Clinical Geriatrics

Case Presentation

Mr. Y is a 68-year-old widowed man brought to the Emergency Department (ED) by his daughter, Ms. S. Ms. S came to see her father while on a business trip and found him to be weak and lethargic. She found very little food in the house and was concerned by the excessive number of bottles of whiskey in the kitchen and living room. Ms. S tells the ED staff that her father had a myocardial infarction 5 years ago and has hypertension. He is supposed to be taking medication for hypertension and heart disease, but Ms. S does not know the names of the medication. Mr. Y has been living alone since his wife died 2 years ago from cancer. Ms. S and her sister both live in other states but try to call and visit their father on a regular basis. Ms. S reports that Mr. Y always tells them that everything is fine. Mr. Y was functioning independently, even working part-time as a security guard until his position was eliminated in budget cuts 6 months ago. Ms. S reports that her mother always took care of everything in the household, including making medical appointments, filling prescriptions, and taking care of her father. She feels that he has been lost without her.

Mr. Y is found to be arousable to verbal stimuli but lethargic. He has alcohol on his breath. He appears thin, frail, and older than his age. His pulse is irregular, and an electrocardiogram reveals atrial flutter. He is found to be hyponatremic, with a sodium level of 128 mEq/L (normal range 134-149 mEq/L). His blood alcohol level is 80 mg/dL (close to the legally intoxicated limit of 100 mg/dL) and the staff is concerned about the possibility of withdrawal. His blood pressure is elevated at 160/100 mm Hg, and his pulse rate is 90-100 beats per minute. Mr. Y is admitted to the Telemetry unit to monitor his atrial flutter and is placed on alcohol withdrawal precautions.

Mr. Y is treated with lisinopril 20 mg daily, metoprolol 100 mg twice daily, and aspirin 81 mg daily for his hypertension and cardiac disease. A computed tomography scan of the head is performed, which reveals mild cortical atrophy but no signs of any acute stroke or head trauma. He becomes more alert and does not show any signs of alcohol withdrawal. His heart rhythm returns to normal by the third hospital day. The patient’s sodium level also returns to normal after oral and intravenous hydration is given. He is transferred to a general medical floor. Physical therapy is consulted due to Mr. Y’s generalized weakness. He is evaluated but shows poor effort. His appetite is also poor, and nutritional supplements are ordered. Mr. Y tells the unit staff that he has not seen his doctors since the death of his wife 2 years ago. He has not filled any prescriptions and does not know the names of his medications. He reports that he has never made a doctor’s appointment for himself in his life, as his wife used to do it for him. Mr. Y has a high school education and worked as a carpenter and building contractor in addition to his security job. He managed the finances for his family, used to attend church regularly, and belonged to a local social club. After his wife died, he reports that he stopped going out, except to weekly church services, but after a few months gave this up as well.

The unit social worker talks to Mr. Y about discharge planning and home care. He appears rather perplexed and states that he does not know what to do. His daughter visits him before she has to return home from her business trip and wants to have her father placed in a nursing home. The social worker consults with the medical staff, who feel that Mr. Y is capable of functioning independently. They note that he has had many visitors outside of his family who may be a source of support. However, the care team has concerns regarding possible depression, noncompliance with medical care prior to admission, and his alcohol use.