Jackie Smith Is an 82-Year-Old Right-Handed Caucasian

Jackie Smith is an 82-year-old right-handed Caucasian woman. She has been diagnosed with dementia and her eldest son has petitioned the court for guardianship in the past. At that time Mrs. Smith's eldest son and his family were living with her. A psychiatrist following her case at the request of her son diagnosed Mrs. Smith with dementia based on interviews with her eldest son, his wife, and an interview with the patient's 16-year-old granddaughter who suggested that the patient was forgetful to the point of being a danger to herself. This led the physician to conclude the patient suffers from a progressive dementia and that the patient needed assistance in her self-care. He also recommended that the patient not drive and informed the Secretary of State regarding his findings. However, the patient's primary care physician asked for a second opinion as Mrs. Smith's son and family had approached him previously and was apparently was attempting to gain control of the patient's property and assets. The patient's son and his wife are unemployed and moved in the patient's home one day while she was out with friends. The patient reported that this initially helped her feel less anxious and depressed, but then they took over control of the patient's affairs. The patient reports that they were stealing money from her and trying to make her crazy by hiding things from her. They would not let her pay her bills and would not let her take her own medications, which she had been doing successfully with a medication organizer and reminders prior to their moving in.

The patient's medical history is significant for CVA in 2004 (although from her description of the symptoms and duration it sounds more like a TIA), coronary artery disease, hypertension, arthritis, depression, and anxiety. With respect to her CVA, the patient reports that it occurred at a casino and that she became very confused for a short period (only a few minutes) without lateralized physical symptoms, changes in her vision, or language difficulties. Neuroimaging performed at St. Bingo's Hospital reportedly revealed some stroke related changes in her left cerebral hemisphere according to her son, but I was unable to read this report. The patient reports another brief period of confusion occurring in November of 2007 that was also transient. She has no seizure history. Her medications at the time of this report included Memantine, Etodolac, Fluoxetine, Simvastatin, Alprazolam, Buspirone, Tramadol, Plavix, Lisinopril, and Isosorbide. She does not smoke, drinks alcohol socially, and does not use illicit drugs.

Recently the patient suffered an episode of confusion and agitation and was hospitalized. She did not recognize her family members, thought that she was in France, and reported to hospital staff that she was having conversations with her deceased husband. Inspection of her laboratory values indicated that all results were within normal limits. The neuropsychologist at the hospital recommended that the patient discontinue the Seroquel that the psychiatrist who diagnosed her with dementia had prescribed and was being given to her by her son. Three days after the discontinuation of the medication her mental status stabilized and she was released, although the social worker at the hospital was suspicious of the patient's caregivers and made an appointment for Family Protective Services to follow the patient.

The patient became very aggressive towards her older son once she returned home and demanded that she be able to monitor her own medications. Her son refused and the patient contacted her younger son and family for assistance. She became more depressed and started drinking two or three drinks at night to help her sleep and her son claimed that her decision-making ability was poor and contacted his attorney. The patient's younger son intervened and the older son backed down when his attorney contacted them. At the time of this report they no longer live with her. Thus, the report made by this patient's elder son, daughter-in-law, and granddaughter was thought to be fallacious and motivated by a desire to make the patient look unable to take care of herself. In addition the patient's primary care physician did not feel that the patient displayed significant dementia so as she was unable to make decisions and an MMSE administered by him was 19, suggesting mild dementia. A full cognitive workup and neurological workup have been scheduled as well as a review of her medications as several of these can lead to cognitive issues.

The patient currently lives at home and receives assistance from her younger son and daughter-in-law. The patient has completed 12 years of formal education. She is retired having worked in a molding plant and as an office worker. She is widowed (13 years) and also recently lost her boyfriend in July of 2007, which most likely made her anxious about being alone. Physical examination revealed a well-nourished female. She is 62 inches tall and weighs 175 lbs. Blood pressure was 150/88. Skin condition: no open areas turgor good. Bowels move every one to two days. There is no history of UTI. She has some arthritis in her hips and uses a walker to ambulate. She has discussed the possibility of hip replacement surgery with her physician, but due to the dementia diagnosis the family wished to discuss this further with her. There were no other abnormal findings on physical examination. MMSE was 18. She was very pleasant and cooperative throughout the evaluation. The patient wears eyeglasses and she wore these during the evaluation. I did not observe any significant difficulties with vision or hearing that would interfere with the test administration or with her performance. Thought processes were logical and goal directed. There was no evidence of a disorder of thought process or content. Expressive language was fluent and within normal limits for volume and prosody. I did not observe significant word-finding difficulties in her conversational speech during this evaluation, but she did display word-finding difficulties on a measure of confrontation naming. The patient's mood was slightly depressed. She reported that she was very distressed over her eldest son's actions and that she had been "down in the dumps" lately over this. She has been drinking alcohol more frequently to relieve her anxiety. She did endorse any thoughts of harming herself.