Here - American Geriatrics Society

P OSTER
A BSTRACTS
cancer, non malignant GI disorders, and medication side effects. In a
quarter of patients, no identifiable cause is found. However, somatic
diseases may be mislabeled as a psychiatric disorder because specific
organic symptoms may be overlooked or misinterpreted by physicians,
psychiatrists, or by the patients themselves.
Design/Methods: Case Reports of three patients admitted in a
Geriatric Psychiatry Unit at RUMC
Results:
Patient #1: 95 y.o. female with decreased hearing and visual acuity,
GERD admitted following suicide attempt by ingesting a bottle of
Advil, complaining of regurgitation, cough and dysphagia. Videofluoroscopic
swallow study showed large air filled esophagus and lack of
peristaltic movement concerning for Zenker’s diverticulum. Patient
declined further work up, her symptoms were managed conservatively.
Patient #2: 74 y.o. female with HTN, DM2 presented with weakness,
weight loss, sore throat, recurrent emesis for 2 months. She expressed
paranoid thoughts of “aliens in her stomach.” Her family believed
she was anorexic. She was diagnosed with gastric
adenocarcinoma compressing the esophagus, necessitating G- tube
and esophageal stent placement.
Patient #3: 80 y.o. female nursing home resident with weight loss,
depression, complaining of food sticking in her chest. Although a barium
swallow was concerning for an esophageal stricture, EGD was
negative. Ultimately, her symptoms resolved as her depression was
treated.
Relevance: Unintentional weight loss may lead to significant
morbidity and mortality in elderly patients if left untreated. Although
this is frequently attributed to an underlying psychiatric disorder,
these diagnoses require absence of somatic disease. Two of these patients
had a somatic cause for their illness, while in the last patient
medical work up was necessary to verify a psychiatric cause of her decline.
As geriatricians, we are taught to not overlook psychosocial
causes of these symptoms. Nevertheless, a careful medical investigation
to exclude a possible somatic disease mimicking a psychiatric disorder
in elderly patients is essential.
D20
A Suspicious Case of Syncope: Can Factitious Disorder Occur in
Persons with Dementia?
M. Grammas, A. Donahue, M. Drickamer. Yale University School of
Medicine, New Haven, CT.
CASE: An 88-year-old man with a history of atrial fibrillation,
dementia and depression presented with frequent episodes of loss of
consciousness. He had several prior negative evaluations. Patient was
OX3 and had a normal physical exam. He had mild, asymptomatic
postural BP changes. CXR, head CT, ECG, echocardiogram and labs
were normal. He scored 24/30 on MMSE with deficits in short-term
recall and visual-spatial domains. His clock drawing showed perfect
planning and ordering of numbers but incorrect hand placement.
During the hospitalization, he had several episodes of loss of
consciousness, some while supine, others when arising to stand. Vital
signs, telemetry review, pacemaker interrogation, and continuous
video EEG monitoring revealed no explanation.After emerging from
one episode, the patient remarked, “You know I am faking all of this.
I like to see you people come around.” Psychiatry consult stated that
due to his dementia, he did not have the capacity to feign an illness.
DISCUSSION: Transient loss of consciousness is not an uncommon
presenting symptom among older adults. The most common
causes are orthostasis, carotid hypersensitivity and cardiac abnormalities.
Nonsyncopal causes include seizures, metabolic, intoxication
and psychogenic. History and physical reveals the diagnosis in approximately
half of cases. Imaging, cardiac and neurologic evaluations
should be performed as indicated. While the spectrum of
feigned medical illnesses are diagnoses of exclusion, they should also
be considered when symptoms persist despite adequate evaluation.
Simulated diseases arise from either unconscious or conscious behaviors.
Among the conscious simulated diseases is factitious disorder,
the intentional production of symptoms for a primary gain, to achieve
the sick role. It is estimated that factitious disorder may account for
as many as 5% of all physician visits with neurologic symptoms being
among the most common. There is scant literature on whether factitious
disorders occur in patients with dementia. Based on fMRI studies,
the act of deception is associated with increased activity in prefrontal
and anterior cingulate cortices, areas involved in executive
function. Our patient, independent of ADLs and some IADLs and
able to follow multiple step instructions, demonstrated a number of
behaviors supporting executive function sufficient to consciously
feign symptoms of illness.
D21
An unexpected death over 3000 miles from home: the importance of
advance care planning.
M. Koya. Internal Medicine, University of Washington, Seattle, WA.
Case: A 66-year-old woman walked in with her husband to the
emergency department complaining of dyspnea. Within an hour of arriving,
the patient became hypoxemic and hypotensive requiring intubation
and initiation of vasoactive agents. Workup revealed severe
biventricular failure with an atrial septal defect (ASD) and a large
right to left shunt. The patient was admitted to the cardiac intensive
care unit (CICU). The husband stated to the on-call resident that they
were visiting from New York, and her only past medical history was a
remote history of breast cancer. They had never discussed advanced
care planning. Efforts were made to contact her primary oncologist to
obtain records; however this was unsuccessful. The husband asked the
resident to “do whatever is necessary” and the patient underwent
intra-aortic balloon pump and Swan-Ganz catheter placement. When
she still did not improve, the team prepared for an ASD repair, but
the patient was too unstable to leave the CICU. With the team’s recommendation,
the husband and other family members who telephoned
from New York agreed to withdraw care and the patient died
immediately.
After her death, medical records from her oncologist revealed
that the patient was diagnosed with Stage II breast cancer over 10
years ago and was status post chemotherapy. She was then lost to follow-up.
Recently, she was discovered to have metastatic disease and
heart failure with a cardiac shunt. Although she was prescribed cardiac
medications, the patient declined to take them. She had never informed
her husband about her cardiac condition.
Discussion: This case illustrates the importance of advance care
planning. The patient was more than 3000 miles away from her home,
became critically ill very rapidly, and had not discussed her medical
conditions or her wishes with her legal next of kin, her husband. Advance
care planning helps ensure that patients have their wishes followed
in the event they are unable to make their own decision at time
of acute illness. In a study of adults 60 years or age or older, subjects
who had living wills were more likely to want and receive limited care
or comfort care than all care possible(1). Given her history of noncompliance
with medical recommendations, there is a strong possibility
that the patient would not have wished for many of the interventions
that were administered. (1) Silverira et al. N Engl J Med. 2010
Apr 1;362(13):1211-8
D22
Not Your Ordinary Syncopal Event: A Case of Aortocaval Fistula.
M. Wirt, L. Cox-Vance. UPMC, Pittsburgh, PA.
Syncope, a common presenting symptom, challenges providers
to determine the underlying cause and any increased risk for death.
Abdominal aortic aneurysm (AAA) rupture and related complications
can be missed if not considered in the patient presenting with
syncope.
A 76 yo man with hypertension, coronary artery disease and
atrial fibrillation presented to the emergency room after a syncopal
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