Clinical Geriatrics

Case Presentation
Mrs. CP is a 64-year-old widowed Filipino woman who came to see a psychiatrist at an outpatient mental health clinic. She had been in treatment intermittently since 1998 for depression and anxiety. Her symptoms included anxious mood, insomnia, hypervigilant behavior, tearfulness, poor concentration, and feelings of palpitations. She reported that over the past year she had been more forgetful and distractible, forgetting where she had placed her keys, pocket cash, and other items. She would forget to get off the bus at a familiar stop and could not remember to purchase needed items at the grocery store. Of greater concern, she had left the stove on several times and had limited recollection of this. Mrs. CP’s behavior included unusual incidents such as leaving rotting bananas in the closet and going back into the shower fully clothed after she had just bathed and dressed herself. Because of these behaviors, her younger son and a close friend moved in with her to assist and monitor her behavior.

The first sign of some unusual behavior began one year prior to Mrs. CP’s current treatment when she described episodes of “sleepwalking” during the day. She reported walking for blocks past a location and past an appointment time, and did not realize that she had done so until something distracted her, such as her cell phone ringing or a taxi honking a horn. She felt that she lost brief periods of time. Mrs. CP also spoke of symptoms occurring at night, such as talking in her sleep, and her waking up to find that all of the windows had been opened, or that the television or air conditioner had been turned on without her awareness. The patient’s son had witnessed the patient flailing about at night and talking in her sleep.

However, the patient’s overall functional performance of her activities of daily living and instrumental activities of daily living were not consistent with someone who had a dementing process or an amotivational or inattentional process. She shopped for her food, cooked, paid her bills, and followed up with her medical appointments. On psychological testing, she did not show poor executive planning, aphasia, personality change, or other signs of early dementia. The patient was very uncomfortable about the increasing dependence on others, and felt helpless and concerned that there would not be an explanation forthcoming about her diagnosis.

Mrs. CP had consulted three neurologists from different hospitals in the past and had been told by one that her problem was “anxiety,” by another that it was “stress and depression,” and by a third that she had early-onset Alzheimer’s disease. The patient’s medical history was significant for hypertension, chronic vertigo, osteoarthritis, osteopenia, and gastroesophageal reflux disease. Medications included hydrochlorothiazide 25 mg daily, meclizine 12.5 mg twice daily, and esomeprazole 40 mg daily. She was diagnosed with seizures as a child but had not taken any anticonvulsant medication for many years. Mrs. CP underwent a noncontrast head computed tomography (CT) scan in April 2006, which revealed bilateral frontal volume loss. A subsequent magnetic resonance imaging (MRI) scan of the brain done in September of that year did not reveal such an abnormality. Due to the uncertain history of seizures, she underwent a three-day electroencephalogram (EEG) study with overnight monitoring, which did not reveal any abnormalities. Laboratory work-up was unremarkable.

During her current treatment, the patient received neuropsychological testing due to concerns regarding her diagnosis, possible cognitive loss, and to assist with treatment planning. Following the evaluation, the findings were found to be consistent with major depressive disorder, mild cognitive disorder versus dementia, and that she had a history of post-traumatic stress disorder.

Mrs.