Clinical Geriatrics

CASE PRESENTATION
Mr. M is a 70-year-old retired typesetter and father of two who was admitted to a psychiatric facility after an attempt to strangle his wife of 50 years. He is a devout Catholic and explained that a message from God convinced him that his wife intended to kill their granddaughter. In the past weeks, he had cluttered the home with religious shrines of candles, flowers, and photographs of religious figures. His wife’s protests only resulted in his mounting anger and accusations that her attention to his needs—both culinary and sexual—was flagging. He had been preoccupied with religious themes before, but the sexual content was new and distressing. Since emigrating from Italy he had persevered through numerous manic and depressive episodes, often associated with religious delusions. With multiple trials of psychotropic agents, a therapeutic effect was achieved. Mr. M had been a successful provider for his family and was well respected in the community. Complicating his condition was idiopathic Parkinson’s disease (diagnosed 2 years ago), type II diabetes, hypertension, hypothyroidism, and benign prostatic hypertrophy with subsequent urinary incontinence. With the exception of recent changes in the dose of carbidopa/levodopa for Parkinson’s disease, his other conditions were stable. Mr. M’s family noted mild cognitive decline and impaired gait over the past year, which they excused as part of his advancing age.

Neuropsychological testing found his overall cognitive abilities to be severely impaired. Attention was assessed with normal digit span, but registration, recall, visuospatial skills, constructional skills, and language were all markedly impaired. These findings were consistent with a diagnosis of dementia, most likely related to Parkinson’s disease. Laboratory and neurology assessments and a magnetic resonance imaging (MRI) of the brain did not reveal any reversible causes of cognitive decline.

As a result of the findings, the psychiatrist suggested adding donepezil to the patient’s regime of lithium and quetiapine, which had been initiated to reduce his psychosis and religious preoccupations. However, his family was worried that he was already taking too many medications. His children had searched the Internet for information on donepezil, and were concerned about side effects of nausea, vomiting, diarrhea, and potential worsening of Parkinson’s symptoms. They also complained that the patient appeared sedated, and that his gait impairment was more noticeable. The family requested a change in medication. To avoid exacerbating his Parkinson’s disease, clozapine was substituted for quetiapine.

Over the course of the admission, Mr. M’s wife and children attended multiple family meetings, often bringing homemade Italian pastries for the patient and staff. The family was able to maintain a sense of humor to deal with their stress over the patient’s decline. His son and daughter were able to express their frustration with his bizarre religious preoccupations that were especially difficult to accept given the importance of Catholicism in the family. They were also very concerned about the heredity of mental illness, and exactly what risk this posed to themselves, and especially their own children. Although the substitution of clozapine for quetiapine had led to some improvement in Mr. M’s delusions and bizarre behavior, the dose had to be reduced because of drooling—a side effect the family found particularly mortifying.

Mr. M’s wife was herself suffering from significant depression but was able to be an active participant in family meetings, despite difficulties with English. She struggled with her distaste and shame over the new, hypersexual twist that his religious delusions had taken. She felt guilt over the thought of transferring her husband to a nursing facility. Mr. M accused her of trying to kill him by sending him to a nursing home.