Clinical Geriatrics

Case Presentation
A 72-year-old female in previously good health was admitted electively to an inpatient geriatric psychiatry unit for evaluation and treatment of a one-year history of anxiety, paranoid delusions, hallucinations, confusion, and memory loss. She had no history of prior psychiatric problems or psychiatric treatment of any kind. According to her children, the first change in her behavior was the onset of hoarding. Shortly after she began hoarding, family members observed that she was becoming withdrawn, displaying odd behaviors, and verbalizing paranoid thoughts, including beliefs of “people hiding under the car,” and “terrorists targeting me.” She had started ignoring necessary household upkeep, including paying bills, and had become generally more confused and forgetful. She had worked for over 20 years in the local post office as a letter sorter, but her psychiatric symptoms interfered with her work to the extent that she was forced into retirement after an employer-mandated psychiatric evaluation determined that she had a psychiatric illness incompatible with ongoing employment. The day prior to admission, she had spent most of the day in bed crying, although she denied depressed mood when questioned.

Evaluations by her primary care physician and a neurologist included a normal metabolic panel, normal hematology panel, normal thyroid function tests, and normal urinalysis. A magnetic resonance imaging scan of the brain and a positron emission tomography scan were performed, and neither revealed any significant abnormal findings. Her past medical history included ablation for Wolff-Parkinson-White syndrome, a prior Bell’s palsy with some residual left-sided facial droop, hypertension, osteoporosis, and a thyroid disorder of unclear nature. The patient did not smoke, drink alcohol, or use recreational drugs. Her medications included lisinopril and alendronate. She had not been prescribed psychotropic medications for her current symptoms.

As part of the standard admission evaluation for patients admitted to the unit, a geriatric internal medicine consultation was obtained. The patient appeared well-hydrated with stable vital signs, and the remainder of her physical examination was notable for a residual left facial droop and a systolic ejection murmur at the base of the heart, consistent with a flow murmur.

The patient’s mental status examination at admission revealed a disheveled appearance, the wearing of large, darkly tinted sunglasses in a dimly lit room, inappropriate laughter in response to what appeared to be internal stimuli, and the verbalization of a belief that there were strange men following her. The patient scored 25 out of 30 on the Folstein Mini-Mental State Examination (MMSE),¹ missing three on delayed recall and two on orientation. Neuropsychological testing was attempted shortly after admission but was limited by the patient’s thought disorder and other behavioral symptoms. A Mattis Dementia Rating Scale² was successfully administered, however, and the patient scored 129 out of a maximum possible score of 144 points, which was consistent with moderate cognitive impairment.

Repeat diagnostic studies revealed a normal hematological panel, normal urinalysis, normal thyroid function tests, normal liver function tests, and a normal metabolic panel, with the exception of a slightly elevated calcium level of 11.0 mg/dL (normal range, 8.8-10.3 mg/dL) with an albumin of 3.7 g/dL (normal range, 3.3-5.0 g/dL). Review of the outpatient medical evaluation showed a calcium level of 10.4 mg/dL (normal range, 8.5-10.6 mg/dL). A repeat calcium level was 10.5 mg/dL, and an ionized calcium level was elevated at 5.73 mg/dL (1.43 mol/L normal range, 4.53-5.29 mg/dL [1.13-1.32 mol/L]).

Further work-up of her hypercalcemia revealed a parathyroid hormone level of 99 pg/mL (normal range, 10-66 pg/mL).