Clinical Geriatrics

Case Presentation
Mr. H is a 66-year-old widowed male who is referred to a psychiatrist by his primary care physician, Dr. D, due to an increase in tic-like movements with occasional verbal outbursts of curse words and noises. Mr. H has worked at an outdoor newsstand for more than 40 years. Since the death of his wife from cancer two years earlier, he has been working double shifts, sometimes spending 16 hours a day at the newsstand.

Dr. D reports that the tics and verbal outbursts have increased over the past several months. She feels that they may be “stress-related” but wants Mr. H to receive appropriate treatment. Per the recommendation of Dr. D, Mr. H had earlier been evaluated by a neurologist and was prescribed pimozide 1 mg twice daily. Mr. H took the medication for several days but felt sedated and had difficulty paying attention at work. He returned to his primary care physician, asking for “something that won’t make me feel drugged.” He is embarrassed because his customers have noticed him making whistling sounds and grunting noises, and he has dropped change out of his hands due to episodic jerking movements. He also has episodes of facial grimacing that he is unaware of, but his boss has noticed. Mr. H desperately wants to keep working but is afraid of losing his job due to the tics.

Dr. D is concerned that Mr. H may have some degenerative disorder and sends him for a magnetic resonance imaging scan of the brain. The result is normal, with no sign of atrophy, stroke, or degenerative changes. Mr. H is quite healthy, suffering from mild osteoarthritis and benign prostatic hypertrophy. He has no prior psychiatric history. His only medications are acetaminophen 650 mg 3 times daily and tamsulosin 0.4 mg daily. Dr. D encourages Mr. H to keep his appointment with a psychiatrist, to whom he has been referred.

Mr. H arrives early for his appointment with the psychiatrist. He is neatly groomed and dressed in layers of clothing that he explains are needed for his long workdays. Mr. H displays episodes of whistling noises, lip smacking, and grimacing facial expressions. He occasionally has movements of his right hand that include making and releasing a fist several times in a row. Mr. H reports that as a child he was a “slow learner,” and that he left school in the 10th grade. He describes periods of restlessness as a child, but reports that the movements, facial tics, and verbal outbursts he is experiencing started when his wife was being treated for breast cancer three to four years ago. He is fearful of losing his job, stating that since his wife died he has nothing else to do with his time. Mr. H follows a very rigid routine but does not appear to suffer from any mood or psychotic disorder. Mr. H is willing to take medication, but repeats his concerns of not wanting to be sedated.

Discussion
Tics are rapid, recurrent, stereotypical motor movements or vocalizations.1 They are characterized by a sudden onset with varying degrees of awareness and control. Simple tics involve a few muscles or limited sounds, such as eye blinking and facial grimacing. Complex tics involve multiple muscle groups and actions, including touching and smelling objects, assuming postures and positions, or repeating words and sentences. Patients may utter curse words, make gestures, and imitate others.2,3 While patients may have some ability to delay or reduce the tics, it is limited, and many patients are unaware of many of the tics. The social and interpersonal distress associated with tic disorders is significant.