.
3. Continue dabigatran for thromboembolic prophylaxis, consider beta-blocker.
4. Continue amlodipine, careful monitoring due to possible previous BP instability.
5. Diet control, monitor HbA1C.
6. Diet control, monitor LDL.
7. Continue levothyroxine, monitor TSH and T4.
8. Monitor renal function – BMP including creatinine currently baseline and urine
output appropriate.
9. Levofloxacin, 1gtt TID OU x 5 days. Lid scrubs/hygiene.
5

6. Summary
This is a 91-year-old lady with an approximate 2-year history of declining mentation who
was admitted to SBMC after her daughter witnessed her experiencing paranoid delusions.
Upon admission, she was found to be in severe mental distress with continuation of these
beliefs. After being found slightly dehydrated and hypotensive, she was given IV
hydration with a dosage reduction in her hypertensive medication. In addition, her
previous anti-psychotic was discontinued and she was placed on a newer generation
atypical anti-psychotic. Her in-patient course shows daily and continued improvement
with respect to her mental status including complete resolution of her delusional beliefs.
She is currently awaiting discharge to a skilled nursing facility.
Assessment
1. Dementia, unspecified. Possible rapid progression during preceding 6 weeks prior
to admission culminating in paranoid psychoses. Clinical evidence of
improvement. Differentials for reversible rapid progression in this patient include
pharmacologic efficacy and/or compliance as well as dehydration and/or
nutritional basis.
2. Osteopenia.
3. Atrial Fibrillation.
4. Hypertension.
5. Diabetes Mellitus Type II.
6. Hyperlipidemia.
7. Hypothyroidism.
8. Chronic Kidney Disease.
9. Bacterial Conjunctivitis OU
Action Plan
1. Continue risperidone. Stressed proper diet and fluid intake. Will be discharged to
skilled nursing facility pending availability. Follow-up appointment made with
geriatric specialist for continued treatment and monitoring.
2. Vitamin D and Ca supplementation. Physical Therapy.
3. Continue dabigatran for thromboembolic prophylaxis, consider beta-blocker.
4. Continue amlodipine, careful monitoring due to possible previous BP instability.
5. Diet control, monitor HbA1C.
6. Diet control, monitor LDL.
7. Continue levothyroxine, monitor TSH and T4.
8. Monitor renal function – BMP including creatinine currently baseline and urine
output appropriate.
9. Levofloxacin, 1gtt TID OU x 5 days. Lid scrubs/hygiene.
5