Clinical Geriatrics

CASE PRESENTATION
Ms. G is a 72-year-old, single white female who lives alone and has no children. She was visited by local mental health services at the request of her neighbors, who complained about an intolerable smell and flies coming from her apartment. On observation from the entrance, the apartment was grossly dirty with an offensive odor. The carpets were soaked with urine and moldy feces. Piles of garbage, each about 5 feet high, restricted the living space. There was no furniture in the house, no refrigerator, and among the garbage the only signs of nourishment were cracker wrappers and soda cans. Ms. G was in a state of gross physical neglect, dressed in layers of dirty clothing stained with urine. The exposed surfaces of her skin were deeply engrained in dirt. She minimized the seriousness of the damage in her apartment, refused to communicate, and vehemently resisted any professional help. Because of concerns that the patient was in imminent harm due to her dangerous living conditions, she was involuntarily hospitalized in an acute geriatric psychiatric unit.

On admission, physical examination revealed arthritic deformities of both hands, and neglected venous ulcers were seen bilaterally on the ankles. The initial psychiatric assessment provided no evidence for dementia, or affective or psychotic disorders. Neuro-psychological evaluation showed no evidence of dementia. Overall, the patient’s general intellectual ability was in the average range. Executive functions, attention, memory, language, and visual and spatial perception were grossly intact. Ms. G had no prior psychiatric history of hospitalization or treatment. She denied any family history of psychiatric illness or history of substance abuse. Her developmental and social history revealed an independent and isolative personality. Her mother passed away when she was 5 years of age. She had no siblings, and she lived with her father and stepmother. She described her relationship with them as “neutral.” At the age of 21, she moved out of her parents’ house, and since then has had little contact with her family. Ms. G reported a lifelong pattern of having no significant relationships and denied having any friends. She displayed a marked indifference to her social isolation and loneliness.

Ms. G reported that she was always advanced academically and had earned a BS degree in sociology. The patient also stated that she has been working as an employment counselor for the past 20 years, but refused to give any phone numbers for her work. No collateral information could be obtained.

While on the inpatient unit, Ms G. showed lack of initiative for most activities. She used a wheelchair instead of ambulating, and continuously refused to shower or change her clothing. She continued to isolate herself in her room. Ms. G appeared aloof, was verbally aggressive and hostile toward the staff, and would not socialize with any of the patients on the unit. A diagnosis of personality disorder with schizoid and paranoid traits was considered.

Laboratory tests were done to exclude organic causes. This included thyroid function tests, vitamin B12 and folic acid levels, urinalysis, urine toxicology, complete blood count, blood chemistry, and computerized tomography of the head. The significant findings were: low hemoglobin level (8.9 g/dL [12-16 g/dL]), low hematocrit level (26.4% [37-47%]), low serum iron level (16 g/dL [35-175 g/dL]), and upper-normal iron-binding capacity (389 g/dL [250-400 g/dL]), suggesting that the patient had iron deficiency anemia possibly due to malnutrition.

Ms. G strongly opposed her hospitalization and alleged that her lifestyle was the expression of her personal freedom. She also exhibited paranoid ideations toward the staff. She was started on risperidone 0.5 mg orally twice per day; however, she refused to take any medications.