Clinical Geriatrics

Case Presentation

Mrs. S is a 72-year-old widowed woman who is brought to the Emergency Department (ED) by her daughter. Mrs. S’s daughter, Mrs. B, returned from a 6-month stay in Europe and found her mother to be weak, pale, and confused. Mrs. B tells the ED staff that her mother has always taken a number of herbal and nutritional supplements in addition to medications for “indigestion.” Mrs. S has been followed in the past by a primary care physician but has not had any regular medical care since her doctor retired two years earlier. Her daughter brought a number of bottles of prescription medications and supplements that she found in her mother’s kitchen cabinet. These include esomeprazole 40 mg, famotidine 20 mg, and a variety of herbal preparations including alfalfa seeds, powdered ginger root, Siberian and Korean ginseng root, ginkgo biloba tablets, echinacea tablets, and several bags of ground leaves without any labels. Mrs. B reports that her mother was treated for peptic ulcer disease many years ago and believes that she has been taking the esomeprazole and famotidine chronically.

Mrs. S is found to appear weak and pale. She is oriented to her name and recognizes her daughter but is unable to provide her address or telephone number. She frequently repeats the questions that are asked to her in an echolalic manner. She asks for a cup of tea and points toward the bag of herbal supplements that her daughter brought. Mrs. S indicates that she takes several doses of these each day and makes tea to “soothe her stomach.” She remains calm but confused and allows her blood to be drawn and an intravenous line inserted for hydration. She is mildly tachycardic with a heart rate of 110 beats per minute. Her electrocardiogram shows sinus tachycardia. Her lab results are troublesome. Mrs. S is anemic with a hemoglobin of 8.3 g/dL (12-15 g/dL) and a hematocit of 24% (36-44%). Her mean corpuscular volume (MCV) is elevated at 108 fL (80-100 fL). Her electrolytes were within normal limits, but her albumin 2.5 g/dL (3.2-5 g/dL) and total protein 5.2 g/dL (6.5-7.9 g/dL) were low.

Mrs. S is admitted to the hospital for further evaluation of her anemia and confusion. There was concern that she was suffering from a malignancy, malnutrition, gastrointestinal blood loss, and, potentially, dementia. Mrs. S is found to be both iron- and vitamin B12–deficient. Her serum iron level is 25 µg/dL (65-150 µg/dL), and vitamin B12 level is 140 pg/mL (200-900 pg/mL). She undergoes endoscopy and colonoscopy, which are negative for malignancy. A neurology consult reveals confusion with recent memory loss with a mild gait disturbance. A computed tomography scan of the head reveals mild atrophy. Tests of her thyroid, liver, and kidney function were normal. Urine toxicology was negative. A diagnosis of dementia is considered.

Mrs. S is started on vitamin B12 supplementation with daily injections and is given oral iron therapy. Her daughter visits daily and encourages her mother to eat. After several days, Mrs. S appears less confused and more responsive. She tells the staff that she has been visiting a local “nutrition consultant” who runs an herbal and dietary supplement store. She has been drinking herbal teas and taking the supplements her daughter found in her house. Mrs. S continued to take both esomeprazole and famotidine daily, as she found that many of the herbal supplements upset her stomach. She often skipped meals because she did not feel hungry after drinking the herbal teas.