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P OSTER
A BSTRACTS
the episodes of unresponsiveness, subsequent code and pacemaker
placement.
C11
Unmasking PTSD in Dementia.
A. H. Chodos, A. Moreno. Geriatrics, UCSF, San Francisco, CA.
Introduction: A new presentation of posttraumatic stress disorder
(PTSD) in the setting of cognitive impairment is increasingly diagnosed
in patients with a history of prior trauma. The effect on caregivers
is not well understood.
Case: Mr. H is an 89-year-old male veteran with hypertension
and glaucoma. At a primary care visit, he had a Montreal Cognitive
Assessment score of 12/30 (normal ≥26) but reported no functional
impairments. A social work and APS evaluation found his home to be
safe and that he lived with his frail wife.
Two months later he was seen by psychiatry, who noted a previous
diagnosis of PTSD two years earlier and that he had since fallen
out of psychiatric care. They documented a history of trauma during
early childhood and WWII. Mr. H reported ongoing symptoms of
nightmares, intrusive thoughts, insomnia and frequently checking the
house at night. He refused any medication.
A neuropsychological battery revealed impaired memory, language
and attention,consistent with dementia.Laboratory tests showed
a B12 of 196, and he was started on B12 supplement. A head MRI
showed volume loss and subcortical white matter hyperintensities.
A month later he presented three times to the ER for nonspecific
symptoms and weight loss, and was admitted on the last visit. He
was discharged home after his symptoms resolved without intervention.
Several days later, he presented to his PMD endorsing severe
anxiety, paranoia about his wife and suicidality. He was admitted to
psychiatry. His suicidality resolved but he remained paranoid about
his family. His providers discovered that prior to his presentation to
his PMD, he had been alone for three days after exhibiting anxious
and paranoid behavior that prompted a stepdaughter to remove his
wife from the home. His family has refused to participate further in
his care, and he awaiting guardianship in the hospital.
Discussion: Mr. H was diagnosed late in life with PTSD in the
setting of cognitive decline. His symptoms worsened as his dementia
progressed and his social environment became strained. His case
demonstrates that protective cognitive strategies may be affected in
dementia, unmasking PTSD symptoms. Evidence also suggests traumatic
memories are better encoded than others and may be preferentially
recalled as dementia impairs recent memory. Older adults diagnosed
with dementia require early social and psychiatric assessment
to prevent harms of unaddressed psychiatric disease, caregiver stress
and social vulnerability.
C12
Foot recognition following amputation.
A. Gupta, 1,2 M. K. Bautista, 1,2 M. Izhar, 1,2 F. Aziz, 1,2 R. J. Beyth, 1,3
K. M. Heilman. 1,4 1. GRECC, NF/SGVHS, Gainesville, FL; 2.
Department of Aging and Geriatrics, University of Florida,
Gainesville, FL; 3. Department of Medicine, University of Florida,
Gainesville, FL; 4. Department of Neurology, University of Florida,
Gainesville, FL.
Background: Studies of body knowledge and imagery may help
us understand disorders of the body schema such as phantom limbs
and anosognosia. Following limb amputation there are alterations of
a limb’s cortical representation. This case report attempted to learn if
shortly after an above-knee amputation of the right leg this patient
had a normal or impaired ability to recognize pictures of the right
versus left foot taken from different angles.
Methods: A 56-year right handed man with history of diabetes,
peripheral vascular disease and remote history of right side stoke 10
years ago without residual neurological deficits, developed a diabetic
foot ulcer of the right lower leg and underwent an above-knee amputation
of the right leg. Two weeks after surgery, the right-left foot
recognition task was performed. The patient was shown, in a random
order, a total of 24 images of either right or left foot at 12 different angles
for each foot, and was asked to tell the examiner as rapidly, but as
accurately as possible, if this picture was either the right or left foot.
The subject made 44 errors recognizing the picture of the right foot
and 44 errors recognizing the left foot. The mean reaction time for the
right foot was 1.60±1.19 seconds, and the mean reaction time for the
left foot was 1.52±1.28 seconds. There was no statistical difference in
terms of the reaction time or accuracy in identifying images of the
right foot compared to the left foot.
Discussion: Previous studies using a limb recognition task with
people who had a unilateral hand amputation and unilateral leg pain
revealed increased reaction time and decreased accuracy in identifying
images of the affected limb compared to the unaffected limb.
Contrary to these prior reports this patient with right leg amputation
revealed no difference in identifying images of the right compared to
the left foot. Cortical reorganization occurs over a period of time and
this patient was tested only two weeks after amputation. Further
studies are needed to learn if patients such as this develop an alteration
of their amputated limbs representation and if this interferes
with recognition.
C13
Hip fractures in Elders Nearing End of Life: Is There a Role for
Palliative Surgery?
A. R. Atreya, S. Arora, M. J. Brennan. Medicine, Baystate Medical
Center/Tufts Univ. School of Medicine, Springfield, MA.
Background:
There are 350,000 hip fractures in the US annually, with over
90% of them in elders. Most patients benefit from rapid surgical repair
but decision making can be complex near the end of life. The authors
present a case of a frail dementia patient whose precarious situation
and limited reserves posed a conundrum regarding surgical
repair of his fracture.
Case Report:
An 88 year old retired pediatrician (Dr. R.) with advanced dementia
was found lying on the nursing home bathroom floor. His history
included CAD, a CABG and AVR, DM and HTN. He had lost
weight due to dysphagia; his BMI was 15.6. He had an advanced dementia
and was cachectic, incontinent of stool and urine; and he slept
most of the day. Dr. R. needed assistance with all his ADLs. He still
was able to speak a bit and could walk short distances unaided. An X-
Ray confirmed an intertrochanteric fracture.
In the ER, he was anemic, hypotensive, in rapid AF and had a
creatinine of 1.5; he was admitted to the ICU. The critical care, medical
consult and orthopedic teams were divided about whether to
proceed to an ORIF. All agreed that Dr. R was high risk but some
MDs felt he would have less pain after surgery and that the mortality
risk was justified. Geriatrics was consulted to render an opinion regarding
“palliative” surgery and to guide the family through this complex
decision. The family reported that Dr. R. had always valued
quality of life and function highly. He had chosen to have a CABG
and AVR at an advanced age (despite the risks) to decrease symptoms
and improve QOL. The family decided to proceed to surgery
but overnight Dr. R. became stuporous, had an MI, developed pneumonia
and worsening renal failure. Thoughts of surgery were abandoned,
comfort measures intensified and Dr. R. died peacefully 3
days after admission.
Discussion and Conclusion:
A search of the medical literature yields little data on the palliative
outcomes of fracture repair for frail elders like Dr. R. High risk
surgery is unjustified unless there is a real potential palliative benefit.
If patients have better pain control, are able to transfer to chairs and
have a lower requirement for opiates with fewer drug side effects,
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