Clinical Geriatrics

CASE PRESENTATION
A 66-year-old widowed male comes to a psychiatrist with his daughter, who acts as a translator and informant. The daughter and patient are concerned that he is “taking too many medications and not getting better.” They are worried about the medical care that he has received, and provide a very detailed history. The patient is a native of Brazil, who immigrated to the United States 40 years ago. He retired from his job as a construction worker at age 63 after being seriously injured at work, suffering a depressed skull fracture requiring insertion of a metal plate over his left temporal and parietal area. The patient recovered well following the accident and lived independently. He suffers from type 2 diabetes mellitus and hypertension. His medications included metformin 850 mg and atenolol 50 mg, each once per day. His two children live nearby. They have noticed that over the past year he has become more withdrawn and often stays in his apartment all day. He has stopped taking walks and socializing in the local park, like he used to. His oldest daughter took him to his primary care physician, also of Brazilian descent, who was able to speak with the patient in his native Portuguese. He found the patient to be lonely, and instructed him to spend time at a local senior center that has a large population of immigrants from South America. The patient had a strong belief in the advice of his physician and became active at the center. His mood improved, and he remained independent.

The patient returned to his physician’s office 6 months later for a routine follow-up visit. He was surprised to find that the doctor had returned to Brazil due to a family emergency and two new physicians had taken over the practice. The patient became nervous when asked if he spoke English, and was embarrassed to admit that he had only attended school through the 5th grade. The new physician spoke rapidly both in English and Spanish, but no Portuguese-speaking staff were available. The patient was asked to draw a clock and recall words in English and in Spanish, but became anxious and overwhelmed by the language difficulties. The patient was found to have a blood pressure of 160/95, and a fingerstick glucose of 210 mg/dL. A chart review noted a history of elevated cholesterol and mild depression. He was given prescriptions for glimepiride 2 mg daily, ezetimibe 10 mg daily, enalapril 10 mg daily, bupropion sustained-release 150 mg twice daily, and donepezil 5 mg daily. He was referred to a memory disorders clinic that was part of the new practice, due to the physician’s impression of “history of depression, with likely dementia.”

The patient kept his appointment at the memory disorders clinic, but unfortunately his daughter was unable to accompany him. He also continued to take his prior medications (metformin and atenolol), along with the additional prescriptions given by the new physician. The patient was feeling tired and weak. He also was embarrassed to admit that he did not speak English, and was given tests administered in Spanish. The patient became frustrated and angry during the testing, and he refused to complete many of the tests. He was given a diagnosis of “probable Alzheimer’s dementia with psychosis,” and was sent home with a prescription for quetiapine 100 mg twice daily. His daughter came to visit him one week later and found the patient sedated-appearing, with hand tremors. She stopped all of his medications and brought him to a psychiatrist recommended by a social worker at the senior center. The patient still appeared somewhat sedated, but was verbal and cooperative. His daughter was able to translate for him. Both the patient and his daughter were angry and upset, feeling abandoned by his primary care physician, but uncertain of where to get care for him.