Clinical Geriatrics

CASE PRESENTATION
Mrs. C is a 74-year-old retired woman who comes with her daughter to see Dr. A, her endocrinologist and primary care physician. Dr. A has cared for Mrs. C for the past 8 years, after she was hospitalized in a hyperosmolar state due to poorly controlled diabetes mellitus. Mrs. C had been recently widowed then, and had difficulty adjusting to life without her husband. Dr. A was gratified to see how well Mrs. C has functioned over the past 8 years. She became compliant with her medications and diet, joined a diabetes support group, and monitored her blood sugars carefully. She always appeared pleasant during her office visits, very neatly dressed and groomed. Both Mrs. C and her daughter are English teachers. Mrs. C works episodically as a substitute teacher.

Dr. A is surprised to see Mrs. C looking tired, thinner than usual, and dressed in somewhat mismatched clothing. Her daughter, Ms. F, explains that the previous night she had to drive to a casino more than 90 miles away to pick her mother up. She tells Dr. A that her mother needs “an intervention” for her compulsive gambling and that she cannot leave the office without getting help. Ms. F is angry, yelling at her mother about money she has wasted gambling. Mrs. C insists she is fine and tells her daughter to leave. They begin arguing in the waiting room.

Dr. A asks his receptionist to take Ms. F into another room. He clearly needs to evaluate Mrs. C and find out more about the situation. Mrs. C tells him that for many years she has gone on bus trips to casinos with a local senior center. These were usually monthly events. Mrs. C met several women who organize their own trips, sharing a car service and staying later at night. She found these trips more interesting, began reading books about gambling, and spent larger amounts of money on poker, roulette, and dice. Mrs. C favored one casino and started arranging her own trips there. She felt welcome when the staff started calling her by name and proudly tells Dr. A about the night she was “comped the high rollers suite” after winning more than $40,000 at the roulette table. Dr. A is startled by what he is hearing. He is also concerned that Mrs. C is mildly tachycardic, with a blood pressure of 180/90 mm Hg. He asks his nurse to check her fingerstick glucose and perform an electrocardiogram. Dr. A goes to see several other patients, while promising Mrs. C’s daughter that he will speak with her later.

Mrs. C tells the nurse that she needs to use the bathroom. She is asked to provide a urine sample and leaves the examination room. Mrs. C quietly walks out of the office. Her daughter looks for her and becomes frantic, telling Dr. A and the entire office that her mother has spent the majority of her pension—over $600,000—gambling. She has sold jewelry at pawn shops. The previous night, Mrs. C ran out of money in her bank accounts and could not get additional credit from the casino. Her daughter has loaned her money but realizes that her mother needs more help than the family can provide.

Dr. A wants to help Mrs. C, but she left the office and clearly was not ready to discuss treatment. Dr. A refers her daughter to a social worker who counsels families of patients with addictions. Mrs. C allowed her blood to be drawn before she left the office, and Dr. A is relieved to find that her complete blood count, chemistry profile, glycosylated hemoglobin, and thyroid function tests are all within normal limits. He tries to reach Mrs. C to schedule a follow-up visit, but she does not respond.

DISCUSSION
The United States has seen a dramatic growth in the gambling and gaming industry since 1975.1 States have found that lotteries are a successful means of increasing revenue, and 37 states plus Washington, DC have legalized lottery systems. Casino gambling is available in 27 states. This offers significant availability of a wide range of gaming activities to a large number of people.