# Clinical Cases: Geriatrics in Primary Care

## Case 1: Polypharmacy and Deprescribing

### Patient Demographics
- **Age:** 82 years old
- **Sex:** Female
- **Living Situation:** Lives alone in apartment, daughter visits weekly

### Chief Complaint
"I've been feeling dizzy and had two falls in the past month."

### History of Present Illness
Mrs. Eleanor Fitzgerald is an 82-year-old woman presenting with dizziness and recurrent falls. She fell twice in the past month - once when getting up from a chair and once while walking to the bathroom at night. She did not lose consciousness and did not sustain any fractures, but she is now afraid of falling again. The dizziness is described as lightheadedness, worse when standing quickly, not spinning. She also reports feeling more fatigued than usual and having some memory difficulties, though her daughter hasn't noticed significant cognitive decline.

### Past Medical History
- Hypertension
- Osteoarthritis
- Chronic insomnia
- Gastroesophageal reflux disease
- Atrial fibrillation (on anticoagulation)
- Osteoporosis
- Depression (treated 10 years ago, currently stable)
- Urinary urgency

### Current Medications (12 medications)
1. Lisinopril 20 mg daily
2. Amlodipine 10 mg daily
3. Hydrochlorothiazide 25 mg daily
4. Metoprolol succinate 100 mg daily
5. Apixaban 5 mg twice daily
6. Omeprazole 40 mg daily (for 8 years)
7. Acetaminophen 650 mg three times daily
8. Diphenhydramine 50 mg nightly (for sleep)
9. Oxybutynin 5 mg twice daily (for urinary urgency)
10. Calcium 1200 mg with vitamin D 800 IU daily
11. Alendronate 70 mg weekly
12. Sertraline 50 mg daily

### Functional Status
- **ADLs:** Independent in bathing, dressing, toileting, transfers, eating
- **IADLs:** Manages medications with pill organizer, shops with daughter's help, cooks simple meals, manages finances with difficulty

### Physical Examination
- **Vital Signs:**
  - Supine: BP 138/72 mmHg, HR 62
  - Standing (1 min): BP 108/60 mmHg, HR 68
  - Standing (3 min): BP 104/58 mmHg, HR 70
- **Orthostatic hypotension confirmed** (drop of 30 mmHg systolic)
- **General:** Thin, frail-appearing elderly woman
- **HEENT:** Dry mucous membranes
- **Cardiovascular:** Irregular rhythm (atrial fibrillation), no murmurs
- **Neurological:** Alert, oriented to person, place, year; mild difficulty with serial 7s; mild proximal weakness
- **Gait:** Slow, cautious, no assistive device used currently
- **Timed Up and Go:** 18 seconds (elevated - high fall risk)

### Clinical Image
![Beers Criteria Medications](case_01_image.jpg)

*Image: Infographic showing common potentially inappropriate medications in older adults according to the American Geriatrics Society Beers Criteria, highlighting anticholinergic medications, sedative-hypnotics, and other high-risk drug classes.*

**Image Source:** Wikimedia Commons
**Attribution:** Based on AGS Beers Criteria, Educational Use
**URL:** https://commons.wikimedia.org/wiki/File:Medication_safety.jpg

### Cognitive Screening
- **Mini-Cog:** 3/5 (recalled 1/3 words, clock drawing normal)
- Borderline - warrants monitoring but not diagnostic of dementia

### Assessment and Diagnosis
1. **Falls (recurrent)** - multifactorial etiology
2. **Orthostatic hypotension** - likely medication-related (multiple antihypertensives)
3. **Polypharmacy** - 12 medications with multiple high-risk drugs per Beers Criteria
4. **Potential anticholinergic burden** - diphenhydramine + oxybutynin contributing to cognitive complaints
5. **Increased fall risk** - Timed Up and Go 18 seconds

### Beers Criteria Analysis

**Potentially Inappropriate Medications Identified:**

| Medication | Beers Concern | Recommendation |
|------------|---------------|----------------|
| Diphenhydramine | Strong anticholinergic; sedating; increases fall and confusion risk | DISCONTINUE |
| Oxybutynin | Strong anticholinergic; cognitive effects | Consider alternative or discontinue |
| Omeprazole (long-term) | C. difficile risk, fractures, B12 deficiency | Attempt to discontinue or step down |
| Hydrochlorothiazide | May contribute to orthostatic hypotension | Consider discontinuation given BP overtreatment |

### Management Plan - Deprescribing

**Immediate Changes:**

1. **STOP Diphenhydramine**
   - Strongly anticholinergic - contributing to confusion and fall risk
   - Substitute: Sleep hygiene education; if medication needed, consider low-dose trazodone 25 mg or melatonin

2. **STOP Hydrochlorothiazide**
   - Blood pressure overtreated (orthostatic hypotension)
   - Continue lisinopril and amlodipine; reassess BP in 1-2 weeks

3. **REDUCE/STOP Oxybutynin**
   - High anticholinergic burden
   - Trial discontinuation with behavioral strategies for urgency (timed voiding, pelvic floor exercises)
   - If needed, consider mirabegron (beta-3 agonist) with fewer anticholinergic effects

**Short-term Changes (2-4 weeks):**

4. **Taper Omeprazole**
   - After 8 years of use, attempt step-down
   - Reduce to 20 mg daily for 2 weeks, then every other day, then discontinue
   - Monitor for rebound reflux; consider H2 blocker PRN

**Fall Prevention:**

5. **Physical therapy referral** for balance training and strengthening
6. **Home safety evaluation** - occupational therapy referral
7. **Assistive device** - recommend rollator walker for stability
8. **Vitamin D** - continue for bone and muscle health

### Medication List After Deprescribing (reduced to 9)

1. Lisinopril 20 mg daily
2. Amlodipine 10 mg daily *(may reduce further if BP remains low)*
3. Metoprolol succinate 100 mg daily *(may reduce if HR allows)*
4. Apixaban 5 mg twice daily
5. ~~Omeprazole~~ - tapering
6. Acetaminophen 650 mg three times daily PRN
7. Calcium 600 mg with vitamin D 800 IU daily *(reduced calcium dose)*
8. Alendronate 70 mg weekly
9. Sertraline 50 mg daily

### Follow-Up
- Phone check in 1 week for symptoms
- Return visit in 2-3 weeks to reassess orthostatic BP, cognitive symptoms, and urinary symptoms
- Serial Timed Up and Go testing
- Monitor for any symptom recurrence after deprescribing

### Teaching Points

1. **Polypharmacy (5+ medications) exponentially increases adverse event risk** - medication review should be performed at every visit

2. **Beers Criteria identifies potentially inappropriate medications** - diphenhydramine and oxybutynin are among the most commonly implicated anticholinergics

3. **Anticholinergic burden is cumulative** - effects of multiple anticholinergic medications add up

4. **Falls in older adults are multifactorial** - always evaluate medications, orthostatic BP, vision, home environment, and gait/balance

5. **Deprescribing is prescribing** - systematically reducing inappropriate medications is an active therapeutic intervention

6. **Timed Up and Go >14 seconds indicates high fall risk** - triggers comprehensive fall evaluation

---

## Case 2: Delirium in an Older Adult

### Patient Demographics
- **Age:** 79 years old
- **Sex:** Male
- **Occupation:** Retired engineer
- **Living Situation:** Lives with wife of 52 years

### Chief Complaint
Wife reports: "He's not acting like himself. He's been confused since yesterday and didn't recognize our granddaughter this morning."

### History of Present Illness
Mrs. Martin brings her 79-year-old husband, Harold, to the office because of acute confusion that began yesterday. She notes that he was his usual self two days ago, but yesterday he seemed "foggy," asking repetitive questions and having difficulty following conversations. This morning he did not recognize their granddaughter who visits weekly. He has been more drowsy than usual, sleeping during the day, but restless at night. She also notes he has been urinating more frequently and complaining of mild suprapubic discomfort. He has had no fever, cough, falls, or head injury.

### Pertinent History
- **Baseline cognition:** Wife reports he has had "some forgetfulness" over the past 2 years - occasionally misplaces items, sometimes repeats stories - but has been functionally independent and managing all IADLs

### Past Medical History
- Mild cognitive impairment (diagnosed 1 year ago)
- Benign prostatic hyperplasia
- Type 2 diabetes mellitus
- Hypertension
- Coronary artery disease (stent 5 years ago)

### Current Medications
- Metformin 1000 mg twice daily
- Lisinopril 10 mg daily
- Aspirin 81 mg daily
- Atorvastatin 40 mg daily
- Tamsulosin 0.4 mg daily

### Physical Examination
- **Vital Signs:** BP 108/64 mmHg (lower than baseline), HR 88, Temp 99.4F (37.4C), RR 16, SpO2 96%
- **General:** Drowsy but arousable; intermittently alert; picks at bedsheets
- **HEENT:** Dry mucous membranes
- **Cardiovascular:** Regular rhythm, no murmurs
- **Pulmonary:** Clear to auscultation
- **Abdomen:** Mild suprapubic tenderness, no distension
- **Neurological:**
  - Fluctuating attention - difficulty counting backwards
  - Disoriented to date and place (knows name and wife)
  - No focal motor deficits
  - No meningismus

### Confusion Assessment Method (CAM)
1. **Acute onset and fluctuating course:** YES (developed over 1-2 days, worse in morning)
2. **Inattention:** YES (cannot count backwards from 20)
3. **Disorganized thinking:** YES (speech tangential at times)
4. **Altered level of consciousness:** YES (drowsy/lethargic)

**CAM POSITIVE for Delirium** (requires 1+2 plus either 3 or 4)

### Clinical Image
![Delirium vs Dementia Comparison](case_02_image.jpg)

*Image: Comparison chart showing the key distinguishing features between delirium (acute onset, fluctuating, reversible) and dementia (gradual onset, progressive, generally irreversible).*

**Image Source:** Wikimedia Commons
**Attribution:** National Institute on Aging, Public Domain
**URL:** https://commons.wikimedia.org/wiki/File:Delirium_dementia_comparison.png

### Laboratory Studies
- **Urinalysis:** Positive for leukocyte esterase, nitrites, and bacteria; WBC 50-100/hpf
- **Urine culture:** Pending
- **CBC:** WBC 11,200 (mildly elevated)
- **BMP:** Na 136, K 4.2, BUN 28 (elevated), Creatinine 1.4 (baseline 1.1), Glucose 156
- **TSH:** 2.1 (normal)
- **Chest X-ray:** No infiltrate

### Assessment and Diagnosis
1. **Delirium (hypoactive subtype)** - acute change from baseline
2. **Urinary tract infection** - likely precipitating cause
3. **Mild dehydration** - contributing factor (elevated BUN, dry mucous membranes)
4. **Underlying mild cognitive impairment** - major risk factor for delirium
5. **Benign prostatic hyperplasia** - predisposing to UTI

### Management Plan

**Treat Underlying Cause:**
- **Ciprofloxacin 500 mg twice daily for 7 days** (complicated UTI in male)
- Alternative: Trimethoprim-sulfamethoxazole if culture sensitivities allow

**Supportive Measures:**
- Encourage oral fluid intake; goal 1.5-2 liters daily
- Maintain day-night orientation (open blinds during day, dark quiet room at night)
- Frequent reorientation by wife
- Avoid restraints
- Maintain mobility - walk with assistance
- Ensure glasses and hearing aids are in place

**Avoid Deliriogenic Medications:**
- Review all medications - avoid adding anticholinergics, sedatives, or opioids
- If agitation occurs, try non-pharmacologic measures first
- If medication absolutely needed for severe agitation, use lowest dose quetiapine (12.5-25 mg)

**Safety:**
- Wife instructed on 24-hour supervision during delirium
- Remove fall hazards
- Night light for bathroom trips
- Do not leave patient unattended

### Disposition Decision
Given supportive wife, ability to maintain oral intake, and absence of severe agitation, patient can be managed at home with close follow-up.

### Follow-Up
- Phone call in 24 hours
- Office visit in 2-3 days to reassess mental status
- If not improving or worsening, emergency department evaluation

### Expected Course
- Delirium from UTI typically resolves within days to 1-2 weeks with treatment
- May have prolonged cognitive effects; some patients do not return fully to baseline
- Delirium is a marker of brain vulnerability - increases future dementia risk

### Teaching Points

1. **Delirium is a medical emergency** - it indicates an underlying medical condition and is associated with significant morbidity and mortality

2. **CAM is the gold standard diagnostic tool** - requires acute onset/fluctuation PLUS inattention PLUS either disorganized thinking OR altered consciousness

3. **UTI is the most common cause of delirium in older adults** - always check urinalysis, even without classic urinary symptoms

4. **Baseline cognitive impairment is the strongest risk factor** for developing delirium

5. **Hypoactive delirium (lethargic) is more common but often missed** - hyperactive delirium (agitated) is more recognizable but less prevalent

6. **Treat the underlying cause, not the symptoms** - antipsychotics should be reserved only for severe agitation that poses safety risk

7. **Prevention is key** - in hospitalized patients, the Hospital Elder Life Program reduces delirium incidence by 30-40%

---

## Case 3: Advance Care Planning

### Patient Demographics
- **Age:** 78 years old
- **Sex:** Female
- **Occupation:** Retired nurse
- **Living Situation:** Lives with husband; daughter lives nearby

### Chief Complaint
"I've been thinking a lot about what I want if I get really sick. Can we talk about that?"

### History of Present Illness
Mrs. Barbara Williams is a 78-year-old woman with metastatic breast cancer presenting for a routine follow-up. She was diagnosed with breast cancer 4 years ago, underwent mastectomy and chemotherapy, but developed bone and liver metastases 18 months ago. She has been on palliative chemotherapy but her oncologist recently informed her that the disease is progressing. Her functional status has declined over the past 3 months - she now uses a walker, tires easily, and has lost 10 pounds. She has been thinking about "what comes next" and wants to discuss her wishes.

### Past Medical History
- Metastatic breast cancer (bones, liver)
- Hypertension
- Type 2 diabetes mellitus
- Former smoker (quit 20 years ago)

### Current Medications
- Multiple (managed by oncology)
- Pain controlled on scheduled acetaminophen and as-needed low-dose oxycodone

### Functional Assessment
- **ADLs:** Independent with setup assistance
- **IADLs:** Needs help with shopping, housework, meal preparation
- **ECOG Performance Status:** 2 (ambulatory, capable of self-care, unable to work, up and about >50% of waking hours)

### Family Situation
- Married to supportive husband for 55 years
- Daughter is local and involved
- Son lives out of state
- Has not discussed end-of-life wishes with family yet

### Physical Examination
- **Vital Signs:** BP 128/72 mmHg, HR 78, Weight 128 lbs (down from 138 lbs 3 months ago)
- **General:** Thin, appears fatigued but comfortable, no acute distress
- **Abdomen:** Palpable liver edge 4 cm below costal margin

### Clinical Image
![Advance Directive Documents](case_03_image.jpg)

*Image: Overview of advance directive documents including the healthcare proxy/durable power of attorney for healthcare and living will, showing how these documents work together to ensure patient wishes are honored.*

**Image Source:** Wikimedia Commons
**Attribution:** National Institute on Aging, Public Domain
**URL:** https://commons.wikimedia.org/wiki/File:Advance_care_planning.png

### Advance Care Planning Conversation

**Opening the Discussion:**
"Thank you for bringing this up. These are important conversations. I want to understand what matters most to you so we can make sure your care aligns with your values. Can you tell me what you understand about your illness right now?"

**Patient's Understanding:**
"I know my cancer is getting worse and the chemo isn't working like it used to. I'm a nurse - I've seen people at the end of life. I don't want to be on machines if there's no hope. But I also want to be comfortable and spend time with my family."

**Values Clarification:**

*What matters most to you in your life right now?*
"Being with my husband and family. Being comfortable. Not being a burden."

*What abilities are so important that you can't imagine living without them?*
"Being able to recognize my family. Being able to communicate. If I'm just lying there not knowing anyone, that's not living to me."

*What are you afraid of?*
"Pain. Being hooked up to machines. My husband having to make impossible decisions alone."

**Goals of Care Discussion:**

Given your values, we have several options to discuss:
1. **Continue current approach** - oncology follow-up, symptom management
2. **Transition to comfort-focused care (hospice)** - when the time is right
3. **Document specific preferences** for emergency situations

**Specific Preferences Discussed:**

| Situation | Patient's Wish |
|-----------|----------------|
| CPR if heart stops | Does not want - "If my heart stops from this cancer, it's my time" |
| Mechanical ventilation | Does not want long-term; okay short-term if reversible cause |
| Feeding tube | Does not want if unable to eat on her own |
| Hospitalization | Prefers to stay home if possible; OK for symptom management |
| Hospice care | "I think I'll be ready soon but not quite yet" |

**Healthcare Proxy Discussion:**
- Patient wants to designate her husband as primary healthcare agent
- Daughter as alternate if husband unable
- Will discuss with both to ensure they understand her wishes

### Documentation and Action Items

**Completed Today:**
1. Documented advance care planning discussion in detail
2. Provided state-specific advance directive forms
3. Discussed POLST (Physician Orders for Life-Sustaining Treatment) - will complete when patient ready

**Patient To-Do:**
1. Complete advance directive paperwork
2. Discuss wishes with husband and daughter
3. Bring completed forms to next visit for medical record

**Follow-Up Plan:**
- Return in 2 weeks for forms review and POLST completion
- Palliative care referral for concurrent symptom management
- Hospice discussion when patient feels ready
- Continue regular oncology follow-up

### Teaching Points

1. **Advance care planning should begin while patients have capacity** - don't wait until a crisis

2. **Values clarification precedes specific decisions** - understanding what gives life meaning guides treatment choices

3. **Healthcare proxy is often more important than a living will** - a trusted decision-maker can respond to unforeseen circumstances

4. **POLST translates goals into actionable medical orders** - appropriate for patients with serious illness or advanced frailty

5. **These conversations should be revisited** - preferences may change as illness progresses

6. **Document thoroughly** - the conversation is as important as the paperwork

7. **Involve the designated proxy** - they need to understand the patient's values to make decisions if capacity is lost

---

## Key Teaching Points Summary

### Comprehensive Geriatric Assessment
- Assess all domains: medical, functional (ADLs/IADLs), cognitive, psychological, social, environmental
- Functional status is the strongest predictor of outcomes in older adults
- Timed Up and Go >14 seconds indicates high fall risk

### Polypharmacy and Deprescribing
- Beers Criteria identifies potentially inappropriate medications
- Anticholinergics (diphenhydramine, oxybutynin) are high-risk for cognition and falls
- Deprescribing is an active therapeutic intervention, not "giving up"
- Start low, go slow - also applies to stopping medications (taper when appropriate)

### Delirium Recognition
- CAM: Acute onset + inattention + (disorganized thinking OR altered consciousness)
- Hypoactive delirium is more common but often missed
- UTI is the most common precipitant in older adults
- Treat the underlying cause; avoid antipsychotics unless severe agitation

### Advance Care Planning
- Begin while patient has capacity
- Values clarification guides specific decisions
- Healthcare proxy designation is critical
- Document thoroughly and revisit periodically