Clinical Geriatrics

Case Presentation

Mr. G is a 61-year-old African-American male who lives with his 81-year-old widowed mother. Mr. G has had cerebral palsy since birth, and also has mild mental retardation and a seizure disorder. Mrs. G has been active in helping her son become as functional as possible and insisted that he be placed in an educational program at an early age. Mr. G was tested and considered to be “educable” under the standards used when he was school-aged. With his mother’s persistence, he completed a vocational training program and works for the local government in the housekeeping department. Due to Mr. G’s slow movements and dysarthric speech, he was given a position working nights. He has held this job for the past 25 years. His coworkers have always found him to be a reliable and friendly employee. His work has been interrupted several times due to episodes of uncontrolled seizures that required hospitalization for adjustment of his medications. Mr. G is proud of his job and always tells people that he wants to be a city employee “forever.”

Mr. G has an older brother who lives in a nearby town. Mr. G’s brother is worried about his mother, as he thinks the stress of caring for his brother is too much for her, and feels that Mr. G needs a more structured living environment. He would like Mrs. G to come and live with him and his family; however, he has never been close with Mr. G and does not feel that he can deal with his disabilities.

Mr. G’s seizure disorder is controlled on phenytoin 300 mg daily and divalproex sodium 750 mg twice daily. He has taken these medications for many years with good result. Mr. G’s chronically ataxic gait and mild muscle stiffness have increased slowly but steadily. He started using a cane 2 years ago, with improvement in his mobility. One night during a period of rain and windy weather, Mr. G slips and falls while crossing the street to get to his bus stop. He sustains a left hip fracture, left wrist fracture, and several facial lacerations. He is hospitalized and undergoes open reduction and internal fixation for his fractures.

Mr. G’s postoperative course is complicated by prolonged delirium, periods of seizures, and marked agitation. His dysarthric speech makes communication difficult. He is placed in physical restraints, which lead to worsening agitation, and he is sedated with lorazepam 2 mg by intramuscular injection every 6 hours. In addition, Mr. G is receiving hydromorphone 4 mg by intramuscular injection every 4 hours, esomeprazole 40 mg by mouth once daily for prophylaxis against gastric ulcers, heparin 5000 USP units subcutaneously every 12 hours for prophylaxis against blood clots, haloperidol 5 mg by mouth or by intramuscular injection every 4 hours as needed for agitation, diphenhydramine 50 mg by mouth or intramuscularly every 4 hours as needed for sedation, phenytoin 200 mg by mouth every 12 hours for seizures, with phenobarbital 30 mg 3 times daily and levetiracetam 1000 mg every 12 hours both by mouth also for seizures. Mr. G’s anticonvulsant regime was changed following surgery by the hospital-based physicians.

Mr. G’s oral intake is poor, and a feeding tube is considered. Mrs. G is very upset by her son’s condition, stating that he has always been a calm and gentle person who should not be “tied up and drugged.” The medical staff caring for Mr. G has noted that he suffers from dementia and will likely need nursing home placement. Mrs. G is adamant that she will never place her son in a nursing home and demands that he receive rehabilitation. She also insists that he is overly sedated and wants his usual medication resumed.