Clinical Geriatrics

Case Presentation

Mrs. J is a 68-year-old divorced African-American woman with a history of depression and a seizure disorder who was admitted from the Emergency Department in the middle of the night to a geropsychiatry inpatient unit for treatment of increasing anxiety, religious and somatic preoccupation, paranoid delusions, and auditory hallucinations. She has no children and has been living alone in an apartment. Her only relatives in the area are a sister who has problems with drug addiction and was recently incarcerated and a brother. Her main social supports are members of the church, which she attends regularly.

While in the Emergency Department, Mrs. J complained of feeling “jumpy” and stated that her television and radio were talking to her and giving her special messages that she refused to describe. She reported good appetite and good sleep but added that occasionally she would not sleep for a few days at a time and had always considered this normal. She was not oriented to date or place. She displayed echolalia, mood lability, and irritability. Intermittently she mumbled to herself and repeated nonsensical words and phrases.

The patient acknowledged two previous psychiatric admissions, the first of which occurred in her mid-20s for “depression,” during which she was treated briefly with trifluoperazine. Subsequently, as an outpatient her depression had been treated with trazodone and then bupropion, which she believed caused her to have her first seizure sometime in the 1990s. Her second psychiatric admission occurred approximately 2 months prior to her current admission when the psychotic symptoms described above first appeared, and at which time she was diagnosed with “schizophrenia” and was started on haloperidol (unknown dose) and escitalopram 10 mg daily. Mrs. J denied any past or present problems with alcohol or drug use, and no toxicology studies were obtained. She had worked as a nurse until she was 63 years old.

The patient’s medical history was remarkable for hypertension, hypercholesterolemia, gastroesophageal reflux disease, and spinal stenosis. She reported that she had been taking opiate pain medication for pain “all over” her body and that she had been diagnosed with temporal lobe epilepsy (TLE) approximately 10 years previously, at which time treatment with phenytoin was initiated. She explained that after her first seizure, she experienced episodes of “confusion,” hypergraphia, and hyperreligiosity, which had never impaired her functioning. Four years ago, Mrs. J was hospitalized on a neurology service at a different hospital due to altered mental status following a witnessed episode of full body shakes, confusion, and inability to speak. This episode occurred after her primary care physician, for unknown reasons, had tapered her off phenytoin. A magnetic resonance imaging (MRI) scan of her brain at that time revealed minimal small vessel ischemic disease. Her electroencephalogram (EEG) showed moderate, diffuse, nonspecific abnormalities, and rare left temporal sharp waves, which appeared epileptiform in character. The possibility of an underlying epileptogenic area in the left temporal lobe was strongly suspected, and treatment with phenytoin was resumed with confirmation of a therapeutic serum level. Subsequently, for unknown reasons, her outpatient neurologist switched the patient to levetiracetam, but she continued to remain free of seizures. The above history and evaluation results confirmed Mrs. J’s seizure disorder diagnosis.

Discussion