The Case of Mrs. C.The Case of Mrs. C. ““Complexity, Confusion, Complexity, Confusion,

ConfabulationConfabulation””

OrOrThe Three The Three ““CC’’ss””

&&Four RosesFour Roses

Panel membersPanel members

ModeratorModerator--Ed Vandenberg MD, CMD, Ed Vandenberg MD, CMD, Panel members:Panel members:Linda Farho, Linda Farho, PharmDPharmD, BCPS , BCPS Brenda Keller MD, CMD, Brenda Keller MD, CMD, Barb Robertson MA, RD, CNSD, LMNT Barb Robertson MA, RD, CNSD, LMNT Laura Bilek PT, PhD, Laura Bilek PT, PhD, Nancy KelleyNancy Kelley--Gillespie, PhD, Gillespie, PhD, Diane McGee RN MSNDiane McGee RN MSN

Setting; the panel must take the position that Setting; the panel must take the position that they are each in private practice in a they are each in private practice in a capitatedcapitated medical system. They do not medical system. They do not have a mutualhave a mutual--shared electronic medical shared electronic medical record system.record system.

MrsMrs C: C: ““Complexity, Confusion, Complexity, Confusion, ConfabulationConfabulation””

8383--yearyear--old Africanold African--American femaleAmerican femaleOutpatient clinicOutpatient clinicProgressive cognitive declineProgressive cognitive declineIADLsIADLs--burning food, medication errors, burning food, medication errors, financial victimization?financial victimization?Alcohol consumption (little or lots?)Alcohol consumption (little or lots?)

CoCo--Morbid Medical problemsMorbid Medical problems

Unintentional Weight loss:Unintentional Weight loss: 22# over 18 mo22# over 18 mo

FallsFalls-- 1 mo. ago, no LOC, unable to get up1 mo. ago, no LOC, unable to get up

Osteoarthritis Osteoarthritis ––Cervical/lumbar spinal Cervical/lumbar spinal stenosisstenosis with with radiculopathyradiculopathy–– chronic pain, numerous meds, unable to travel or clean chronic pain, numerous meds, unable to travel or clean

house.house.

DepressionDepression--active x 15 yrsactive x 15 yrsUrinary incontinenceUrinary incontinence--urgeurgeHistory of strokes x 2History of strokes x 2 (1991 & 2006)(1991 & 2006)

Past medical historyPast medical history

HypertensionHypertension-- poor controlpoor control

Allergic rhinitisAllergic rhinitis-- lots of symptom complaintslots of symptom complaints

AnemiaAnemia--chronic diseasechronic diseaseVitamin B12 deficiencyVitamin B12 deficiency-- no replacementno replacement

HypothyroidismHypothyroidismVision impairedVision impaired--glaucomaglaucoma-- no eye examsno eye exams

? Restless leg syndrome? Restless leg syndrome

Social HistorySocial History & Advanced Directives& Advanced Directives

Seven children, all Seven children, all ““coming and goingcoming and going”” with limited responsibilitywith limited responsibilityWidow x 15 yrWidow x 15 yrJehovahJehovah’’s Witnesss WitnessFamily members claiming to be Family members claiming to be POAPOA’’ss without documentswithout documentsFull codeFull code

MedicationsMedications

LL-- thyroxinethyroxine 0.125 mg/0.125 mg/ (thyroid)(thyroid)

DetrolDetrol ((tolterodientolterodien) LA 4 mg/d ) LA 4 mg/d (bladder)(bladder)

ValsartranValsartran/HCTZ 160/25 q. d. /HCTZ 160/25 q. d. (hypertension)(hypertension)

RequipRequip 1 mg/d1 mg/d (restless legs)(restless legs)

IMDUR ( IMDUR ( isosorbideisosorbide) 30 mg/d ) 30 mg/d ( ( htnhtn & heart)& heart)

Ferrous sulfate 325 mg Ferrous sulfate 325 mg tidtid (iron)(iron)

AggrenoxAggrenox bidbid (stroke prevention)(stroke prevention)

GabapentinGabapentin 300 mg bid 300 mg bid (neuropathic pain)(neuropathic pain)

More MedicationsMore Medications (the (the ““goodgood”” and the goofy stuff)and the goofy stuff)

FentanylFentanyl 50 mcg patch q. three days50 mcg patch q. three daysPercocet 7.25/325 mg 2 Percocet 7.25/325 mg 2 tidtid (pain) (pain) (narcotics)(narcotics)

Herbal life one per dayHerbal life one per day

Physical examPhysical exam

VSVS; ; lying 170/100; standing 160/90lying 170/100; standing 160/90--118 # 118 # -- HR 70HR 70ENTENT; normal hearing; vision 20/40 corrected; normal hearing; vision 20/40 correctedCORCOR; normal; normalABD/pelvic/rectalABD/pelvic/rectal: normal, : normal, hemeheme negative stoolnegative stoolMSK; ROM normal with pain right legMSK; ROM normal with pain right legNeuroNeuro; Mild right ; Mild right hemiparesishemiparesis. Gait; shuffling, . Gait; shuffling,

problems with initiation. Fails up and go test.problems with initiation. Fails up and go test.MS;MS; MMSE; 22/30 (1/3 IR); GDS 10/15MMSE; 22/30 (1/3 IR); GDS 10/15

Neuropsychological testing.Neuropsychological testing.Moderate impairment Moderate impairment -- language, language, visualvisual--spatial, memoryspatial, memorySevere impairment Severe impairment -- Trails BTrails B

LabsLabs

AbnormalsAbnormals;;HemoglobinHemoglobin--11, 11, reticulocytereticulocyte countcount--30,000 (0.8%), 30,000 (0.8%),

ferritinferritin 286, K286, K-- 3.1, TSH3.1, TSH--13, vitamin D < 7, 13, vitamin D < 7, vitamin B12; 200vitamin B12; 200

NormalsNormals;; CMP, UA, ESR, LFT, CMP, UA, ESR, LFT, albumin 4.2,urine drug screen negative, albumin 4.2,urine drug screen negative, heavy metal screenheavy metal screen--negativenegative

IMAGINGIMAGINGCT headCT head; ; 1. Bilateral 1. Bilateral lacunarlacunar infarcts caudate infarcts caudate

head and anterior internal capsule. 2. Atrophyhead and anterior internal capsule. 2. Atrophy..Mammogram/chest xMammogram/chest x--rayray

normalnormal

LS spineLS spineL1 mild compression fracture.L1 mild compression fracture.Mild to moderate degenerative lumbar Mild to moderate degenerative lumbar spondylosisspondylosis..Postsurgical decompression L3 through L5Postsurgical decompression L3 through L5

Home healthcare/pharmacyHome healthcare/pharmacy findingsfindings

Medications not refilled or unMedications not refilled or un--used.used.DetrolDetrol ((tolterodinetolterodine) LA ) LA (bladder) (bladder) --not refillednot refilledRequipRequip (restless legs)(restless legs)--not refillednot refilledIMDUR ( IMDUR ( isosorbideisosorbide) ) ( ( htnhtn & heart)& heart)--not refillednot refilledFerrous sulfate 325 mg Ferrous sulfate 325 mg tidtid (iron)(iron)--bottle empty and refilled bottle empty and refilled with Lwith L--thyroxinethyroxineAggrenoxAggrenox ((stroke prevention) stroke prevention) --not refillednot refilledGabapentinGabapentin ((neuropathic pain)neuropathic pain) --not refillednot refilledFentanylFentanyl (narcotic)(narcotic)--applies intermittentlyapplies intermittentlyPercocetPercocet 2 tabs TID probably2 tabs TID probably -- takes regularlytakes regularlyHerbal lifeHerbal life 1 tab q. d.1 tab q. d. --takes regularlytakes regularly

Home Healthcare Nurse findingsHome Healthcare Nurse findings

House disarrayedHouse disarrayedOld food in the refrigeratorOld food in the refrigeratorEmpty alcohol bottles (Southern Comfort, Empty alcohol bottles (Southern Comfort, Four Roses)Four Roses)Family members visiting, eating but Family members visiting, eating but providing little support.providing little support.

Putting the plan togetherPutting the plan together

What the clinical team didWhat the clinical team didProblem list;Problem list;

1. Mixed dementia (vascular1. Mixed dementia (vascular--alcohol).alcohol).2. Depression 2. Depression -- minor.minor.3. Falls secondary to CVA, dementia, alcohol use, and medicatio3. Falls secondary to CVA, dementia, alcohol use, and medications.ns.4. Osteoarthritis.4. Osteoarthritis.5. Weight loss secondary to dementia and possible alcohol.5. Weight loss secondary to dementia and possible alcohol.6. Hypertension.6. Hypertension.7. CVA.7. CVA.8. Anemia.8. Anemia.9. 9. HyperlipidemiaHyperlipidemia..10. Hypothyroidism, 10. Hypothyroidism, noncompensatednoncompensated..11. Cervical11. Cervical--lumbar spinal lumbar spinal stenosisstenosis..12. B12 deficiency12. B12 deficiency--compensated.compensated.13. Impaired vision 13. Impaired vision -- under care.under care.14. Urinary incontinence14. Urinary incontinence--urge.urge.15. Vitamin D deficiency.15. Vitamin D deficiency.

Family MeetingFamily Meeting

Patient and family goals;Patient and family goals;1.To have her remain independent and in 1.To have her remain independent and in

her own home as long as possible.her own home as long as possible.2. Improve her cognitive and physical 2. Improve her cognitive and physical

conditioncondition

What the team didWhat the team didDementia Dementia

--establish powerestablish power--ofof--attorney, attorney, --activated poweractivated power--ofof--attorney, attorney, --stopped alcohol, stopped alcohol, --increased social and cognitive activities, increased social and cognitive activities, --added Aricept (added Aricept (donepezildonepezil) (watch weight closely)) (watch weight closely)

DepressionDepressionMirtazapineMirtazapine 7.5 mg nightly x 2 weeks then up to 15 mg, 7.5 mg nightly x 2 weeks then up to 15 mg, stop stop trazodonetrazodoneincrease social and cognitive activities. increase social and cognitive activities. ENOA has added case manager and will add 18 hours ENOA has added case manager and will add 18 hours per week of home care.per week of home care.

What the team didWhat the team did

FallsFalls--Physical therapy, home safety assessmentPhysical therapy, home safety assessmentOsteoarthritisOsteoarthritis--PainPain

Stop Percocet, Stop Percocet, Begin Tylenol 500 mg 2 tablets Begin Tylenol 500 mg 2 tablets t.i.dt.i.d. . Begin Begin oxycodoneoxycodone 5 mg 2 tablets 5 mg 2 tablets t.i.dt.i.d. and 1 q. 8 . and 1 q. 8 hrs. hrs. p.r.np.r.n. . Future convert to Future convert to OxyContinOxyContin & limit the number & limit the number of of p.r.np.r.n. . oxycodoneoxycodone..

What the team didWhat the team didWeight lossWeight loss--dementia, alcohol, living alone.dementia, alcohol, living alone.

Regularly scheduled meals, Regularly scheduled meals, Family eating with her Family eating with her ––scheduledscheduled

CVACVA--HypertensionHypertensionneeded for lipid & BP control, needed for lipid & BP control, continue with continue with AggrenoxAggrenox..

Vitamin B12, D deficiency & hypothyroid,Vitamin B12, D deficiency & hypothyroid,improved replacement, medication administrationimproved replacement, medication administrationHome orthostatic blood pressuresHome orthostatic blood pressuresVitamin D 50,000 units 2 times per week times five Vitamin D 50,000 units 2 times per week times five weeksweeks

What the team didWhat the team did

Vision impairedVision impaired--glaucomaglaucomasee ophthalmologysee ophthalmology

Urinary incontinenceUrinary incontinence--urgeurge(worsened off (worsened off DetrolDetrol))

Attempt to teach delayed void exercisesAttempt to teach delayed void exercisesIf fails trial of biofeedback.If fails trial of biofeedback.Adult incontinence briefsAdult incontinence briefs

Most recent PT report Most recent PT report

GoalsGoals--improve endurance, strength, balanceimprove endurance, strength, balanceAssessments:Assessments:

Tolerates reTolerates re--strengthening exercises wellstrengthening exercises wellPain main limiting factorPain main limiting factorShowing slow progressShowing slow progress

Plan:Plan:Continue therapy 4 more weeks, if no further Continue therapy 4 more weeks, if no further

improvement discharge from therapyimprovement discharge from therapy