Clinical case presentation June 2023

Prepared by, Dr Thinesnee Sithambaram

First year in geriatric medicine fellowship Hospital Seberang Jaya, Pulau Pinang Supervisor: Dr Alan Ch’ng Swee Hock

Case Scenario

Mr NP/ 79/ CFS 6

Recurrent ETD visits since July 2022 for worsening numbness over both hands and feet and breathlessness. BADL: Able to walk with support from furniture and attend to personal care. IADL: Spends most of his time at home. No longer drives due to poor eyesight. Household chores, finances and grocery shopping handled by wife and son. Patient was treated for heart failure with superimposed pneumonia and diabetic neuropathy and often sent home with antibiotics and Neurobion. Sought complimentary medicine such as acupuncture and Ayurvedic medicine but there was no improvement in symptoms.

Background history of :

1. Type 2 diabetes mellitus

2 Hypertension

3. Coronary artery disease •

COROS was 2012; stenting done for 2 vessels

Medications:

• T. Frusemide 40mg OD

• T.Bisoprolol 3.75mg OD

• T. Felodipine 10mg OD

• T. Cardiprin 100mg OD

• T. Atorvastatin 40mg ON

•T. Trimetazidine 20mg TDS

•T. Glicazide MR 120mg OD

He had stopped taking atorvastatin and glicazide due to dizziness for nearly 3 months prior to admission

He became progressively weaker and unsteady and was brought back to HSJ in February 2023 with recurrent falls. Patient needed assistance to get up from sitting or lying position and needed support from his wife to use the toilet. Mr. NP mentioned having burning pain over hands and feet that frequently disturbed his sleep. Family members reported his oral intake has been poor and he has lost a significant amount of weight in the in the last 8-9 months. He was previously using size L clothing which had become ill fitting. During admission he was using size M clothing.

He was found to be clinically dehydrated and lethargic. He was afebrile but slightly tachypneic. Vital signs at ETD as the following:

Temperature: 36˚C, Capillary blood sugar: 7.6, Blood pressure: 141/99 mmHg, Pulse rate: 76 per minute, Respiratory rate: 22-24 breaths per minute

• CVS: DRNM, no murmur

• Lungs there was bibasal crepitation

• Abdomen: Soft

• CNS

Cranial nerves was found to be normal. 4AT:0

 Social history

• Mr. NP is a retired engineer who served in TUDM. He has two sons; the eldest is a biochemist, and another son based in Singapore

• He lives with his wife and eldest son, Mr. M.

• Main caregiver is his wife who also prepares his meals. Patient has a preference towards soup based, non spicy food. Meals at home:

Breakfast: Bread & coffee or idli/ thosai with dhall & chutney.

Lunch: Vegetable and chicken soup with rice and deboned fried fish/ ikan bilis

Dinner: Rice porridge with shredded chicken and vegetables. At times patient has thosai or idli for dinner

• During his younger days he used to consume liquor 4 to 5 times a week over a period of 30 years but stopped doing so about 3 years ago.

• Never used tobacco products.

Investigations

CT Brain

He was reviewed by physiotherapist and occupational therapist in ward every day.

Physiotherapist reported:

• Power of both upper limbs was 3/5 while lower limb power was 2/5. Muscle tone was normal. Wasting of both upper and lower limb musculature. Needed moderate assistance from supine to lying on his side but maximal assistance from lying on his side to sitting and from sitting to standing.

• Balance while sitting was reported to be fair.

• Knee control when bridging fair

• However he was deemed unsuitable for walking frame ambulation due to poor knee control and was suggested to use reclining wheelchair.

• Unable to do TUG/ JAMAR

Occupational therapist reported that

• Patient was alert and co-operative, good orientation. MBI 23/100.

• Sensation was absent up to both elbows and both calves.

• Power both upper limbs was 3/5 and lower limbs was 1/5. Muscle tone was reported to be normal.

• Hand function assessment: Able to extend elbow joints and able to grasp and release stacking cones with left hand. Right hand grasp was documented to be weak. He was able to hold on to cup and wash his face with minimal assistance.

Progress in ward

• He was treated with antibiotics and was started on intravenous fluids. Bowel movement was regulated in ward. Caregivers were taught on various methods to minimize fall risk and also to use weighted spoon and plastic cups with handles in order to enable him to be as independent as possible. •

• Premeal capillary glucose in ward ranged between 6.1 to 14.4.

• No documented postural drop in blood pressure.

• He was co managed by our neurology team who offered lumbar puncture which he and his son refused.

• He described burning sensation over hands and feet to be bothersome and interrupted his sleep.

• Patient was found to be having low mood in ward. We gathered that at home, patient had often mentioned that he will not recover and he is being a burden for his family.

He was started on esitalopram to help with his mood and pregabalin for the pain. In ward, he claimed pain had much improved and was able to sleep longer once pregabalin was started

During discharge, he was scheduled for an outpatient visual acuity assessment and DEXA Bone scan along with occupational therapy and physiotherapy appointment. A geriatric clinic appointment date was scheduled 6 weeks after discharge to reassess mood and MOCA. Patient and his son were not keen for outpatient MRI Brain appointment.

Medications on discharge:

• T. Folate 5mg OD

• T. Cardiprin 100mg OD

• T. Atorvastatin 20mg ON

• T. Calcium Carbonate 500mg BD

• Syp Multivitamin 10ml OD

• T.Esitalopram 5mg OD

• T. Pregabalin 75mg OD

• T. Metformin 500mg BD

• T. Bisoprolol 2.5mg OD

GDS and MOCA was performed just before discharge to be used for comparison during clinic visit.

Unable to perform trail making test

DIAGNOSIS

1. Neuropathic pain due to bilateral peripheral axonal motor & sensory neuropathy likely due to diabetes & alcohol abuse.

2. Recurrent fall due to multiple factors; bilateral lower limb sensory motor neuropathy, deconditioning.

3. Possible pseudodementia likely due to geriatric depression  Mixed dementia (Alzheimer & vascular)

4. Folate deficiency

• However within a month of discharge, he was readmitted for worsening pain over all limbs and meal refusal since discharge. He had become bedbound since discharge and was completely dependent on his wife for his BADL.

• He had missed all his appointments and stopped taking most of the medications except gabapentin (which they were buying from a private hospital).

• He had lost a significant amount of weight since the last encounter, he was previously using size M clothing but the clothes were visibly too large for him. Unable to weigh him in ward due to lack of chair/ bed weighing scale. He was lucid and 4AT: 1(unable to count backwards).

• Swallowing test in ward, patient was able to swallow.

• Often refused meals because he had no appetite. When fed, patient only ate 2-3 spoonfuls and refused the remaining portion.

• He was reviewed by the hospital dietician who prescribed ONS in addition to high protein soft meal. Patient’s family was also advised to bring his favorite food items and serve snacks such as yogurt and ice cream between meals to increase his calorie intake. However patient refused all of it and hardly finished his ONS servings, often refusing after consuming one third to half of the serving claiming he felt full.

• According to his son, he had often expressed feeling hopelessness and had said that there is no point in living as he was becoming a burden to others. He was assessed by psychiatry team in ward and was diagnosed with adjustment disorder.

• In ward patient at times refused to participate in physiotherapy sessions as he felt there was no point.

• He was started on T.Mirtazapine 15mg ON to help with his mood and appetite and at the same time T.Gabapentin 100mg BD was started to help with the neuropathic pain.

• He was evaluated by a speech therapist in ward who found swallowing to be normal. Patient preferred soft or liquid based meals compared to solid food. His wife was taught to prepare meals of his preferred consistency.

• The hospital dental team had examined him and found the dentures to be in good condition and well kept. There was no oral lesions that may be causing pain during eating.

• Meal refusal was a major cause of concern for his wife who used to cry whenever he refused meals. Possibility of NG tube feeding to supplement his poor oral intake was raised several times throughout the admission and the importance of nutritional support for recovery was explained however patient firmly refused NG tube. His son and wife were in the loop regarding patient’s decision and decided to respect his wishes.

• After family conference, patient was allowed to return home once he no longer needed nasal prong oxygen support in the hope that his mood and appetite would improve in a familiar environment. Respite care options was discussed with the son & wife in order to reduce caregiver stress.

• We arranged for a home visit the following week and a geriatric clinic appointment in 4 weeks to reassess his mood and appetite. Unfortunately patient passed away at home a few days after discharge from ward.

POINTS TO PONDER

• Could his low mood and chronic pain be alleviated by any other modality apart from pharmacological methods?

• If MNA score was available and indicated malnutrition, how would you proceed?

• Assuming hand grip strength score in this patient and was found to be weak, what would be the treatment approach?

• Should we consider NG tube feeding In elderly patients with anorexia after all other measures have been exhausted?

• Should patients wishes in this regard be taken into consideration although his decision was potentially harmful?