Elderly Mental Health and Substance Abuse. Case 1. Dr. John McCahill, MRCPsych, FRCPC Alberta Hospital Edmonton September 11, 2008 Case Studies

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1 Elderly Mental Health and Substance Abuse Dr. John McCahill, MRCPsych, FRCPC Alberta Hospital Edmonton September 11, 2008 Case Studies Case 1 69 y/o woman,recently divorced Presenting complaint: admitted medical unit having been found unconscious.blood alcohol level 330/100ml History of presenting complaint: regained consciousness with uncomplicated medical recovery transpired she drank wine regularly through most of her adult life, about 5 bottles/week, but more when stressed or down Alcohol consumption increased in past few months after divorce from her husband Rather dependent on others and feared she couldn t manage on her own so drank more to soothe her fear but then lost control Previous psychiatric history: various antidepressants over the past few years but never hospitalised had received and overused prescribed benzo s and codeine based analgesia in past 15 years for mild emotional and physical complaints 1

2 Family history: no mood disorder or alcoholism Physical assessment: obesity, 1 st degree heart block,no evidence of drug overdose Mental status examination: unremarkable on recovery from alcohol induced coma and assessed as not a suicidal act Further progress: joined AA and regular attender abstained for 5 years gradually weaned off longstanding daily doses of diazepam However, after 2 years had not adapted to living alone and developed symptoms of major depression(low mood,poor appetite,anergia, weight loss and hopelessness) Further progress continued: Admitted to psychiatric unit and commenced on Mirtazapine She continued on this and supportive psychotherapy to help her live more independently after 3 further years ahe hadn t had a depressive relapse and attended her granddaughter s wedding in the US 2

3 Diagnosis :Early onset alcohol dependence Major depressive disorder Case 2 80 year old widow, lives alone Presenting complaint: low mood, poor short term memory, anxiety, sleep disturbance.family concerned she was dementing History of presenting complaint: husband died 18 months ago.he died suddenly.she became low in mood which persisted past the normal grieving period.she became increasingly anxious and forgetful. As an aside the family mention she likes a drink everyday and they find empty bottles in various parts of her apartment but they re not sure if it s important. Previous psychiatric history: nil Previous medical history: nil Physical investigations: raised MCV(mean corpuscular volume), raised GGT Family history: father abused alcohol,family endorse history of regular family gatherings with alcohol in plentiful supply. Personal history: homemaker, occasional glass of wine no more than 3 times /week 3

4 Mental status examination: well kempt, alert, anxious affect, very cooperative no obvious motor agitation mood mild to moderately low but no strong neurovegetative features cognition revealed MMSE score 22/30 deficits in orientation to day,date,building,recall of 3 items and impaired serial 7 s (did appear to have some impaired concentration) Initial diagnosis: Late onset alcohol abuse Query alcohol induced depression or major depressive disorder Management:Psychoeducation re alcohol and risks and possibility of affecting her mood and cognition. asked to abstain and reassess in 2 months time On review,hadn t completely abstained,still had a glass of wine with Sunday lunch at daughters but mood much improved and MMSE score 28/30 (recall of 3 items 100%) Final diagnosis Late onset alcohol abuse Alcohol induced depression Case 3 77 y/o retired cook Presenting complaint: admitted following a seizure he d had soon after arriving at a local alcohol detox centre History of presenting complaint:50 year history of daily alcohol consumption to point of intoxication multiple DWI charges and drunk and disorderly charges recently living in in a hostel and consuming approx a pint of whisky/day 4

5 No other drugs but heavy smoker Physical findings: drowsy but rousable, disorientated to time and place unable to cooperate with further cognitive testing eye movements normal only other medical prob was osteoarthritis blood alcohol level 125mg/100mls Physical investigations: mildly raised LFT s,mcv raised CT head generalised cerebral atrophy, no focal lesions EEG intermittent slowing compatible with delirium or diffuse structural disease Progress: one week later, after alcohol detox with benzo s reducing regimen MMSE 18/30 deficits in attention,memory,orientation,construction Further progress: cognitive deficits persisted during 9 month stay in a locked,alcohol free nursing home MMSE 21/30.Further neuropsychological testing found previous impairments persisted as well as mild impairment in language,repetition,judgement,calculation.langu age comprehension and naming were intact Neurological examination:unsteady gait and Rombergs sign positive.loss of proprioception and vibration sense in feet 5

6 Diagnosis: Early onset alcohol dependence Alcohol induced persisting dementia Other possible diagnoses are Wernicke Korsakoof syndrome but cognitive impairments found are more generalised than what you d expect in W-K syndrome( this is a memory disorder without the impairments in orientation,visuospatially etc) Alzheimer s Disease another possibility but has stable cognitive deficits and intact naming ability 6