Clinical case presentation May 2023

Name: Tan In Jiann Location: Selayang Hospital Supervisor : Dato’ Dr Tunku Muzafar Shah

Case scenario

Madam SSY@ TSY 79 years old lady

Co-morbidities

1. CKD Stage IV secondary to diabetic nephropathy -seeing nephrology, creat 214, creat clearance 18

2. Type 2 DM

3. Hypertension

4. History of left bipolar hemiarthroplasty in May 2019 for left neck of femur fracture done in private hospital under GA, uneventful

5. Incomplete periprosthetic fracture proximal left femur in June 2021 -Treated conservatively, patient is ambulant with no pain

Medications

T. Amlodipine 10mg OD

T. Metoprolol 50mg BD

T. Furosemide 40mg BD

T. Gliclazide 60mg OD

T. Atorvastatin 40mg ON

Noted to have blurring of vision for the past 2 years Also forgetful of recent events and “more stubborn” for past 1 year Reviewed by ophthalmology, noted bilateral eyes dense cataract left >right Concern of patient unable to lie still on table due to the “stubbornness” Plan for left eye cataract surgery (phacoemulsification + intraocular lens) under general anaesthesia

Pre-operation assessment by anaesthesiology team noted newly diagnosed atrial fibrillation on ECG, otherwise asymptomatic “Not passed” for operation by the anaesthesiology team, referred to general internal medicine for further assessment and management of the atrial fibrillation

Seen by general internal medicine; risk assessed: CHA2DS2-VASc: 5 high risk HAS-BLED: 2 intermediate risk Suggested for cataract operation under local anesthesia Not for anticoagulation for the atrial fibrillation in view “elder age group”, “bleeding risk”, and “family not keen” Referred to geriatric medicine for further assessment of the forgetfulness

Reviewed at the geriatric medicine clinic in October 2022 Accompanied by sister, Madam TSL (history obtained from sister and patient herself) Patient is described as pleasant, calm, quiet Studied till primary 2, English medium school Was working as baby sitter till her early 70s Speaks fluently in English and Hokkien dialect Not married, has 6 siblings in total Stays in Taman Maluri, double-story home with sister TSL (working office hours), patient is alone at home when sister is working

Cognition Onset 1 year ago, 2021 age 78 years- rather insidious, short term memory impairment, slower in response, forgets recent events, misplace items, repetitive in questions, no longer orientated in time & date

+Likely visual illusion, seen items in front of her as people (strangers) walking in front of her, not distressed by it, could say that can be a misperception due to poor vision

Sleeps well No delusions or auditory hallucination Symptoms not progressively worsening, remained static till date

iADLs Since 1 year ago- meds organized in Dosette box by sister, previously patient was able to manage by self, but as memory and vision impaired due to cataract, needs assistance

Since 9 months ago- forgets more complex recipe of cooking, e.g. frying fish- also disallowed by sister to cook more complex dishes due to visual impairment, cooks more simple dishes now e.g. cooking rice Still does simple household chores Handles money and groceries- but not quite sure about actual calculation of money.

bADLs Independent for bathing, dressing, personal hygiene, toilet, mobility, transfer, feeding

Mobility Walks with Zimmer frame after the hip fracture as feels more confident, walks without assistance if on Zimmer frame, mostly home bound Able to climb stairs unassisted as stays on 2nd floor When outdoors; prefer to be on wheelchair, can walk with quadpod with 1 person assist

Falls No recent falls past 1 year.

Continence PU/BO in toilet No urinary or bowel incontinence.

Physical symptoms Worsening of bilateral vision past 2 years Worse over the left eye Items appear blurred especially under high intensity lighting Unable to read/look at fine prints NYHA class I, no PND or orthopnea No chest pain or palpitation Good oral intake No musculoskeletal pain.

Physical examination Comfortable, pleasant Answers questions relevantly Kyphotic Gait- walks with quadpod, unassisted, slight stooped forwards due to kyphosis, quite apraxic and slow BP 110/70 PR 86 bpm irregularly irregular CVS S1S2 no murmurs Lungs Clear No pedal oedema Speech is clear Bilateral eye dense cataract Visual field intact No ophthalmoplegia No facial asymmetry Tone of limbs normal Power of limbs generally 5/5 no focal deficits Reflexes not brisk Plantar down going bilaterally Sensation to pinprick intact Proprioception intact

Obeys 2-step command MMSE 9/26- limited by visual impairment, orientation 1/10, attention/calculation 0/5, recall 1/3 GDS 3/15 Investigation Hb 10.4 / PLT 405 Urea 13.8 Na 143 K 4.6 Creat 223 creat clearance 17 TSH 2.86 T4 12.1 B12, folic acid, iron studies not deranged FSL, HBA1C well controlled ECG Atrial fibrillation, HR 68bpm; Q wave II, III, aVF; PR interval not measurable; QTC 427 msecs

CT Brain plain Infarcts at right corona radiata, head of left caudate nucleus, left externa capsule and bilateral lentiform nucleus Ventricles, sulci and basal cisterns are prominent in keeping with cerebral atrophy Periventricular lucencies in keeping with deep white matter ischaemia

Questions

1. Based on the comprehensive geriatric assessment, what are the geriatric issues presented in the case above?

2. How would atrial fibrillation be managed in this case? Do justify the options.

3. In regards to the cognitive impairment, how would you classify the disease?

4. How would you manage this patient based on the 5Ms (Mind, Mobility, Medications, MultiComplexity, Matters most) ?