Clinical Geriatrics

Case Presentation
Mrs. W is a 65-year-old retired school teacher. Her husband died two years ago in a car accident. Mrs. W’s two daughters are both school teachers who live nearby. She has five grandchildren and often cares for them when her daughters need help. Mrs. W went through a period of grief and mourning following the sudden loss of her husband but continued to teach until 6 months ago after reaching her 65th birthday. She decided to retire and traveled to Europe with some friends. While traveling, Mrs. W started drinking coffee each morning with her friends, and often drank several cups during the day while touring. She began to have difficulty sleeping, which she blamed on the traveling. After returning home, she continued to meet her friends at a local coffee shop almost every morning. She frequently drank several cups of coffee to help her “get going,” and started bringing a cup with her when she ran errands. On weekends or days when she did not meet her friends, Mrs. W began having headaches. She started taking an over-the-counter analgesic that contained aspirin, acetaminophen, and caffeine. This was helpful, but Mrs. W started feeling nervous at night, with difficulty falling asleep. She has developed a sensation of restlessness in her legs, and finds that she needs to get up and walk around her house to relieve it. Mrs. W wakes up several times each night to use the bathroom and has a great deal of difficulty falling back to sleep. She sees a neurologist about her headaches and restlessness and is asked about any prescription drugs that she takes, but not about over-the-counter medications. She reports taking alendronate 70 mg once weekly for osteoporosis. Her blood pressure is noted to be slightly elevated at 145/90 mm Hg. She describes feeling anxious and restless at night. Her neurological examination does not reveal any focal findings. Mrs. W is given a diagnosis of tension headaches, anxiety disorder, and restless legs syndrome. She is given a prescription for levodopa-carbidopa 25/100 mg at bedtime, gabapentin 100 mg 3 times per day, and paroxetine 20 mg once daily. She feels somewhat drowsy after taking the gabapentin, and increases her coffee consumption throughout the day. She is still sleeping poorly, wakes up often, and is very irritable and anxious. Her daughters are concerned about her frequent complaints of restlessness, ongoing headaches, a racing feeling in her chest, and her irritability. They convince her to see a primary care physician, Dr. D, affiliated with her health plan who specializes in cardiology.

Dr. D finds Mrs. W to be a nervous-appearing woman, with an elevated blood pressure of 150/ 95 mm Hg and a heart rate of nearly 100 bpm. Her electrocardiogram reveals sinus tachycardia, and the remainder of her physical examination in essentially normal. Dr. D asks many more questions about her use of caffeine, alcohol, smoking, and over-the-counter medications. He finds that Mrs. W is drinking at least 8-10 large cups (12-16 oz) of coffee per day and takes the over-the-counter analgesic containing 65 mg of caffeine per tablet. She drank 2 large cups of coffee and took 2 tablets of headache medication prior to her appointment. Dr. D feels that Mrs. W does not suffer from restless legs syndrome, tension headaches, or an anxiety disorder. He discusses her coffee and other caffeine consumption and points out that her symptoms seem all related to the more than 500-600 mg per day of caffeine that she has been ingesting. He strongly advises her to stop all of her caffeine use. He also recommends that she stop the paroxetine and levodopa-carbidopa. Mrs. W is very skeptical, as she feels coffee has been a main part of her socializing, has helped her feel more alert when she watches her grandchildren, and is a beverage she has become accustomed to drinking throughout her 35-year teaching career. She stops the medications without any problems. She follows Dr.