85-year-old-female Case Scenario

QUESTION

85-year-old-female with type 2 diabetes mellitus with neuropathy,  hypertension, rheumatoid arthritis, iron deficiency anemia, hypokalemia, and obesity. Patient is well known to you and in for scheduled visit. Upon entering the examination room, you observed patient sitting in chair with her head down avoiding eye contact, with sad facial expression and depressed mood. When you ask patient what she is in for today? Patient shows you her arms which have various sized abrasions and bruises on hands, wrists, and lower arms. You asked patient if she would give you more information about what’s going on.

Patient reports that there has been a change in her living condition since last visit to the clinic 3 months ago.  Patient reports that 10 weeks ago her daughter lost her job and her daughter and her daughter’s four children moved in with her 2 months ago. Patient reports that she has not been sleeping well at night and not getting much rest during the day due to excessive amount of noise and moving around in the house. Patient’s glucose log shows an average of 78mg/dl (fasting) to an average of 180 mg/dl (2 hours after eating), which is in target range for patient. She denies signs or symptoms of hypo/hyperglycemia. Patient admits to not taking medications as prescribed and sometimes not eating but once a day. Patients reports since her daughter moved in sometimes there are no food in the house and on separate occasions, she has given her daughter a $50.00 bill to pay $1.00 co-pay for Metformin; $20.00 bill to purchase to a dozen of eggs; $50.00 bill to purchase thirty Tylenol Arthritis tablets; and patient reports her daughter does not give her any change back. Three weeks ago, patient reports she had not had any visitors and $540.00 was taken from her purse. Patient reports that sometimes her daughter is rough with her. Patient shows you her arms which have various sized abrasions and bruises on hands, wrists, and lower arms.

Medications: 

• Metformin 1000 mg 1 tab twice a day for high blood sugar. Take with food.
• Gabapentin 600 mg 1 tab every morning, 300mg every 12 noon,  and  600 mg at bedtime for neuropathy.
• Olmesartan/HCTZ 20/25 1 tab every morning for high blood pressure.
• Hydroxychloroquine 100 mg 1 tab twice a day for rheumatoid arthritis
• Methotrexate 2.5 mg 5 tabs once a week for rheumatoid arthritis
• Vitron-C 1 tab daily for iron deficiency anemia
• KCL 20 MEq 1 tab twice a day for low potassium.
• Tylenol Arthritis 650 mg 1 tablet three times a day prn pain.

O:

Vital signs: BP 130/88; P 90; R 18; T 98.4 F(orally); HT 66 inches; Weight 229 lbs., (wt. down by 8 lbs. since last visit 3 months ago); BMI 37.

Lab:  HgA1c 7.8% (was 7.6% three months ago; in target range for patient).

Glucose: 160 mg/dl (random, no metformin today; in target range for patient).

CBC, BMP, lipid profile, liver profile, TSH , Folic acid, Urine albumin, and

U/A.  All lab results in normal range.

Other than: patient avoiding eye contact; sad facial expression and depressed mood; abrasions and bruises on bilateral arms, wrists, and hands; the provider’s physical assessment is normal for this woman age and health status.

Questions: 

• List 2 questions would you ask the patient and why?
• List 1 to 2 new dxs related to today’s visit?
• What actions would you implement at this visit and why?

ANSWER

As the healthcare provider, it is essential to assess and address the concerns and needs of the 85-year-old female patient with multiple comorbidities and presenting signs of neglect and potential abuse. The following are two questions that would be crucial to ask the patient in this scenario:

1. Can you tell me more about the changes in your living conditions since your last visit? This question allows the patient to share additional details about the recent living situation with her daughter and grandchildren moving in. It provides an opportunity to explore how this change has impacted her overall well-being, including her physical and emotional health.

2. Can you describe the nature of the interactions with your daughter that have resulted in the abrasions and bruises on your arms? This question aims to gather more information about the patient’s daughter’s behavior and potential mistreatment or abuse. It allows the patient to express any concerns or incidents of mistreatment she may have experienced, providing an opportunity for intervention and protection if necessary.

Based on the information provided, two new diagnoses related to today’s visit could be

Elder neglect and abuse: This diagnosis is based on the patient’s reports of her daughter being rough with her, her daughter’s misuse of money intended for healthcare needs, and the presence of multiple abrasions and bruises on her arms, wrists, and hands. These findings raise concerns about the patient’s safety and well-being, suggesting a potential case of elder neglect and abuse.

 Major depressive disorder: The patient’s avoidance of eye contact, sad facial expression, depressed mood, and reported difficulty sleeping and lack of rest due to noise and disruption in the household are indicative of depressive symptoms. These symptoms may be attributed to the challenging living conditions and potential mistreatment she is experiencing.

In response to this visit, several actions should be implemented

Ensure the patient’s immediate safety: Assess the patient’s safety and well-being, ensuring that she is no longer in immediate danger. If there is an ongoing risk of harm, appropriate measures should be taken to ensure her protection, including involving the necessary authorities.

Provide emotional support: Validate the patient’s feelings and experiences, expressing empathy and understanding. Allow the patient to express her emotions and concerns, and offer reassurance that her well-being is a priority.

Conduct a comprehensive assessment: Perform a thorough physical examination, paying attention to any other potential signs of abuse or neglect. Additionally, conduct a mental health assessment to further evaluate the patient’s depressive symptoms and overall psychological well-being.

Collaborate with the appropriate team members: Involve the necessary healthcare professionals, such as social workers, psychologists, or abuse counselors, to address the patient’s complex situation effectively. Collaborate with these professionals to develop a comprehensive care plan that addresses her physical, emotional, and social needs.

Ensure ongoing support and follow-up: Establish a plan for ongoing monitoring and follow-up visits to ensure the patient’s safety and well-being. Provide appropriate referrals for counseling, support groups, and community resources that can assist the patient in addressing her current living situation and potential abuse.

The actions implemented during this visit aim to address the patient’s immediate safety concerns, provide emotional support, and initiate appropriate interventions to address the reported abuse and neglect. The multidisciplinary approach involving healthcare professionals from different disciplines will help ensure a comprehensive and holistic approach to the patient’s care, with a focus on her physical and emotional well-being.