Clinical Geriatrics

Case Presentation
Mr. V is an 84-year-old male who came to the Geriatric Psychiatry outpatient clinic accompanied by his female partner of 18 years, Ms. Y. Both Mr. V and Ms. Y reported that over the past three years he has suffered from progressively worsening anger issues and mild memory problems, which had intensified more over the past year. Mr. V was raised in a traditional Orthodox Jewish community. According to the patient, he agreed to see a psychiatrist because Ms. Y had become insistent on the idea. He therefore felt that it was important for him to have an evaluation as a result of the distress his behavior caused her. He did acknowledge that he sometimes had angry outbursts, but he felt that these episodes were almost always well justified. He revealed having discussions at social events regarding political issues, and becoming upset when the person with whom he was talking had an opinion different from his own. Mr. V described himself as an intelligent man, and generally felt that his views and opinions were correct.

Ms. Y added that his reaction to those with a different opinion than his was much more pronounced than what the patient had described. She reported episodes where he would yell publicly at people who had opinions different from his own, often causing her significant embarrassment. She provided examples of them traveling together on group tours, where he became enraged during dinnertime conversations on a variety of topics with other tour members.

Both Mr. V and his partner have significant involvement in community and artistic endeavors, such as attending art galleries, lectures, and other cultural events. Ms. Y reported that his behavior in public had transgressed to the point where she felt she no longer wanted to attend activities with him, and had even considered leaving him. She recently made the decision to stop attending the same adult education classes as him. She cited an example in the past few months in which he had an outburst on a flight after the plane had landed. While the airplane was on route to the gate, Mr. V jumped up from his seat and started emptying his belongings from the overhead bin. The pilot stopped the plane, and the flight attendant announced that he needed to be seated. Mr. V subsequently shouted expletives at her. The patient also provided an example of becoming intensely frustrated with people who “walk down the wrong side of the street.” He described how he often sticks out his elbows, resulting in him bumping into people, due to his anger with this perceived problematic behavior. Mr. V described frequent verbal outbursts toward bus drivers for seemingly minor issues such as not stopping in exactly the same place each day.

The patient’s daughter, who was interviewed via phone, reported that her father has always been somewhat disagreeable and difficult to engage with socially; however, she noted that his behavior had worsened over the past several years, and she was oftentimes frustrated by his lack of insight into it. Mr. V’s daughter did not think his memory was impaired.

Mr. V described problems losing items and being unable to remember where he had placed belongings in his apartment. He also reported that he was unable to recall names of people with whom he was quite familiar. Mr. V and Ms. Y denied any impairment in his ability to perform activities of daily living and noted that he continues to pay all of the household bills and goes grocery shopping.