Case Studies

An 87-year-old woman with gradually worsening dementia and stiffness became more resistant to having her briefs changed. She developed a painful red skin irritation in her groin area that compounded the problem. She gritted her teeth, hit the caregivers and pulled her body up into a ball, making it difficult to dress her or bathe her. Medications: Haldol, Ativan, Ambien, Imodium as needed

In this case the woman had become more stiff from the Haldol, which did not decrease her combativeness. Haldol is an antipsychotic—it lessens delusions, hallucinations and paranoia. Ativan, a tranquilizer chosen to combat anxiety or agitation, can also be disinhibiting—like a shot of vodka—and is not likely to make her calmer, but more confused and is also associated with an increased risk of falls. Similarly, the Ambien, a sleeping pill, might only work for 4 hours and can also cause more confusion. Imodium, for diarrhea, may further increase confusion and combativeness with dementia, and may also mask a serious problem from diarrhea. This combination of medicines was affecting her behavior.

This woman needed more gentle care cleansing in her groin area—it probably was quite painful. Also, she likely had a yeast rash that needed to be treated, and soiled briefs can worsen skin irritation. As far as which medications would successfully calm her, medication is very individual and must be decided on a case-by-case basis

In this case, the patient was given Celexa®, an antidepressant, and was less combative. We also worked with her caregivers to explain that they needed to be more gentle and slow with her care, and to begin by massaging her arms, gradually working down to changing her briefs.

An 80-year-old man with a history of avoiding doctors lived at home with a caregiver. He developed pneumonia and was admitted to the hospital. After being discharged from the hospital, he was transferred to a nursing facility. After six months in the facility, he was found to have iron deficiency anemia. The patient could say he understood that colon cancer might be a cause, but would not answer when asked if he would agree to have a colonoscopy to confirm this diagnosis. The patient subsequently stopped eating. Medications: Iron, potassium, Motrin®

Several things affected this patient’s appetite. First, the medications he was taking can irritate the stomach. The first step in devising a course of treatment was determining what, for this gentleman, were his goals of care? In other words, what, for him, makes life worth living? His family at first wanted him admitted to the hospital, which terrified him. With further discussion, they learned that we could perform a diagnostic exam without moving him.

The patient stated that if cancer was discovered, he did not want any stomach surgery. He did not like doctors and did not want blood tests. Instead, we did a swallowing x-ray study and found that his esophagus did not contract, which made it impossible for him to eat solid food.

This man lived in comfort for the next 1 ½ years on a diet of ice cream and Ensure. Ice cream provides protein, calories and fluid. It is a very rare patient who will refuse to eat ice cream. He was not subjected to the fear and discomfort of hospital interventions he did not understand, NOR other tests or procedures he did not want. When he grew much weaker, the family chose hospice support and he ended his days in comfort surrounded by his loved ones.

An 83-year-old woman, a retired nurse, lived alone and had become progressively weaker. She had difficulty getting food, because she no longer could drive. She was suspicious of neighbors, calling the police 83 times in the previous two months. In addition, she has had many police complaints filed against her by taxi drivers, bankers and pharmacists due to her abusive behavior. Many of the appliances in her home do not work. She refuses to have help at home or to let her physician speak with her sons or her previous doctors. She claimed she would sue him. Medications: Restoril®, Wellbutrin® and Ativan®

The woman is living with frontotemporal (FTD) dementia, which can be the most challenging of cognitive declines. The person may know the date and current events, but their interpretation of events and their judgment can be severely flawed, and often gets them into trouble. It can be perplexing for the family to know exactly how to help their loved one. Usually the patient in these cases often refuses help or does not acknowledge any difficulties.

In most cases, if a person has refused to let anyone speak to the doctor, the best option is to gather the pertinent information from the caregivers, family, and police, anddiscuss the case with the local Adult Protective Services office. When there are health complications arising from a decline in judgment, further steps can be taken in compliance with HIPPA (The Health Insurance Portability and Accountability Act) privacy rules.

In this case, the patient’s medications contributed to the problem;: Ativan® can impair judgment and affect behavior; Wellbutrin® can be overstimulating and make some people more irritable; and Restoril® can also make those susceptible, more confused. Restoril®, like Ativan®, is addictive which can cause more problems, or can precipitate delirium if stopped suddenly.

When this patient fell and had several fractures, she entered the hospital and became delirious because her dose of Ativan® was changed in the hospital. The family, geriatrician and the eldercare attorney collaborated to address her unsafe living conditions and decision-making capacity. It was determined by the court that she lacked sufficient judgment to live alone safely, and since she refused help at home, she was transferred to a safe assisted-living arrangement. She was tapered off the Ativan®, Restoril® and Wellbutrin®, and given a gentle antidepressant and mood stabilizer. She tolerated care much better thereafter.