Clinical Geriatrics

Case Presentation
Mr. M is a 78-year-old male who lives at home with his wife. He suffers from dementia of the Alzheimer’s type that was diagnosed four years ago. Mr. M also has diabetes, hypertension, and coronary artery disease. His medications include metformin 500 mg twice daily, glipizide 5 mg once daily, lisinopril 10 mg once daily, metoprolol 50 mg twice daily, aspirin 81 mg once daily, and donepezil 10 mg once daily. Over the past three to four months, Mr. M has become increasingly resistant to showering and changing his clothes. He also frequently spits out his medications, and his wife is uncertain whether he is really taking them. In order to help with daily care, Mrs. M hired a home health aide for four hours a day three times per week. The aide is able to wash Mr. M in bed and changes his clothes. However, he often yells, curses, and makes loud moaning noises during care.

Mrs. M takes her husband to see his primary care physician. Mr. M is very agitated and restless in the waiting room and starts to call out “Go, go, go,” in a loud voice. The physician sees him quickly and finds that his blood pressure is in good control, and his fingerstick blood sugar is also fine. He tells Mrs. M that her husband’s dementia is progressing and recommends starting memantine 5 mg daily. Mrs. M tells the doctor about the problems her husband is having taking pills. He suggests crushing them and putting them in applesauce. Mr. M starts yelling and making moaning noises. The doctor gives Mrs. M prescriptions for all of Mr. M’s medications and asks her to bring him back in three months.

Mrs. M returns home feeling frustrated. She is trying to keep her husband at home but has recently thought about placing him in a nursing home. She increases the home health aide to seven days per week but is worried about her finances. The home health aide tells her that Mr. M seems to do better in the morning in terms of accepting care and taking his medications, so they start doing as much as possible while the aide is there in the morning hours. Evenings are very difficult, as Mr. M will often call out his wife’s name repeatedly, even when she is sitting next to him, and makes moaning noises or shouts curse words.

Mrs. M takes her husband back to the neurologist who had diagnosed him with dementia four years earlier. Mr. M is very disruptive during the appointment, often calling out and cursing. The neurologist attributes this to his progressive dementia and prescribes trazodone 50 mg twice daily and gabapentin 100 mg three times daily for agitation. Mr. M starts taking the medications in the morning when his home health aide is with him. After one week, he is calmer during the day but still calls out, yells, and curses at night. Also, he is sleeping a great deal during the day and staying up later at night. One night, Mr. M starts walking around the house and suffers a fall in the kitchen, hitting his head on the table. Mrs. M calls 911, and he is taken to the Emergency Room (ER).

Mr. M sustains a laceration to his scalp that requires sutures. He is very disruptive in the ER, cursing, screaming, moaning, and calling out his wife’s name. He is given haloperidol 5 mg by intramuscular injection three times over a one-hour period until he falls asleep. Mrs. M tells the ER staff that she cannot manage him at home and asks for help in finding a nursing home.