Clinical Geriatrics

Case Presentation

Mrs. S is a 55-year-old married woman who is employed in the Finance department of a community college. She has two children. Her older son recently graduated from college and moved across the country to attend graduate school; her younger son, age 20, has Down’s syndrome, lives at home, and attends a daily workshop program where he is learning life skills with the goal of eventually moving to his own apartment. Mrs. S has been married for 35 years. Her husband had been recently diagnosed with prostate cancer and underwent surgery followed by radiation therapy for a high-grade malignancy. His illness and her son’s move were stressful events for Mrs. S, but she had begun to feel that everything was returning to a more manageable state. During her husband’s illness, she fell behind in her own medical appointments and knows that she is overdue for a mammogram and general check-up. Mrs. S has had hypertension for many years, but her blood pressure has been controlled on lisinopril 20 mg with hydrochlorothiazide 25 mg once daily.

Mrs. S receives a telephone call one day while at work from the local police in the town where her 87-year-old mother has been living in the family home. Her mother, Mrs. D, was found wandering on the highway in a confused and disheveled state. She was taken to a local hospital where she was admitted due to dehydration and concerns regarding her malnourished state. Mrs. S makes arrangements for a neighbor to check in on her husband and son, and is able to take a few days off from work. She travels to see her mother and is shocked to find her confused, thin, and frail. Mrs. S realizes that she has relied on weekly telephone calls with her mother instead of visits since her husband became ill. When she visits her mother’s house, she finds it in disarray, with little food, unwashed dishes, and piles of unopened mail. Mrs. D responds well to hydration and nutritional support in the hospital. No cause can be found for her confusion, and she is diagnosed with Alzheimer’s dementia. Mrs. S realizes that her mother cannot be left alone and decides to bring her to her apartment to live with her and her husband and disabled son.

Mrs. S soon finds that she is devoting increasing hours each day to the needs of her family. She gets up before 5:00 AM each day to prepare meals for her husband and mother. She helps her son get ready to catch the bus to his day center, and then goes to work at her full-time job. Even with the assistance of neighbors who check on her husband and mother, she has had to leave work early several times when called about her mother wandering outside of the building. When she returns home from work in the evenings, Mrs. S typically finds her apartment full of dirty dishes and soiled laundry, and her husband and mother arguing with each other. Her son’s performance in his job program has declined because Mrs. S has been unable to help him practice his assignments at home. Mrs. S feels determined to keep her family together but starts feeling tired all of the time.

One day at work, Mrs. S develops a throbbing headache, one in the latest of a series of aches and pains. She takes a break and develops blurred vision while walking to the bathroom. One of her coworkers notes how unsteady she appears and calls an ambulance. Mrs. S is taken to the Emergency Room, where she is found to have a blood pressure of 220/160 mm Hg. She also is found to have a cardiac arrhythmia, and the physician wants to admit her to the hospital Telemetry unit for monitoring and treatment of her hypertension. Mrs. S bursts into tears, insisting that she cannot be admitted to the hospital. She reports that she has to go home to care for her family and wants to leave the hospital.