Clinical Geriatrics

Series Editor: Melinda S. Lantz, MD

Dr. Iwuagwu is Assistant Professor of Medicine, and Dr. Steiner is Assistant Professor, College of Medicine, University of Toledo, Health Sciences Campus, Toledo, OH; and Dr. Raji is Associate Professor, Director of Memory Loss Clinic and Medical Director of the Acute Care for the Elderly (ACE) Unit, Sealy Center on Aging, Department of Internal Medicine, University of Texas Medical Branch, Galveston.

Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Ave @ 16th Street #6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659; e-mail: mlantz@chpnet.org.

Case Presentation
Mr. W, a 65-year-old, married Caucasian male, presented to a memory loss clinic for evaluation and management. He was still living at home with his wife, who accompanied him to the clinic visit. Mr. W presented with a 6-month history of memory loss for recent events associated with disorientation and easy confusion. Onset of symptoms was gradual and has not been progressive. He had a history of coronary artery disease and hyperlipidemia treated with atorvastatin 20 mg daily, metoprolol 25 mg twice daily, and aspirin 325 mg daily. 

A year before the clinic visit, he had a coronary artery bypass graft (CABG) surgery. His hospitalization for the surgery was complicated by delirium and agitation, requiring psychiatric and neurological evaluations. During his 17-day hospital stay, the patient received diagnoses of delirium complicating dementia and bipolar disorder. Mr. W was subsequently discharged home on additional medications including lithium two 300-mg tablets twice daily, doxepin 25 mg 3 times daily, clonazepam 1 mg twice daily and two tablets at bedtime, naproxen 220 mg daily, and rivastigmine two 1.5-mg tablets twice daily. At his home, the patient relied exclusively on his wife to perform most activities of daily living including laundry, shopping, cooking, transportation, house work, and managing medications and finances. Mr. W also required assistance from his wife and other caregivers for transferring from bed to chair, dressing, bathing, and toileting. His memory problems became more obvious to his wife and other caregivers 6 months after his discharge from the hospital. Three months before the memory loss clinic visit, he started using a wheelchair for mobility because of easy fatigue and near falls.

At the time of evaluation of Mr. W in the geriatric memory loss clinic for a second opinion regarding his memory problems, he carried diagnoses of dementia and bipolar disorder. The second opinion was requested by his primary care physician, who had seen the patient two times after his hospital discharge. Mr. W was also seen by a cardiologist and two psychiatrists following his discharge from the hospital. At the memory loss clinic, his Mini-Mental State Examination (MMSE) score was 13/30 and he was taking rivastigmine two 1.5-mg tablets twice daily for his memory impairment. His complete blood count, chemistry panel, liver function tests, thyroid function tests, and other blood tests were normal. His computed tomography scan was negative. His doxepin and naproxen were stopped. His clonazepam, rivastigmine, and lithium were tapered off over a 2-week period. Arrangements were made for Mr. W to receive in-home physical and occupational therapy.