Establishing a Treatment Plan for an Elder With a Complex and Incomplete Medical History and Multiple Medical Providers, Diagnoses, and Medications

Author, Discussant, and Attendee Affiliations: Cleveland Clinic, OH (Hope Torregosa, MD, and Amanda Lathia, MD); Community Care for the Elderly, Milwaukee, WI (Linda Culhane, GNP, and Priscilla Sharpless, CAPSW); Johns Hopkins University School of Medicine, Baltimore, MD (Ashley Hicks, MD, and Jessica Golin, MD); Madison VA Hospital, Madison, WI (Timothy Howell, MD); Mayo Clinic, Rochester, MN (Aimee Yu-Ballard, MD, and Bernard Aoun, MD); University of Texas Health Science Center, San Antonio (Liliana Oakes, MD); University of Texas Southwestern Medical Center, Dallas (Vivyenne M.L. Roche, MD, and Sarwat Jabeen, MD); and University of Wisconsin School of Medicine and Public Health, Milwaukee (Michael Malone, MD, Ejus Culleth, MD, and Julie Luks, MD).

This department in Annals of Long-Term Care: Clinical Care and Aging focuses on real-world difficult cases that clinicians have encountered in their practice. A case presentation will be followed by a discussion about the case that includes teaching points and clinical pearls from clinicians at collaborating medical schools. The case presentation in this article was written by a geriatrics fellow from the Cleveland Clinic, OH. The teaching points were prepared by faculty at the University of Texas Southwestern Medical Center, Dallas; Madison VA Hospital, Madison, WI; and the University of Wisconsin School of Medicine and Public Health, Madison and Milwaukee. The discussion was compiled from a transcript of a monthly telephone conference hosted by Aurora Health Care.
____________________________________________________________________________________________________________________________________________________

Case Presentation 

A 73-year-old white woman with a history of depression for more than 30 years visited the clinic with her son and daughter for a comprehensive geriatric assessment. The patient’s family was concerned about her deteriorating mental state and confusing medical diagnoses, especially over the previous 5 years. Without access to her medical records until recently, and because the patient had a tendency to keep her health problems to herself, the children were unsure about certain specific information regarding their mother’s health. Even when her cognition was clear, the patient did not want to reveal much information to her children or to her husband. Her children were, however, able to access some of her medical records.

Relevant History

As a child, the patient lived in Poland and was in hiding with her family for 8 years during the Holocaust. She received a depression diagnosis after her first husband left her in the 1970s, but she remained functional, managed a business, and took care of her children despite her diagnosis; therefore, her children remained unaware of her diagnosis at that time. The patient’s daughter reported that her mother’s mood again deteriorated when the youngest child got married and moved out of the family home. She was treated with lithium and other unknown psychiatric medications in the 1980s for depression and may have had a diagnosis of bipolar disorder. She still remained fully functional, however, remarried in 1991, and continued to run a successful business. Her second husband was initially unaware that she had been treated for depression and had received psychiatric care.

According to her daughter, the patient remained on lithium until around 2005. She recalled a situation when the patient visited her that year looking “dopey and drugged.” At that time, the patient was taking lithium, trazodone, alprazolam, and an unrecalled antidepressant after having had several medication changes, including stopping lithium for a period of time. The patient’s children were aware that she was seeing a psychiatrist around that time, but they did not know how often. However, they noted a dramatic decline in her cognitive and functional abilities and decided that she should stop seeing her current psychiatrist and seek a second opinion from another psychiatrist. At her first visit with her new psychiatrist in 2005, a workup was initiated, and a magnetic resonance imaging (MRI) scan showed the following: intact orbits and retro-orbital structures; an asymmetric rightward gaze to the right lobe; a mildly hypertrophic pituitary gland; no intracranial mass or mass effect; no hydrocephalus; and age-related involutional changes, which included subtle ex vacuo enlargement of the subarachnoid spaces and ventricular system with confluent regions of T2 prolongation within the subcortical white matter of both frontoparietal junctions and, less substantially, within the temporal lobes, compatible with chronic microangiopathic gliosis.

The patient’s daughter was told that her mother demonstrated some mild impairment on cognitive testing. Her family informed the psychiatrist that they noticed the patient had some memory loss. They recalled that she had gotten lost on occasion while driving starting a few years before the initial assessment with the second psychiatrist. The patient was started on donepezil and memantine, taking them concomitantly or separately for short time periods, but they were discontinued at an unknown time after the patient showed no improvement. At the time of her first visit with her new psychiatrist, she was taking scheduled alprazolam and trazodone for sleep, but these were changed to quetiapine, as-needed alprazolam, sertraline, and as-needed lorazepam. The chart review noted “bipolar disorder.”

In 2007, the patient was hospitalized twice at a psychiatric unit for depression and anxiety. Around that time, she began experiencing difficulty initiating movements, slowing of movements, and tremors. There was also a situation at her daughter’s birthday party when she complained that she could not get up from her chair. She was referred to an orthopedic surgeon, a neurosurgeon, and, subsequently, a neurologist. She also changed psychiatrists again. MRI scans of the spine showed multilevel degenerative disc disease, which occurred after her inpatient psychiatric hospitalization.

Her neurologist noted further slowing of movements in July 2008 at a regular follow-up appointment. The patient informed him that she had difficulty initiating ambulation and that her handwriting had become smaller over the previous 2 to 3 years. She was drooling, but had no difficulty chewing or swallowing. Her neurologist noticed that her voice had become softer and lower. She informed him that she experienced difficulty getting out of a car for the previous 6 months and that she suffered from back pain, joint stiffness, and chronic constipation. She had no history of syncope, fainting, or seizures. Her memory was mildly impaired. She and her family were unclear as to whether she had visual or auditory hallucinations. She was experiencing no diplopia or vision changes. At the time of this visit with the neurologist, her medications were quetiapine, escitalopram, mirtazapine, omeprazole, and polyethylene glycol, and it is unknown when these agents had been initiated. On physical examination, she had masked facies, a slow gait without festination, mild bradykinesia, slowed fine finger movement, a mild resting tremor without pill rolling, and cogwheel rigidity. The electroencephalogram results were normal. Somatosensory evoked potentials were consistent with sensory polyneuropathy or lumbar radiculopathies. The patient received a diagnosis of parkinsonism superimposed on lumbar and cervical spondylosis. A trial of carbidopa, levodopa, and entacapone was initiated. The rest of her medications (quetiapine, escitalopram, mirtazapine, omeprazole, and polyethylene glycol) were continued.

One month later at a follow-up visit, it was noted that the patient’s bradykinesia had improved; however, she scored 22 of 30 on the Mini-Mental State Examination (MMSE), and the results of the Clock Drawing Test were abnormal. Her neurologist discussed the diagnosis of parkinsonism and cognitive impairment with the patient’s husband and daughter. Carbidopa-levodopa was started and carbidopa-levodopa-entacapone was stopped, as the latter had caused diarrhea. Physical therapy was recommended, but the patient did not follow through, despite urgings from her family.

On subsequent visits to the neurologist over the next year, the patient’s parkinsonian symptoms continued to improve. Her main symptoms were micrographia, tremors, constipation, and difficulty buttoning her shirt and standing up from a seated position. Ropinirole and propranolol were added to her medication regimen, despite concerns over her history of extreme sensitivity to numerous medications. She could no longer manage her finances or shop alone, and she required assistance leaving the house. The patient’s children became aware that she began having difficulty preparing meals and keeping track of current events and television shows; however, her husband, who lived with her, denied these reports to her children and to her doctors.

In November 2009, her family decided to seek a second opinion and consulted with another neurologist, as they felt that her current neurologist did not communicate well with her psychiatrist, whom she was seeing regularly. Her new neurologist noted that the patient had significant tremors, severe bradykinesia and rigidity, postural instability, and dysphonia. Her examination showed masked facies, axial rigidity, bradykinesia, resting tremor, cogwheel rigidity (left greater than right), festinant wide-based gait, retropulsion/anteropulsion, and postural instability. Her neurologist made the diagnosis of severe Parkinson’s disease of relatively recent onset. Carbidopa-levodopa 25/100 mg was increased to 1.5 tablets three times daily, and ropinirole XL 2 mg every evening was continued. Home physical therapy and gait training were again suggested, and a workup was restarted.

On NeuroTrax testing, her cognitive performance was 1 standard deviation (SD) below the average in memory, executive function, attention, and visual/spatial. Her global cognitive function performance was 1 SD below the average. The complete blood count, metabolic panel, thyroid panel, vitamin B₁₂ levels, folate levels, rapid plasma regain screening test, and fluorescent treponemal antibody absorption test were all normal. A brain MRI scan revealed stable areas of chronic ischemic demyelination in the subcortical deep white matter, generalized atrophy of the brain parenchyma, a prominent pituitary gland, and a mucous retention cyst in the left maxillary sinus. The patient’s brain parenchymal signal was normal, without any mass, mass effect, ischemia, or abnormal extra-axial fluid collection.

Regular clinic visits to her neurologist and psychiatrist from January 2010 to September 2010 resulted in several medication changes. The rivastigmine patch was added, initially at 4.6 mg every 24 hours, then increased to two patches, and later changed to 9.5 mg every 24 hours. Ropinirole was increased to 1 mg three times daily, with ropinirole XL 2 mg given at night. Escitalopram was decreased from 30 mg to 20 mg daily, and she was started on scheduled clonazepam, quetiapine, and lorazepam, as needed. Clinically, the patient was still manifesting signs of memory loss, dementia, anxiety, and depression. She was restarted on memantine by her primary care doctor.

By March 2010, she had become dependent in activities of daily living (ADLs) and instrumental ADLs (IADLs) and required caregiver assistance 24 hours a day 7 days a week, which was paid for by her children. Around this time, the patient’s children noted that she was having hallucinations and delusions, including believing that her husband was having affairs with the caregivers. Her husband had become very stressed about his wife’s situation and was deteriorating physically. Her children suspected that he was verbally abusing her. After visiting with the neurologist in September 2010, the family decided to move the patient from her home into an assisted living facility near one of her sons, who lived in a different state. The patient’s husband was amenable to this arrangement, and the children acquired power of attorney. Her daughter said that the patient’s psychiatrist had declared her incapable of making her own decisions. At this time, she was advised to stop the as-needed lorazepam, and rasagiline was added to her medication regimen due to her worsening parkinsonian symptoms.

The facility provided meals, ADL and IADL assistance, and medication administration. The patient did not have an around-the-clock companion, as her husband remained at home; however, her family was willing to hire someone to fill this role, if needed.

After the patient moved to the assisted living facility, her children were able to observe her more closely. They noted regular fluctuations in her mental status throughout the day that appeared to coincide with her carbidopa-levodopa dosing, which was still being administered three times daily. They discovered that she was often lucid and alert in the mornings, but became confused and appeared “spaced out” by lunchtime. She then became more alert after her midday carbidopa-levodopa dose, only to become more confused later in the afternoon, followed by another period of alertness in the evening. Her children also observed that her appetite coincided with her mental state. She ate a very good breakfast, very little lunch during her period of declined cognition, and a good dinner as she became more alert. The patient’s children described their mother as severely anxious. Whenever the patient’s husband came to visit her, she became very agitated, and she told her children that he was part of the problem.

Current Presentation

On the morning of October 2010, 1 month after the patient was admitted to the assisted living facility, she was seen in a movement disorders clinic. A diagnosis of a parkinsonian disorder and dementia was made; rasagiline was discontinued. She was noted to be “very alert, pleasant, and cooperative.” That afternoon, she was seen at the Cleveland Clinic in our geriatrics clinic for the first time per her family’s request. She was confused, barely able to follow commands, and was moaning. Her family provided her history and whatever medical records they were able to obtain.

A review of systems revealed a significant history of weight loss (5-20 lb over the previous 6 months and approximately 20 lb over the previous 5 years) and constipation. The patient had been reporting constipation and abdominal pain for at least 5 to 7 years prior to her current presentation. She experienced pain in her left upper quadrant after eating, which was associated with nausea and occasional vomiting and was relieved by having a bowel movement. She had two colonoscopies and a polypectomy in 2005; the polypectomy showed benign lesions but no other abnormalities. A computed tomography scan of the abdomen and pelvis in March 2009 showed a benign Bosniak category II renal cyst. She had never had an upper endoscopy examination. Her constipation was very severe at times, with more than one episode of impaction. She manually disimpacted herself on occasion. She had been treated with omeprazole and scheduled psyllium at some point for her gastrointestinal problems. Her last normal bowel movement had been over 1 week prior to her current presentation.

During her physical examination at the Cleveland Clinic, she was sitting in a wheelchair. We noted that she was well nourished, kempt, diaphoretic, and anxious. Her vital signs were within normal limits. The patient’s head, eyes, ears, nose, and throat were examined. Her head was normocephalic/atraumatic. Her tympanic membranes could not be viewed due to soft cerumen in the external auditory canals. The patient’s neck was supple, her trachea was midline, her thyroid was not enlarged, and there was no cervical lymphadenopathy. Her respiratory system was clear on auscultation bilaterally, with no rales or wheezing observed. Her cardiovascular examination revealed a regular rate and rhythm; normal S1 and S2 heart sounds; and no murmurs, rubs, or gallops. Her gastrointestinal examination was positive for bowel sounds on auscultation; her abdomen was soft and mildly tender diffusely, and there was no hepatosplenomegaly. On her extremities, we noted minimal grade 1 bipedal edema, but no clubbing or cyanosis, and 2+ bilateral dorsalis pedis pulses. There was no evidence of skin breakdown or rashes.

The patient was unable to stand without assistance on the Get Up and Go Test. Her upper extremities demonstrated four-fifths strength. She then stopped following directions, so lower-limb strength, finger-to-nose testing, heel-to-shin testing, rapid alternating movements, and fine finger testing were unable to be assessed. The patient moved her extremities spontaneously, and a resting, pill-rolling tremor of her hands and left leg were noted. She also demonstrated cogwheel rigidity greater on the left side than the right and masked facies. Cranial nerves II through XII were intact. A sensory examination showed a normal light touch. On the MMSE and the Geriatric Depression Scale (GDS), she scored 12 of 30 and 3 of 15, respectively. For her Clock Drawing Test, she drew three short lines inside a circle. The patient appeared to be very confused and continued to be unable to follow directions.

Her current medications were omeprazole 40 mg orally per day; rivastigmine patch 9.5 mg every 24 hours; mirtazapine 30 mg at bedtime; escitalopram 20 mg orally per day; carbidopa-levodopa 25/100 mg, 1.5 tablets three times daily; ropinirole XL 2 mg at bedtime; ropinirole 1 mg twice daily; memantine 10 mg twice daily; clonazepam 0.5 mg, one tablet in the morning, one-half tablet at lunch, one-half tablet at 4 pm; vitamin D 1000 IU daily; vitamin A/C/E combination, one tablet daily; multivitamin, one tablet daily; and psyllium, two tablets twice daily.

(Continued on next page) 

Case Summary

Multiple factors make this a difficult case. The patient has a complicated history, marked with multiple medical providers and multiple psychiatric diagnoses with numerous trials of medications further complicated by polypharmacy, with a continued cognitive and functional decline. The patient’s history features a challenging and complex chronology of events, which makes it difficult to clarify the diagnoses and treatment plans. Her children often had little or no information about certain details of the patient’s history because they did not always have access to her medical records and because the patient did not like to share her health information. The patient’s case is further complicated by the stress caused by her husband and the concern of verbal abuse.

Clinically, the patient has progressive parkinsonian symptoms, with further decline in cognition and function that is associated with fluctuations, hallucinations, delusions, and worsening anxiety/depression. Per the report from her family, she began having mild cognitive deficits 2 to 3 years prior to the onset of her parkinsonian symptoms. It is unclear whether the patient’s cognitive impairment was also secondary to depression, polypharmacy, or both.

It is critical to assess the timing of her dementia onset in relation to her parkinsonism. Her dementia is unlikely to be due solely to Parkinson’s disease, as her cognitive impairment precedes her parkinsonian symptoms. The patient’s symptoms could be indicative of Alzheimer’s disease with parkinsonism. The differential diagnosis includes Parkinson-plus syndromes, Lewy body dementia, and drug-induced parkinsonism.

The case discussion that follows is based around the Wisconsin Star Method (explained further in this article), which guides clinicians in addressing the five realms of this patient’s complex, interconnected problems: (1) medication use; (2) medical problems; (3) behavioral factors; (4) personal factors (traits and values); and (5) social factors. Assessing these then enables us to approach the most difficult aspects of the case.

Case Discussion

Jabeen: Was a urinalysis or human immunodeficiency virus (HIV) test performed? Did the patient have any sleep disorders?

Torregosa: No urinalysis was done. She did not have an HIV test or risk factors for HIV. We did not ask about rapid eye movement (REM) sleep disorders.

Lathia: One of the challenging aspects was that her children, who provided the history, had relatively little information. She had just moved from her home to an assisted living facility near one of her sons. Prior to this move, her children did not have the opportunity to witness these symptoms.

Culleth: Dr. Torregosa, apart from her complex history, what was your initial impression? More importantly, what was your impression of her parkinsonian symptoms? Did she have Parkinson’s disease or drug-induced extrapyramidal symptoms?

Torregosa: We saw her once, and her presentation was not consistent with straightforward Parkinson’s disease, based on the timeline of events. She had memory loss and cognitive issues for at least 1 year before she developed her parkinsonism. Her clinical presentation exhibited classic parkinsonian features: masked facies; asymmetric rigidity, with more on the left side; tremor; bradykinesia; and micrographia.

Malone: Are there any questions regarding the patient’s medications, the behavioral health needs of the patient, or the patient’s sociability?

Oakes: If she had Lewy body dementia, would Lewy bodies affect the peripheral nervous system and cause prolonged absolute latencies in the myelinated sensory nerve fibers and peripheral neuropathy? Would it be seen on testing?

Torregosa: She had records of spine MRIs available, and the neurosurgeon and the neurologist felt that her peripheral neuropathy was due to the radiculopathies from spinal degenerative disease. We do not think that it was related to Lewy body dementia.

Lathia: That’s a very good question, Dr. Oakes. I’m not aware of Lewy bodies being present in peripheral nerves. Lewy body dementia was a strong possibility with her parkinsonian features and memory loss. Her hallucinations, however, were not prominent and seemed to be more recent.

Oakes: One of our geriatric psychiatrists at San Antonio has done some preliminary work showing Lewy bodies extending beyond the brain to the autonomic system. This may explain her symptoms, such as orthostatic hypotension and constipation. Quetiapine was started very early in the patient’s history, correct? Do you think that she had psychosis then? Her hallucinations seem to have started in 2000. If you can clarify the time of onset, it could support the diagnosis of Lewy body dementia.

Lathia: Yes, I agree. That period of the patient’s history was difficult to figure out because her family had limited involvement in her medical care at that time. There is a long-standing history of depression and anxiety. We don’t have more details. There was some question of bipolar disorder. I’m not sure what symptom was treated with quetiapine. She was on other medications as well, mostly antianxiety medications, antidepressant medications, and lithium for possible bipolar disorder. She had taken lithium for many years. What made this case so difficult was that we did not know how she initially presented with her psychiatric illness and what the primary features were, and whether her recent presentation was different.

Malone: Dr. Torregosa and her colleagues pointed out some of the dilemmas. The family wants to know the diagnosis and why the patient is continuing to decline in the setting of multiple interventions. As we go from one fellowship program to the next, I want you to suggest strategies that you would use to help this patient and her family.

Golin: I agree with Dr. Torregosa and her colleagues. We would taper as many medications as possible to distinguish polypharmacy from disease. This may help clarify the clinical picture. Begin with the neuroactive medications and then reassess. Do it in a stepwise fashion, so that you can assess the patient’s response and new symptoms. We would probably admit her to our combined geriatric psychiatry and geriatric medicine facility; however, this type of facility is not available everywhere.

Culleth: We agree. We would also consult geriatric psychiatry to optimize her medications and taper unnecessary medications.

Jabeen: This family appears to have been under a lot of stress. I would arrange a family meeting to address their fears, assess the goals of care, and discuss the plan of care.

Teaching Comments

Before the case conference, Dr. Howell was asked to prepare some general teaching points, and Dr. Roche was asked to prepare some summary teaching points.

Howell: I was struck by the complexity of this case on multiple different levels. The dilemma of complexity is commonly encountered in geriatrics and geriatric psychiatry. It can be very challenging to figure out precisely the chronology and how things fit together when there is a lack of information. Important details can be lost—they are not available or people do not remember. Why did the family know so little about the patient’s psychiatric issues for so long? Was that attributed to the family’s culture or the patient’s beliefs with regard to discussing her mental health issues, and then later on also due to HIPAA [Health Insurance Portability and Accountability Act] regulations blocking their access to her psychiatric records? Did the personality traits and values that she had as a younger adult account for that? Although her grown children had limited access to her medical records, they could provide valuable insight into those traits and values, shedding light on her usual ways of coping and how these methods may have been changing.

Consider systems issues when complexity leads to diagnostic ambiguity. It is interesting that this woman presented with overlapping symptoms of numerous syndromes. The many different diagnoses over several years may be explained by specialists and subspecialists focusing on just one or two arms of the star map (Figure), and missing the big picture. On the other hand, she may have had more than one disease—a useful geriatric rule of thumb is to remember to also consider “both/and” rather than just “either/or.” Some of her parkinsonian symptoms may be due to antipsychotic medications. That would be something to explore further. The neuroimaging shows that she has some deep white matter ischemic changes, suggesting a vascular component to her dementia, which could certainly affect her mood and her psychosis. She has some variant sort of parkinsonian syndrome. Is there a vascular component to the parkinsonism in addition to a Parkinson-plus syndrome? Could this be Lewy body disease? There are many possibilities, and without 
an autopsy to review the histopathology, we may not have a clear clinical diagnosis, as there may be several diseases present.

The patient emigrated from Poland to the United States after hiding out with her family during the Holocaust, which may have contributed to her anxiety and depression. Does she have symptoms of posttraumatic stress disorder (PTSD)? I have encountered some patients with a similar history who have continued to be haunted by these experiences even decades later. She graduated from high school, worked as a clerk, and ran a successful business, so she appears to have been resilient despite traumatic experiences, and she was likely very independent. I would check with her family if this fits her premorbid personality and values. The patient is now forced to be more dependent, and this may also contribute to her anxiety and depression. Based on her wartime experiences as a child, she may feel increasingly vulnerable and in need of protection.

I would like to conclude with the higher-level systems issues. Do HIPAA regulations pose a barrier to accessing important information, both from a psychiatric and a geriatric medicine perspective? This case illustrates the challenges in trying to obtain an integrated history. The patient has been seen by multiple specialists and has received multiple diagnoses. It demonstrates the current lack of integration in the healthcare system. One of the things we can offer our medical colleagues as geriatricians is our familiarity and relative comfort with diagnostic, treatment, and prognostic ambiguities. We can show them how to manage the complexity of multiple diseases, rather than trying to come up with a single unifying diagnosis.

(Continued on next page) 

Roche: I’d like to thank Dr. Torregosa for an excellent presentation, and the Cleveland Clinic faculty for a very detailed and informative case. It’s quite remarkable that you met her once and provided us with this amount of detail. This case highlights the importance of a thorough clinical history and examination. This case includes geriatric syndromes, such as elder mistreatment, polypharmacy, weight loss, and dementia, and incorporates key geriatric domains, such as decision-making capacity, interprofessional team members’ input, caregiver burden, and managing a complex frail patient who has multiple providers.

Today, I’m going to focus on six teaching points: (1) when treating patients with dementia, pay particular attention to their medical, personal, and social histories; (2) differentiate medical decision-making capacity from incompetence; (3) discuss patient safety and elder abuse; (4) perform a thorough history and clinical examination; (5) review all medications; and (6) work with an interdisciplinary team to formulate a plan of care for complex patients.

As geriatricians, we often find that a patient’s history and upbringing helps us, particularly in individuals with dementia. We are told that the patient is 73 years old now. She went into hiding for 8 years starting in 1939, when she was just 2 years old. These were her formative years. This has several important clinical implications. As a child, she was exposed to severely traumatic events and loss. I agree with Dr. Howell that we need to consider PTSD in this patient, and that her childhood experience may be one source of her current anxiety and depression. She is a Holocaust survivor. We know that she emigrated from Poland, so English is her second language. We should also take this into account when we perform cognitive testing, especially as her memory loss worsens. Considering her experiences during the Holocaust as a kind of child abuse, she may be more likely to be abused again later over the course of her life. As we place her in a higher level of care—assisted living—it will be important to think about her surroundings and certain things that we consider innocuous or routine. Taking a shower at the facility, for instance, might be very sinister or frightening for this particular patient.

The second teaching point is that there is sometimes confusion between competency and capacity. This is a very important distinction. We are told that her children acquired power of attorney and that a psychiatrist declared her incompetent. As geriatricians, we make clinical assessments to determine whether a patient has the capacity to make certain clinical decisions. The terms competence and incompetence are usually confined to legal rulings, and they imply that a court has taken action. So, we cannot say that a psychiatrist declares a patient incompetent, as only a court can do this. We need to determine that her children have durable powers of attorney for her healthcare and finances, so that they can make health decisions on her behalf and supervise her finances.

The third teaching point is patient safety and addressing elder mistreatment. This patient has particular red flags because she has cognitive impairment and significant functional impairment. She was a victim of traumatic experiences early in life, and there’s some evidence that the family has only relatively recently become involved in her care. Perhaps the patient and her husband were quite isolated before she moved closer to her one son. As Dr. Torregosa already mentioned, it seems that her husband now has increasing health issues, so it is very good that she has moved to a higher level of care. It is important to monitor her current caregivers to prevent further abuse.

The next teaching point is the importance of her history and clinical examination. I would like to highlight some points. Her cognitive function did fluctuate, so it is important to exclude delirium. To diagnose Lewy body dementia, we need to determine the onset of cognitive impairment in relation to her parkinsonism. Depression may impact cognitive assessment. I would like to know if her children noted any mania as they grew up. On initial review of the case, it appears that she lost a tremendous amount of function and cognitive ability within 2 years. However, the detailed history indicates that her daughter noticed driving issues several years before 2005. She scored 12 of 30 on her MMSE—I would like to know in which areas she performed well. Useful information would also include whether she had a history of sleep disorders, when the hallucinations began, and the timing of the onset of her dementia and her parkinsonism. That would confirm my primary diagnosis of Lewy body dementia. She has significant Parkinson’s features. To exclude progressive supranuclear palsy (PSP) as a diagnosis, ophthalmoplegia must be assessed by asking her to look up and down. Patients with PSP are more likely to have neck extension than patients with Parkinson’s disease, who typically have neck flexion. Multiple system atrophy should be considered and orthostasis assessed for. If she has either of these diagnoses, she is unlikely to respond to antiparkinsonian medications and they may cause side effects, including hallucinations. I would like to know her vitals, orthostatics, height, and weight, and would perform a rectal examination in the clinic to check for impaction. As her cognition fluctuates, I would schedule her to return when she is likely to be alert enough to discuss her goals of care.

The fifth issue is her medications. She is not likely to have depression, with a GDS score of 3 of 15, but the GDS is less helpful in patients with moderate to severe dementia. The examination, however, is conflicting. She has masked facies and yet she appears very anxious. I am concerned that the hallucinations may be very frightening for her. I would choose quetiapine rather than mirtazapine. The regimen is not optimal for ropinirole, a dopamine agonist. The recommended dose is 3 mg to 8 mg three times a day. The patient’s current dose of 4 mg in a 24-hour period is not therapeutic, but it may cause side effects, such as hallucinations and imbalance. We do not use ropinirole XL at our clinic because the shorter-acting form is cheaper and just as effective. I would stop the ropinirole. For her Parkinson’s symptoms, I would continue the carbidopa-levodopa for now. I agree with tapering memantine. She needs a bowel regimen; I would stop the psyllium and start scheduled lactulose. I would like the geriatric psychiatrist’s input regarding PTSD and to review mirtazapine, escitalopram, and clonazepam, with a goal of tapering to just one drug for anxiety.

Finally, the interdisciplinary team members are pivotal in helping this frail, cognitively impaired, functionally challenged woman. Physical therapy will improve her function, but it is important to ensure that the therapists come at a time of day when she is alert. Other essential steps include addressing her abdominal pain by providing a bowel regimen; optimizing the medical management of the patient’s parkinsonism with the help of a pharmacist (if available); and encouraging her caregivers to have her sit out of bed and do range-of-
motion exercises. Her anxiety should be treated with input from a geriatric psychiatrist, and a dietician (if available)should be consulted to improve the patient’s calorie and protein intake. A social worker should review the documentation to see if the family has durable powers of attorney and if her code status was addressed. Living at a facility may be particularly challenging for this Holocaust survivor, so the patient should have a follow-up appointment as soon as possible—when she is alert—to determine her goals of care. A translator may be needed, which is something that should be considered when arranging her next appointment. Thank you.

Malone: Dr. Torregosa, would you give us a one- or two-sentence summary, or any additional updates with regard to the patient?

Torregosa: Yes. To answer some questions, the patient was very reluctant about sharing her prior psychiatric history with her children and husbands, and kept the diagnosis from her second husband for as long as possible. On the MMSE, she lost points for registration, attention, calculation, orientation, language, recall, and commands. We did consider Parkinson-plus syndromes; she did not demonstrate ophthalmoplegia. Her vitals were normal, including orthostatics. We will see the patient again next week. Her daughter recently called us with an update. Her children have been with her every day and noted that she has trouble eating, but they are unsure if this is a new or chronic problem. Otherwise, there are no significant changes in her mental status. We started a bowel regimen and stopped psyllium. We will take note of all of your suggestions, and we thank you very much for your insight.

Malone: Thank you everyone for your input with this most interesting case.

(Continued on next page) 

Plan of Care

Continue the rivastigmine patch for the patient’s parkinsonian disorder and taper her parkinsonian medications (rasagiline had already been stopped and the neurologist recommended lowering the dose of ropinirole). Would taper ropinirole first and then consider tapering carbidopa-levodopa, and would reassess the patient before choosing an antipsychotic to control her hallucinations and delusions. Memantine is unlikely to provide much benefit, so taper this medication slowly. It is also important to maintain communication with her neurologist. Depending on her treatment response, have her see a geriatric psychiatrist, per her family’s request.

The patient’s constipation with abdominal pain is likely to be secondary to poor function and medications. A rectal examination should be considered, with disimpaction if needed. Schedule stimulant laxatives and stool softeners. She may continue drinking prune juice, increase her fluid intake, and use a suppository, if indicated. The patient should discontinue psyllium. If her pain continues despite regular bowel movements, consider further workup. In light of her weight loss, she may need an upper endoscopy. We will monitor her response to the bowel regimen and address her mood and dementia before considering further interventions.

For the patient’s depression and anxiety, continue her other medications (mirtazapine, escitalopram, and clonazepam for the present); monitor her progress and adjust the medications as needed. Try to slowly taper the clonazepam to address any somnolence. To address concerns of polypharmacy, discontinue vitamins A, C, and E, but continue the multivitamin and vitamin D. The laboratory results revealed a normal complete blood count, basic metabolic panel, and hepatic function tests. Her vitamin D level was 24 ng/mL. A post-void residual revealed no urinary retention.

__________________________________________________________________________________________________________________________________________________

The Wisconsin Star Method

The Wisconsin Star Method (WSM) was developed over several years, with input from clinicians, medical educators, and patients. It is a simple concrete tool for addressing the problem of complexity in geriatrics. The high frequency of multiple interacting patient and systems issues in clinical practice has long called for the development of a user-friendly method that allows clinicians to get a better handle on difficult situations more quickly and provide effective care with greater clinical integrity.^1,2

The value of the WSM is supported by the principles of heuristics,^3-5 cognitive science,^4-7 information visualization,⁸ecological interface design,⁹ team functioning,⁴ and network theory.^10,11 The method involves a low-tech graphic user interface—drawing a small five-pointed star on a surface, such as paper or whiteboard, and mapping out clinical data about a patient’s situation in list form at the appropriate field or domain. Each datum is an element in a network of potentially interacting variables, with the links between them ranging from very weak (ie, negligible) to very strong (ie, directly causal). The primary identifiable clinical challenge (eg, ability to live safely at home) is written in the center of the star. In some cases, the primary challenge may not be entirely clear at the outset, but emerges gradually as the situation is reviewed.

Each arm of the star represents one domain: medications, medical, behavioral, personal, and social. The medication arm includes all of an individual’s current medications (ie, prescribed, over-the-counter, and “borrowed”) and other relevant substances (eg, dietary). The medical and behavioral arms list known diagnoses, functional status (eg, abilities regarding IADLs), and symptoms. The personal arm highlights a person’s individual traits, values, and usual ways of coping. These include the rules of thumb that individuals use to guide their assessment of situations, their learning and communication styles, and their general approaches in dealing with stressful experiences. The social arm covers interpersonal problems, environmental problems, assets (eg, family support, finances, housing, transportation, legal issues), and access to needed resources.

Each arm of the star also represents a different ecological aspect at which problems may occur. The medication arm is considered the biochemical or molecular interface; the medical arm, the area of organ systems; the behavioral, the interface mediating between the brain, the body, and the environment; the personal arm, the interface of the “mind and heart”; and the social arm, the interaction of the interpersonal and the environmental.

Per the WSM, it is essential that the data be written down, as effective implementation is simply not possible in complex cases if the data is kept in the user’s head, because the carrying capacity of the conscious human brain is on the order of approximately seven simultaneous variables.^5,9 The WSM serves as a two-dimensional map that becomes an extension of the users’ working memory⁸ and, whether used by individuals or a team, enhances executive functioning for situation awareness and problem-solving. Writing the elements down creates a small but significant distance between the user(s) and the problems, thus providing cognitive and affective 
perspectives.

The WSM also facilitates the ability to attend simultaneously to multiple interacting variables and to identify those data that are most relevant. One simply travels around the star, assessing and highlighting those elements in each arm that appear to connect significantly with, and thus contribute to, the challenge in the middle of the star. This process allows the user to identify any potentially relevant data that is missing (eg, is the person able to manage all the required steps to refill a prescription?) and reconsider whether data initially considered irrelevant might have some bearing on matters after all.

Using the WSM in this manner helps ascertain which problems have multifactorial origins and thus avoid the common hazard in complex situations of coming to premature closure.^6,12 It can ease shifting sets when considering pairs of problems at different levels that might have linear-causal relationships (eg, poor blood pressure control despite three antihypertensive medications and an inability to afford medication or an unrecognized problem with alcohol abuse). It can also be applied holistically to identify how multiple problems may be interconnected, such as parkinsonian gait instability, falls, loss of usual means for coping, depression (low mood and motivation), and social isolation. The resulting map provides a big picture of the case, with strong and weak ties highlighted, and can be viewed as the person’s unique ecosystem.

By integrating holistic and linear-causal perspectives into an ecological approach, the WSM can enhance the recognition of diagnostic patterns within domains and the identification of vicious cycles between domains (eg, falls + embarrassment about using a walker→decreased activity→physical deconditioning→falls). It also facilitates novel problem-solving: generating hypotheses, prioritizing and sequencing interventions, integrating clinical pearls¹³ with evidence-based guidelines,¹⁴ and transforming vicious cycles into virtuous ones (eg, arranging for a friendly visitor—someone who also needs a walker—to visit and walk with the person regularly).

Likewise, the WSM can be used to help identify traits, values, and usual ways of coping and thus promote better appreciation of the anxieties that may underlie puzzling behaviors, such as recurrent falls and worry about being seen in public as being dependent on a walker.^15-17 When the user attends to these issues and assesses how he or she feels when confronted with a challenging clinical situation, it can enhance the user’s emotional effectiveness and reduce the likelihood of affective errors. Thus, the WSM can help in cultivating collaborative relationships with older persons rather than confrontational ones, such as blaming them for refusing to use a walker. Often, the personal arm of the star points the way to a good clinical outcome, helping the user acquire a sound appreciation for a patient’s understanding of the issues and preferences for addressing them.¹⁸

Using the WSM has the potential not only to enhance proficiency at providing comprehensive care, but also to reduce cognitive and emotional burdens and errors.^6,19 The WSM can help individuals and teams become more confident and mindful²⁰ in addressing the complicated interacting physical, emotional, and social issues of older adults with greater sensitivity and specificity to each one’s uniqueness.

The authors report no relevant financial relationships.

(Continued on next page)

References

1.   Tinetti ME, Bogardus ST Jr, Agostini JV. Potential pitfalls of disease-specific guidelines for patients with multiple conditions. N Engl J Med. 2004;351(27):2870-2874.

2.  Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005;294(6):716-724.

3.  Michalewicz Z, Fogel DB. How to Solve It: Modern Heuristics. 2nd ed. Berlin: Springer-Verlag; 2004.

4. Page SE. The Difference. Princeton, NJ: Princeton University Press; 2007.

5. Gigerenzer G. Gut Feelings. New York, NY: Penguin; 2007.

6. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142(2):115-120.

7. Heath C, Heath D. Made to Stick. New York, NY: Random House; 2007.

8.  Ware C. Information Visualization. San Francisco, CA: Morgan Kaufmann Publishers; 2004.

9.  Endsley MR, Bolté B, Jones DG. Designing for Situation Awareness: An Approach to User-Centered Design. Boca Raton, FL: Taylor & Francis; 2003.

10. Barabasi AL. Linked. New York, NY: Plume; 2003.

11. Csermely P. Weak Links. Berlin: Springer-Verlag; 2006.

12.  Groopman J. How Doctors Think. Boston, MA: Houghton Mifflin; 2007.

13. Mangrulkar RS, Saint S, Chu S, Tierney LM. What is the role of the clinical “pearl”? Am J Med. 2002;113(7):617-624.

14. Hunink MGM, Glasziou PP, Siegel JE, et al. Decision Making in Health and Medicine: Integrating Values and Evidence. Cambridge, UK: Cambridge University Press; 2005.

15. McCrae RR, Costa PT Jr. Personality in Adulthood. New York, NY: Guilford Press; 2006.

16. Agronin ME, Maletta G. Personality disorders in late life: understanding and overcoming the gap in research.Am J Geriatr Psych. 2000;8(1):4-18.

17.  Agronin ME. Personality is as personality does. Am J Geriatr Psych. 2007;15(9):729-733.

18. Epstein RM, Peters E. Beyond information: exploring patients’ preferences. JAMA. 2009;302(2):195-197.

19.  Graber ML, Franklin N, Gordon R. Diagnostic errors in internal medicine. Arch Intern Med. 2005;165(13):1493-1499.

20.  Epstein RM. Mindful practice. JAMA. 1999;282(9):833-839.