Clinical Geriatrics

Case Presentation
Mr. P* is a 71-year-old widowed male resident of an assisted living facility who was recently diagnosed with Parkinson’s disease (PD), depression, and generalized anxiety. Mr. P had no prior history of mental illness. He acknowledged some regular alcohol use as a young man, consisting of drinking three to four alcoholic beverages per day over many years, but denied any alcohol-related blackouts, seizures, or treatment. Recent symptoms of anxiety and depression were attributed to a prolonged grief reaction from the loss of his wife just two years prior to admission. Mr. P is highly educated and was active in the community until the death of his wife. Following her death, Mr. P began to experience a steady progression of his parkinsonian symptoms, including a mild intention tremor, cogwheel rigidity, and prominent bradykinesia. Functional decline eventually led him to the assisted living unit, where he required increasing assistance with bathing, dressing, and medication management. He was referred to a neurologist for evaluation of his worsening PD and was started on a low dose of pramipexole.

Over time, assisted living staff observed him to be engaged in heated discussions while sitting alone in his room. Mr. P became more disturbed by images of people and animals he saw in his room, but he was often content to interact with the hallucinatory figures. On one occasion, he expressed concern that someone in the assisted living facility was attempting to murder him. He also described feeling as though he was a character in a play, and that nothing around him was real. Staff expressed concern that Mr. P was increasingly volatile, losing his temper easily for unclear reasons, and becoming confused at various times during the day and night. On medical evaluation, Mr. P was found to be mildly febrile, diaphoretic, and with persistent parkinsonian symptoms. Laboratory studies suggested dehydration and mild leukocytosis. He was transferred to a local community hospital where a chest x-ray revealed a small left lower lobe infiltrate. Mr. P was started on intravenous antibiotics and fluids with minimal difficulty.

A psychiatric consultation was requested to assess Mr. P’s increasing paranoia about the intentions of other patients and the small animals he noticed running through the ward. Pramipexole was discontinued, and a neurological consultant suggested that further trials of dopaminergic agonists be held until his psychiatric condition was more clearly defined and stabilized. Routine laboratory studies were all within normal limits, and a brain magnetic resonance imaging scan did not reveal any evidence for vascular disease, tumor, or cortical atrophy. Mr. P was started on quetiapine 12.5 mg at bedtime, and this dose was tolerated well. The dose was increased gradually in increments of 12.5 to 25 mg per day, until he reached a dose of 100 mg twice daily. Although he had some difficulty tolerating the sedating side effects, Mr. P was notably more organized in his thinking, less anxious during the afternoon, and markedly less paranoid about other patients harming him; however, his mobility was notably worse on quetiapine, and he required a walker to reduce the risk of falls. Mr. P was also started on donepezil 5 mg at nighttime.

* Details of this case have been altered to protect the identity of this patient.