May 2003 Geriatric Presentation

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May 2003 Geriatric Presentation

• Toby Andrew Hampton, M.D.

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Patient ID

• 75 y.o. White male
• Veteran admitted to VAMC Mountain Home Nursing
  Home on 5/12/2003

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Chief Complaint and HPI

• CC Weakness, Falls, Hallucinations
• Pt. Has Parkinsons disease and has had
  hallucinations since starting Sinemet. Recent
  addition of Seroquel has not alleviated
  hallucinations.
• Pt. Also c/o recent increase in weakness and
  falls about 1X q day.

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HPI Continued

• Pt. Had been living at home with his wife but due
  to the increase in weakness and falls, the wife
  is no longer able to care for him.
• He is admitted to NH here for med adjustment and
  for PT to increase strength and endurance.
• Dizziness worse with Seroquel

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PMH

• Coronary artery bypass times 4 on 5/30/1996
• Peptic Ulcer Disease
• Ocular histoplasmosis dx in 1980, legally blind
• Degenerative joint disease, Arthritis
• HTN
• Hyperlipidemia
• Phlebitis of superficial vessels in lower
  extremity

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PMH Continued

• Sensorineural Hearing Loss
• Shy-Drager Syndrome
• Benign Prostate Hypertrophy
• Chronic Constipation
• Parkinsons Disease

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Other Hx

• Social hx Lives at home with wife until
  admission, No alcohol, No tobacco for the past 20
  years, No illegal drugs. Has 3 children
• Fam. Hx Pt. Cant recall any illnesses is the
  family.

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Current Meds on Admission

• Aspirin
• Tylenol
• Sinemet
• Fluocinolone
• Latanoprost
• Daily Multivitamin
• PRN Nitroglycerin SL

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Meds Continued

• Nitroglycerin patch
• Pramipexole
• Seroquel
• Ranitidine
• Simvastatin
• Sorbitol and Mag Citrate prn
• Allergic to Pcn and IVP dye

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Review of Systems

• 20 lb weight loss over past 6 months
• Dry eyes
• Cough each am with brown sputum
• Constipation
• Some night-time incontinence
• Arthritic pain in hands, knees, and hips
• Hallucinations, No depression

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Physical exam

• Vital signs
• Wt. 181.7 lb
• Temp 95.3
• Pulse L-70 SI-70 St-78
• Resp 18
• BP L-133/65 SI-119/70 St-94/55

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Physical Exam

• General alert, oriented to person and place, but
  not to time resting tremor
• HEENT masked facies, missing two molars, TMs
  occluded by cerumen
• Neck No thyromegaly, No carotid bruit
• CV RRR, no m,r,g Chest- gynecomastia
• Lungs CTAB
• Abd Soft, BS, NT, ND

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Physical Exam

• Extremities no c/c/e, UE muscle strength 5/5
  bilat. And LE 4/5 stength bilat. DTRs UE and LE
  1 bilat.
• Neuro- CN 3-12 intact. CN 2 affected by near
  blindness. Gait very unsteady. Monofilament exam
  reveals sensory deficit to ankles bilat.
  Proprioception of toes and foot is intact bilat.
  Skin-Mult. bruises

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Misc.

• MMSE- 26/30
• Geriatric Depression Scale 2/30
• Pt. Does need assistance with his ADLs and
  cannot perform any IADLs
• Pt.s wife states hat their inances are holding
  OK for now.

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Pertinent Lab DATA

• 5/12/03 UA-WNL INR 1.25 BMP-WNL Total
  Chol-140 WBC 7.3 HGB 14.7 HCT 42.5 PLT 188
• 4/23/03 NH3 lt0.9, FOLATE 317 RPR-nonreactive
  TSH-2.2 VIT B12-749

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Nursing Home Course

• Pt. Tolerating PT quite well.
• Seroquel discontinued.
• Geodon 20 mg po bid started with a decrease in
  hallucinations per pt.
• Pt. Still suffering from night-time incontinence.
• Falls decreased to 1 q 2-3 days.

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Assessment and Plan

• 1. Parkinsons (Possible Shy Drager)- Cont.
  Sinemet and pramipexole.
• 2. Hallucinations- Cont. Geodon and Geropsych is
  following.
• 3. Weakness- Cont. PT
• 4. Orthostatic Hypotension- monitor fluid intake
  and advise pt. To hold on to something as he
  stands up slowly to decrease orthostasis.

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Assessment and Plan

• 5. Night-time incontinence- restrict fluids after
  8 pm
• 6. Constipation- Cont. prn sorbitol and Mag
  Citrate
• 7. Falls- Likely multifactorial including
  Parkinsons, orthostatic hypotension, poor
  sensation in feet, weakness, and blindness.

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Shy-Drager Syndrome

• AKAMultiple System Atrophy

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Facts about Shy-Drager

• Prevalence of 4.4 per 100,000
• 10 as common as Parkinsons Disease
• Avg. age of onset 54
• Predominately MalegtFemale
• 75 of patients with diagnosis present with
  complaints related to autonomic dysfunction.

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Autonomic Dysfunction Symptoms

• Urinary retention, incontinence
• erectile dysfunction
• orthostatic hypotension
• apnea, or inspiratory stridor
• snoring or loud respiration
• Inability to sweat
• Resistance to levodopa

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Movement Presentation

• 25 of patients with Shy-Drager Syndrome will
  present with movement symptoms related to
  cerebellar or striatonigral lesions.
• These patients show the typical autonomic
  symptoms within 5 years of the movement symptons.
• Movement symptoms of Shy-Drager are very similar
  as for Parkinsons.

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Treatment

• Dietary increases of salt and fluid
• L-Dopa may be useful in some cases
• sympathomimetic amines
• NSAIDS
• salt-retaining steroids
• alpha-adrenergic meds
• Sleeping in a head up position reduces am
  orthostatic hypotension

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Prognosis

• Progressively fatal disease
• Death usually occurs within 7-10 years of
  diagnosis
• Death usually ensues secondary to stridor,
  aspiration pneumonia, or cardiac arrest.

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The End