Course Case Studies

Geriatric Failure to Thrive: A Multidimensional Problem

Course #69202 • 5 Hours/Credits

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CASE STUDY 1

Patient E is a woman, 82 years of age, recently hospitalized for pneumonia. Her medical history is positive for hypertension, diabetes, coronary artery disease, and heart failure. She is admitted to the rehabilitation center with functional decline, unsteady gait, weight loss, and difficulty swallowing; the rehabilitation will be short term.

During the initial medical evaluation the patient appears frail, alert, and cooperative. She is able to answer questions appropriately. Patient E has been living alone in a senior independent living apartment for the last seven years. She has a daughter who lives nearby who is very involved in her care. The daughter states that Patient E has been slowly losing weight over the last six months. The patient states she has never been a big eater but admits her appetite is not what it used to be. The daughter has noticed the patient coughing and clearing her throat frequently while eating. Since the pneumonia, Patient E has had poor activity tolerance and requires frequent rest periods.

Patient E has both a healthcare proxy and a DNR on record. Her chief complaints are fatigue, poor appetite, leg weakness, and nonproductive cough. Her weight is 107 pounds and height is 5 feet 4 inches, with a BMI of 18.4, which is slightly underweight. She appears frail, though alert and cooperative. She is in no apparent pain or distress sitting up in a wheelchair. Upon initial physical examination, her blood pressure is 104/60 mm Hg, apical pulse 86 beats per minute, regular rate and rhythm with systolic ejection murmur (grade 2/6). Her respirations are 22 breaths per minute, with an oxygen saturation of 92% (on room air). Respirations are even and unlabored at rest, and crackles are noted in the right base. Patient E's abdomen is soft and nontender with active bowel sounds. Trace ankle edema are present bilaterally, and muscle atrophy and kyphosis are noted. The patient displays no focal deficit, and cranial nerves are normal.

Several assessment tests are administered, and the scores of each are noted:

  • MMSE: 24 (mild cognitive impairment)

  • Clock-drawing test: 4 (normal)

  • GDS: 6 (suspicious for depression)

  • MNA: 7 (malnourished)

In addition, several laboratory/diagnostic tests are ordered. The results are as follows:

  • Hemoglobin: 10.4 g/dL

  • Hematocrit: 31%

  • Platelet: 132 platelets/L

  • Comprehensive metabolic panel

    • Glucose: 124 mg/dL

    • Blood urea nitrogen (BUN): 35 mg/dL

    • Creatinine: 1.4 mg/dL

    • CO2: 30 mmol/L

    • Albumin: 2.9 g/dL

    • Estimated glomerular filtration rate: 36 mL/min

  • Thyroid stimulating hormone: 2.05 mIU/L, urinalysis-negative

  • Vitamin B12: 318 pg/mL

  • Vitamin D hydroxyl: 18 ng/mL

  • Zinc: 55 mmol/L

A chest x-ray shows right lower lobe infiltrate and cardiomegaly. Finally, the modified barium swallow test indicates aspiration on thin liquids.

The patient is referred to several specialists for evaluation of potential causes of weight loss and continued failure to thrive. After two weeks, the results of the consultations are available. The physical therapist indicates muscle disuse atrophy of both lower extremities, poor endurance, and dizziness upon standing; however, the patient is able to walk 10 feet with assistance and walker. Occupational therapy indicates that Patient E requires assistance with bathing, dressing, and eating. The speech therapist recommends that the patient be placed on a mechanical soft diet with thickened liquids. Finally, the dietician finds that the patient's appetite is fair to poor, as she eats only 25% to 50% of meals. Patient E is resistant to modified diet and supplements; therefore, the dietician recommends liberalization of diet to regular with fortified foods.

Based on abnormal exam and laboratory findings, Patient E is diagnosed with anemia, chronic kidney disease, pneumonia (still on treatment), and functional decline, particularly a decline in mobility and nutritional status. She also displays evidence of vitamin and mineral deficiencies, with low vitamin D, protein, and zinc levels. Her vitamin B12 level is also borderline low. The blood pressure is below normal and may be responsible for the patient's dizziness. She is malnourished, with a low BMI, and symptoms of depression are present.

Patient E is taking several daily medications, all of which are assessed for necessity and potential interactions. Her current regimen includes:

  • Coated aspirin: 81 mg/day

  • Metoprolol: 50 mg twice per day

  • Furosemide: 40 mg/day

  • Potassium chloride: 20 mEq/day

  • Metformin: 500 mg twice per day

  • Levofloxacin: 500 mg daily for five more days

  • Ipratropium/albuterol: Unit dose per nebulizer every four hours as needed

Evaluation of the medication regimen indicates that the patient's dizziness or weakness upon standing may be due to medication side effects. Furthermore, metoprolol is associated with fatigue in the elderly. Patient E's diuretic dose may need to be decreased due to her elevated BUN level. Metformin is not recommended in patients older than 80 years of age or with creatinine levels 1.4 mg/dL or greater. As a result of this information, the physician orders that the patient's prescriptions for furosemide and potassium chloride be halved to 20 mg/day and 10 mEq/day, respectively. The metoprolol dose is tapered gradually and held if the systolic blood pressure is less than 110 mm Hg.

In addition to adjustments to the patient's existing medication regimen, it was determined that Patient E could benefit from the addition of a medication to address the signs of osteoporosis and a vitamin and mineral supplement. The physician prescribes calcium carbonate with vitamin D 500 mg/200 mg twice daily as well as a daily multivitamin. To treat the patient's depressive symptoms, 7.5 mg of mirtazapine is prescribed to be taken at bedtime.

Supplementary diagnostic tests are ordered, including anemia profile, ferritin level, stool for presence of occult blood, and folate level. Patient E is instructed to return in one week for a follow-up appointment, at which time another blood test and metabolic profile will be completed.

When Patient E returns for her one-week follow-up appointment, her lungs are clearer and she appears to be more alert. Although she continues to complain of fatigue and poor endurance, she is experiencing less dizziness. She has completed the antibiotic therapy for her pneumonia and has been participating in skilled therapy, increasing her assisted walk distance to 25 to 50 feet.

Her vital signs are normal, indicating a blood pressure of 112/64 mm Hg, pulse 88 beats per minute, and respirations 18 breaths per minute.

The patient intake has also improved, as she is reportedly consuming 50% of most meals and accepts one to two cans of liquid supplement daily. She has gained three pounds, to a weight of 110 pounds and a BMI of 18.9, which is considered healthy. Her completed blood test and metabolic panel indicate the following values:

  • Occult blood test: Negative

  • Hemoglobin: 10.5 g/dL

  • Hematocrit: 31.8%

  • Ferritin: 245 mcg/L

  • Folate: 18 mcg/L

  • Serum iron: 54 mcg/dL

  • Blood glucose: less than 150 mg/dL

  • BUN: 29 mg/dL

  • Creatinine: 1.4 mg/dL

The physician instructs Patient E and her family to continue on the current plan of care. She is scheduled for a follow-up chest x-ray to confirm the absence of pneumonia, and she is instructed to return to the physician in one month to evaluate the continued effectiveness of the treatment plan.

At her one-month follow-up appointment, Patient E has continued to have daily rehabilitation and her weight has stabilized. She is lucky to have the support of her daughter, who encourages her through the process. Her medical conditions have stabilized, which required adjustments to her medication regimen. The patient has progressed well and is discharged home to her apartment. Future considerations for health maintenance include a dual-energy x-ray absorptiometry scan to evaluate osteoporosis treatment, a mammogram, and a colonoscopy.

Learning Tools - Case Studies

CASE STUDY 2

Patient S is a man, 70 years of age, who was admitted to the hospital with altered mental status, exhibiting symptoms of delirium, agitation, and confusion. He was found to have a urinary tract infection and obstructive uropathy leading to acute renal failure. His condition is stabilized, and he is admitted to the rehabilitation facility. The physician completed the initial assessment shortly after his admission to the rehabilitation center. Findings from medical record review indicate a positive history for hypertension and hyperlipidemia. The patient has no advance directives on record, and medical care prior to hospitalization was sporadic. Patient S has lived in a studio apartment for 12 years and does not have any close family members. His support system consists of friends and neighbors. He smokes one-half pack of cigarettes per day and usually drinks two to three beers each day. Prior to hospitalization, he was found by a neighbor; he was delirious, with poor hygiene and incontinent of urine and stool.

Patient S is examined while sitting bedside. His chief complaint is pain in his right knee with walking, though no injury is noted. He also complains of stomach discomfort, gas, and constipation. The patient appears to be suspicious of the physician and makes it clear that he is not staying long. He requests discharge as soon as possible. The patient has gaps in his memory as to what happened prior to hospitalization. He indicates that he eats regularly and does not know why he has lost weight. When dinner is provided, he requests that a beer be provided as well. The Foley catheter is maintained pending further urologic evaluations and treatments.

The initial physical examination indicates that Patient S's height is 5 feet 8 inches, weight 140 pounds, and BMI 21.3; however, the patient's usual weight is 158 pounds. His blood pressure is 134/82 mm Hg, apical pulse 82 beats per minute, and respirations 20 breaths per minute. He has poor dentition, but the mouth is otherwise healthy. The lungs are essentially clear, with slightly diminished breath sounds in the bases. His abdomen is soft and nontender, with active bowel sounds, and the Foley catheter is draining clear, yellow urine. The right knee is mildly edematous and warm to touch. Slight resting tremor is noted of the right hand, but there is no focal deficit. A complete blood test, metabolic panel, and knee x-ray are ordered, as are physical therapy, occupational therapy, speech therapy, and dietician evaluations.

Assessments of function, nutrition, and depression are administered and indicate:

  • MMSE: 18 (moderate cognitive impairment)

  • GDS: 10 (moderate depression)

  • MNA: 9 (at risk of malnutrition)

The laboratory tests return the following results:

  • Hemoglobin: 12.8 g/dL

  • Hematocrit: 38%

  • BUN: 22 mg/dL

  • Creatinine: 1.0 mg/dL

  • Thyroid-stimulating hormone: 3.86 mIU/L, urinalysis-negative

  • Vitamin B12: 585 pg/mL

  • Vitamin D hydroxyl: 22 ng/mL

  • Zinc: 88 mmol/L

The knee x-ray displays evidence of mild degenerative joint disease. The physical therapist's report indicates that Patient S has weakness of the lower extremities with unsteady gait. The patient's right knee pain is causing limited range of motion and mobility. In spite of these limitations, the occupational therapist finds that the patient requires minimal assistance with activities of daily living and hygiene. The speech therapist finds that the patient has poor short-term memory and retention, but no difficulty swallowing. Finally, the dietician notes that Patient S eats about 50% of most meals, refuses liquid supplements, and refuses to go to the dining room because "it is depressing looking at all those sick people."

Because the patient has no advance directives on file, he is referred to a social worker for assistance in planning his care. The patient declines DNR and names a neighbor as his healthcare proxy. The social worker notes that it is questionable if the patient will be able to live alone after rehabilitation is completed due to the lack of regular caregiver and the presence of cognitive deficits.

Finally, the patient's medication regimen is assessed. Patient S is currently prescribed the following medications:

  • Coated aspirin: 325 mg/day

  • Amlodipine: 5 mg/day

  • Simvastatin: 20 mg/day at bedtime

  • Trimethoprim/sulfamethoxazole: One double-strength tablet twice daily for three more days

  • Dutasteride: 0.5 mg/day

Based on the laboratory and examination findings, Patient S is diagnosed with moderate cognitive impairment/dementia and has symptoms of depression. The degenerative nature of the patient's joint impairment indicates osteoarthritis of the right knee. Alcohol dependence is suspected, though the patient refuses assistance with smoking or alcohol cessation. The patient is dyspeptic and constipated. He has developed obstructive uropathy due to undercare of urology.

Assessment of Patient S's medication regimen shows several undertreated conditions, including no medication prescribed for depression, dementia, or vitamin/mineral deficiencies (resulting from weight loss). It is also noted that the aspirin may be causing adverse gastric effects and that side effects related to antibiotic use may be contributing to the decrease in appetite and food intake.

Patient S is started on a regular diet with fortified foods and high-calorie snacks, with the addition of a daily multivitamin. However, the physician advises the patient to decrease alcohol intake to one beer daily (preferably a low-alcohol type). To address the constipation, daily prune juice and milk of magnesia (30 cc as needed) are recommended. Omeprazole 20 mg taken 30 minutes before a meal is prescribed for the patient's continued dyspepsia. Finally, acetaminophen (1 g three times per day) is added to Patient S's regimen to treat his arthritic knee pain. If the patient experiences side effects of the oral acetaminophen, a topical nonsteroidal anti-inflammatory drug may be substituted. The patient is also instructed on physical therapy modalities to manage his pain, including heat, use of a brace, and massage. He continues physical, speech, and occupational therapy for therapeutic exercises, strengthening, endurance, gait training, and cognitive/memory training.

In addition, Patient S is referred to a urologist, psychiatrist, and social worker for continued care planning. It is important that the patient consider options for long-term care, assisted living, and financial assistance, as returning to living alone in his apartment will likely not be a possibility. He is instructed to return in one week for a follow-up appointment.

At Patient S's one-week follow-up appointment, the patient states that his right knee is still sore but slightly improved and his stomach discomfort is relieved, with improvement in constipation. The patient appears mildly confused but is able to answer questions appropriately. He does have multiple complaints regarding food, staff, and policies of the skilled nursing facility where he has been living. He feels he is making good progress with his therapy and is eager for discharge. The patient also expresses a hope that his catheter will be removed soon. He continues to decline assistance with smoking cessation.

At this visit, Patient S's blood pressure is 130/80 mm Hg, pulse 74 beats per minute, respirations 16 breaths per minute, weight 141 pounds, and BMI 21.4. The report from the urologist indicates the ongoing need for the Foley catheter due to obstructive uropathy. The patient has been scheduled for cystoscopy and ultrasound of the bladder and kidneys. Occupational and speech therapies are to be discontinued this week, but continued physical therapy is necessary for gait training, therapeutic exercises, mobility, and balance with a cane.

The psychiatrist reports an MMSE result of 19 and has diagnosed Patient S with depression and vascular dementia. She recommends computed tomography (CT) scan of the brain with contrast. The patient has been prescribed citalopram 20 mg/day, and the future consideration of cholinesterase inhibitors for dementia treatment is noted. His physician instructs Patient S to continue with the current treatment plan, including following up with psychiatry and urology as necessary.

Although Patient S's weight stabilizes, he never regains the weight loss of 18 pounds. The CT of his brain shows microvascular ischemic changes consistent with vascular dementia, possibly a result of the combined risk factors of alcohol and tobacco use, hyperlipidemia, and hypertension. The potential for self-neglect and inadequate medical care is high, and Patient S is not able to return to his apartment to live independently. The lack of family or caregiver is a contributing factor.

After many discussions and care meetings and the intervention of a social worker, the patient moves into an assisted living facility that is subsidized by the government. He continues to be treated by his urologist and psychiatrist. His appetite improves, but he never returns to his pre-illness status.

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