Elderly woman with early dementia, scoliosis and chronic back pain

81-year old Caucasian woman with the following presentation: -

  • She has enjoyed a lifetime of general good health without life-threatening illness. However, she now feels generally unwell and seeks consultation before “it is too late”.
  • She lives alone and admits to feeling lonely. She does have 3 adult children who call and visit her regularly.
  • She reports that they have expressed concern over her memory, her ability to complete complex tasks and also don’t believe her concerns about her neighbour. She offers these instances:
  • She often misplaces her wallet and her cell phone.
  • She has to write down every appointment otherwise she forgets the appointment and the time of the appointment
  • She was unable to do her own taxes this year – something she could do previously.
  • She suspects that her neighbour is dealing drugs and that he has recently broken into her home. She believes this because she has heard loud noises at night and recently, upon returning from doing errands, she found a piece of scrap paper on the floor and her oven light was on. Her children have inspected her home and talked with her neighbour and have told her that this is not the case. She doesn’t understand why they don’t believe her.
  • She has never had a cognitive assessment and she asserts that she continues to read the newspaper everyday. Upon questioning, she does, in fact, accurately recall current news events.
  • The patient also reports that 3 weeks ago, while washing her windows, she fell off of a step ladder. She did not hit her head, but did bruise her left arm. She has residual arm pain, no wrist pain and has full ROM of her left arm.
  • She says that her balance is poor and she walks much more slowly than she used to. She says that her low and mid back are painful most of the time, citing a 6 on a scale of 0-10 (0= no pain; 10= unbearable pain)
  • She has a history of untreated scoliosis from adolescence and developed osteoporosis 10 years ago.
  • She states, “I just want to feel better. Everything seems so difficult now. I am also worried that I might fall and no one will find me.”

Review of Systems (pertinent only):

  • Occasional headaches – worse with seasonal allergies
  • Low appetite and frequent bloating after eating
  • Regular bowel movements, somewhat difficult to pass
  • Urinary incontinence – wears a pad

Past Medical History:

  • Hypothyroidism diagnosed 40 years ago – takes 1.25 mcg Synthroid
  • Scoliosis diagnosed in early adulthood – no treatment
  • History of tooth decay and root canals – corrected with implants and a bridge. She notes that the pain medications provided by her dentist also improve her back pain.

Family History:

  • Father: deceased from unknown causes in his late 80’s
  • Mother: deceased from metastatic breast cancer in her 50’s
  • One older brother with diabetes, one older brother with Alzheimer’s disease (diagnosed in his 80’s)

Medications:

  • Levothyroxine 1.25mcg

Supplements:

  • Calcium citrate (1g), Gingko (60mg), CoQ10 (30mg)

Typical Daily Diet:

  • B: coffee, 1 scoop whey protein powder in 1 cup orange juice
  • L: skips or handful of crackers or raisins and carrots
  • D: small salad, 1-2 pieces cheese
  • Alcohol: 1 -2 glasses of red wine
  • Water: 2 glasses
  • Snacks: cookie
  • She notes, “I don’t like to eat. I am just not hungry. This has been true my whole life.”

Activity:

  • Walks daily for 1 to 1 1/2 hours. Does yard work (strenuous) and household chores.

Sleep:

  • 8 hours most nights

Psychosocial:

  • Does errands; enjoys going to the community library. She has no friends locally.

Assessment Considerations:

  • Consider mental health history and breadth of current psychological symptoms.
  • Rule out pseudodementia (depression) vs. early onset depression; nutritional deficiencies; substance use (alcohol, potentially opioids).
  • Assess fall risks, instability, and behavioural considerations. Is instability and fall occurring in the evening after a few glasses of wine? This is a modifiable risk factor.
  • How are her pain comorbidities currently being treated?
  • Did social circumstances recently change? (e.g. death of spouse or friend)
  • Food sensitivities and intestinal permeability.
  • Stool panel with PCR bacterial analysis and digestive assessment.
  • Follow up on thyroid with free T4, free T3 and reverse T3.
  • Check 4-timed cortisol, neurotransmitters.
  • Check CRP, homocysteine, methylmalonic acid, ferritin, HgbA1c.

Insights, Tips and Perspectives:

  • Providing your clients with basic education on pain and evidence-based pain management skills immediately equips them with an adaptive way to reduce their own pain and symptoms. Begin with relaxation training. Recommend simple books they can read, including The OpioidFree Pain Relief Kit (Darnall, 2016).
  • Partnering closely with this patient for several months may facilitate trust and further disclosure of symptoms.
  • Referral to a pain psychology, health psychologist, or geriatric psychologist will yield deeper insights into the patient's mental, emotional, behavioural, and social functioning, thereby clarifying therapeutic targets.
  • Helping patient to implement diet changes, decreased alcohol and sugar, plus continued sleep and exercise, has the potential to make a big difference.
  • Aim to validate patient's concerns and help her understand her symptoms and what she can do to feel better.
  • Gut health and nutrient deficiencies seem probable; gut-brain axis affects memory, mood and can cause headaches.

Management Considerations:

  • She reports multiple pain comorbidities (headache, arm pain, and severe mid- and low-back pain). How does she respond to pain (physiologically, psychologically, and behaviourally). Often people respond by becoming less active, which fosters disability. A pain psychologist could help the patient learn pain management skills to reduce the impacts of pain, calm the nervous system, and provide tools for self-soothing.
  • Social and environmental interventions could reduce isolation, support improved mood, and provide a safety net around some medical symptoms and concerns. Expanded social activity helps reduce negative focus on pain and is actually good pain treatment!
  • Ketogenic diets are an effective way to manage the non-physical symptoms associated with Parkinson’s disease; i.e. depression and dementia.
  • First help with diet and ability to digest food.
  • Need to optimize thyroid dosing and function.

Assess how stress is affecting her cortisol and adrenaline, then address.

Last modified: Tuesday, 26 February 2019, 1:50 PM