The Geriatric Patient

An 85-year-old woman, with a history of moderate dementia (with an MMSE of eighteen 6 months ago), hypertension, hyperlipidemia, coronary artery disease was admitted to the hospital because of altered mental status. History reveals worsening agitation after a fall about a week ago. Her current medications include oxybutynin for urinary incontinence, cimetidine for acid reflux, and citalopram 40 mg daily for depression, in addition to her antihypertensive and cardiovascular medications. Because she was agitated she had also been started on haloperidol (5 mg total daily) and 1 mg lorazepam every 6 h as needed a week ago with no improvement in behavior, but with further decrease in her eating and self-care. On physical exam she was noted to have cogwheeling, restlessness, and bruises on her arms and her left hip area. When palpating and performing range of motion of her left lower extremity, it was noted that she pulled back and got more agitated. Mini-Mental Status Exam was 12/30 with difficulties with orientation, spelling “WORLD” backwards, and recall. During the interview she stated that she wants to go home and dislikes medications. Staff reported that she has been refusing some of her medications. Labs were performed which indicated sodium 120, urinalysis positive for leukocyte esterase and nitrites, an EKG with QTc 490, and X-ray indicating ankle fracture. The patient was started on ciprofloxacin for urinary tract infection. A psychiatric consultation is requested for management of altered mental status and agitation, as well as for assessment of capacity to refuse treatment.