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Clinical case presentation May 2023

Updated: May 3, 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) ?


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3 comentarios


  1. cognitive impairment, functional decline, polypharmacy, multiple comorbidities, high fall risk with history of osteoporotic hip fracture

  2. DOAC for SPAF (apixaban 2.5mg BD due to CKD), rate control

  3. mixed AD + VCI (SVCI)- mild

  4. advocate for cataract surgery, SPAF, consider cognitive enhancer, CST, depending on vision recovery may consider low vision rehab, BMD and bone protection

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Hi all.


I am going to provide a summary on the management and progress of our patient. I will not provide answers to the questions as I suppose the case was already discussed with our respective supervisors.


We do note that this patient has cognitive issues, osteoporosis, multiple co-morbidties especially atrial fibrillation which is not optimised medically, and the bilateral dense cataract which could limit her cognition, mobility and function. We initiated her on apixaban 2.5mg BD (age of almost 80 years and CKD stage 4) and she is rate controlled with bisoprolol.


She has clinical features to suggest possible mild vascular dementia. The impaired cognition may be attributed by the poor visual perception caused by the dense cataract. W…


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Contestando a

Hi In Jiann,


I read your case with great interest. You have done well to get her cataract fixed. I am curious to know how you diagnose her as VCI and possible VaD if her cognitive impairment persists after the other cataract is removed. Is it based on her CT - SVID ? If so, why memantine is your first drug of choice ?


Keng

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