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Clinical case presentation July 2023

Prepared by: Dr Tay Hwei Wern

Supervisor: Dr Alan Pok

Current posting: HKL


Case Scenario

Madam H, 84 year- old lady with the following comorbids:

1. Idiopathic Parkinson Disease since 2010

  • previously under neurology clinic

  • Transferred care to geriatric clinic since 2021.

2. History of lacunar infarct in 2010

3. Major neurocognitive disease possible Parkinson disease dementia

4. IgM paraproteinemia with cold AIHA •

  • on conservative management (transfusion prn)

5. Osteoporosis with L3 compression fracture in Feb 2022.

6. History of thyroidectomy secondary to multinodular goitre.


Medications

  • T. Ferrous fumarate 200mg OD

  • T. Madopar 125mg QID

  • T. Calcium carbonate 50mg BD

  • T. Calcitriol 0.25mcg OD

  • T. Alendronate 70mg/ week

During clinic visit on 17/5/23

  • Came with daughter in law and maid (main carer).

  • Carers complained of:

  • Became ‘hyperactive’ for past 4 months

  • • -> increase of wandering/ aberrant behaviour/ delusion of theft

  • • -> irritable, verbally abusive to maid, threatened to hit maid with her walking stick

  • • -> increased nightmares and hallucinations (shouting almost every night due to nightmares, seeing ‘snakes’ at least 3-4 times per day).

  • Had multiple falls (countless) due to increase wandering and behavioural issues.

  • Last fall was 2 days prior to TCA, requiring suture in ETD due to laceration wound of the occipital region of scalp.

Further History

  • No recent increase or adjustment of medications (had been on same dose of Madopar for past 1 year. No h/o over the counter medications or traditional medications.

  • Denies recent intercurrent illness or fever.

  • Denies constipation or altered bowel habit

  • No CT Brain was done during her last visit to ETD with scalp laceration wound.

  • Mobility: Ambulate with walking stick (quadripod) or held by maid during walking. For past 4 months, patient often walked without aid/ refused to be held while walking, hence the falls.

  • BADL: Dependant on maid except able to self feed.

  • Previously loved watching TV, refused to watch for past 4 months, keeps wandering around.

  • Medications, finance and appointments all taken care by carer.

  • Cognition: Memory decline started since early 2020 (about 10 years after diagnosis of IPD). She has poor short term memory, misplacing items and forgetfulness. She only recognizes close family members. Language is still fairly intact.

  • Mood/ behavior: Has BPSD since year 2020 (visual hallucinations and delusions of theft), but much worse for past 4 months.

  • Appetite: very good, able to finish all her food served by maid.

  • Sleep: Markedly reduced sleep for past 4 months, only sleeps about 3x per week. When patient is awake at night, she will have wandering and aberrant behaviors. Maid needs to sleep in front of her room to block her from walking out of her room. Patient would only sleep after remained awake for 2-3 days when she was too exhausted.

  • PU: PU in toilet mostly as refused to use diapers. Occasionally she will have urinary incontinence (too sleepy after few days of not sleeping, hence unable to wake up to pass urine and the incontinence).

  • BO: Able to BO daily, no constipation.

Physical Examination

  • Clinically pale, not agitated.

  • Dressing at the occipital region due to suturing of laceration wound.

  • Few dressings at bilateral forearms (small wounds while fighting with her maid, when maid tried to stop her from ‘hugging’ water heater).

  • Not orientated, answers simple questions eg name.

  • Obey 1 step command

  • Mildly dehydrated clinically

  • Vital Signs: BP: 110/68 PR: 78 bpm

Physical Examination

  • Reduced facial expression

  • Resting tremors seen

  • Cogwheel rigidity, right> left, not particularly stiff.

  • Bradykinesia

  • Power all 4 limbs at least 4/5, equal both sides.

  • Sit-> stand: Required 1 person assistance

  • Gait: unsteady without aid, +shuffling gait.

  • Respiratory: Lungs clear

  • CVS: DRNM

  • PA: Soft, non tender, no bladder palpable.

  • No pedal edema.

  • PR Examination: empty rectum, no melaena or PR bleed.

Cognition

  • MMSE: 6/27

  • Recall: 0/3

  • CDT: patient refused to proceed.

Investigations

  • ECG: 1st degree heart block.

  • Blood investigations:

  • FBC: Hb: 6.1 WCC 4.81 Plt: 257 MCV: 115.2 MCH: 48.8

  • RP: Urea:7.0/ Na: 141/ K: 3.9/ Creat: 57

  • LFT: Albumin: 29 • ALT: 9 • ALP: 81

  • Corr Ca: 2.60 • Po4: 1.01 • Hba1c: 4.5%

  • Serum Iron: 7.3 TIBC: 26.7 T sat: 27.4%

Questions

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

  2. What is your approach in managing the above patient? Please include any further information and/ or assessments that would be helpful and justify.

  3. Will you adjust her Parkinson’s medication? If yes, how will you adjust it and justify.

  4. Will you proceed with full workout for her cold AIHA and why?

  5. Will you start antipsychotic for her? Please justify your reason.





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3 Comments


Sorry for the late reply, as a wrap up of this case, I think Dr Angel had given very comprehensive comments for all the questions. After we have seen this patient in clinic, we decided to admit her into the ward for further workout and management as stated below:

  1. CT Brain TRO ICB/ traumatic brain injury or new stroke (recurrent falls with altered behaviour)

  2. Workout for possible causes of delirium

-> Ensure proper hydration (clinically under volume with borderline high urea, high calcium)

-> Rule out any sepsis/ infections

3. Physiotherapy and proper falls assessment

4. Adjustment of Madopar (dose of Madopar was tapered down to 62.5mg QID as clinically patient was not stiff and Madopar dose may be…


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  1. Acute delirium (severe macrocytic anaemia ?hemolysis, dehydration, hypercalcemia), recurrent falls

  2. hemolysis workup-- need to ensure not due to sepsis, hydration, off calcium/calcitrol, CT brain TRO ICB/new stroke, PT (limb strengthening, balance and gait), OT (ADL training, reorientation, ADL training)

  3. consider reduce dose-- may contribute to confusion and hallucination/slight bradykinesia could be more beneficial while recovering from hyperactive delirium

  4. should screen for infection and treat, investigating for underlying malignancy may not be beneficial-- 10 years IPD with PDD (moderate), prognosis guarded, treatment of malignancy could be of more harm than good (immunosuppression, risk of sepsis, prolonged hospitalisation)

  5. Will focus on non-pharm measures (2. and 3. as well) . If distressing psychotic sx and physical aggression persists after a few days, then…

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Thanks Angel for your comments

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