Case Report: 93-Year-Old Man Misdiagnosed with Memory Impairment

A 93-year-old man presented to Cleveland Clinic from out of state with memory impairment and depression. When Cleveland Clinic geriatrician Ardeshir Hashmi, MD, met with the patient and his family, they explained that following a hospitalization for heart problems two years prior, the husband and father’s health had declined rapidly.

“The patient’s wife and two daughters described how, throughout the past two years, the 93-year-old had experienced profound weakness, fatigue and confusion,” says Dr. Hashmi, Cleveland Clinic Endowed Chair for Geriatric Innovation and Director, Center for Geriatric Medicine. “He had become completely dependent on his family for his basic needs.”

At previous doctor visits with primary care providers in his home state, the patient was told the cause of his decline was dementia. Moreover, the family was told the patient’s deterioration was just in his head. Preparations were even in process to move the 93-year-old into a nursing home.

At Cleveland Clinic’s Center for Geriatric Medicine, providers empower older patients to stay healthy and thriving through the years. Because of this mission, Dr. Hashmi had immediate doubts about a dementia diagnosis.

“At 93 years old, he was very sharp. He could manage his own finances and medications. He could clearly and quickly tell me all of his dosages,” Dr. Hashmi explains. Searching for the reason for his rapid decline, Dr. Hashmi began to analyze the patient’s prescriptions.

Medication analysis leads to discovery

Dr. Hashmi learned the 93-year-old was taking four different medications which could potentially be linked to his fatigue and confusion. One, which was prescribed for anxiety, was intended for allergy relief and magnified his fatigue. All four were slowing down his thinking and affecting his balance. And because of his age, his kidneys weren’t able to fully excrete the medications.

“Medications may stay in an older patient’s system for an extensive amount of time,” Dr. Hashmi says. “If the dosages don’t decrease or if patients don’t stop taking medications, they can potentially cause harm.”

Dr. Hashmi worked with the geriatric pharmacist at the Center who discovered the 93-year-old was taking four times the prescribed dosage of one medication.

“Multiple clinicians and pharmacists at home had been adding medications and increasing dosages without discontinuing or decreasing the previous prescription. This was contributing to the problem rather than solving it,” Dr. Hashmi says. “Combining three different antidepressants of the same medication family that interact with each other can — and in this case did — cause negative effects regarding balance and memory.”

Decreasing multiple medications lifts fog, restores memory

Dr. Hashmi worked with the patient and his family to create a treatment plan that included decreasing medications. One medication at a time and under the supervision of his family, the patient began to halve one dose every two weeks.

“The family began to see a change right away,” Dr. Hashmi reports. “The fog lifted. The husband and father became much more engaged. His balance improved. From being completely bedridden, he was now able to go to the bathroom independently.”

Multidisciplinary care, dynamic team

Dr. Hashmi credits the multidisciplinary team at Cleveland Clinic, especially the geriatric pharmacists.

“We work with a very dynamic team at Cleveland Clinic. Care is tailored for each patient,” Dr. Hashmi says. He mentions that visits within the Successful Aging Program at the Center for Geriatric Medicine, unlike many appointments with a primary care physician, allow the luxury of time. “An entire team of individuals with different areas of expertise and knowledge spend an hour talking with a patient and his or her family.”

In this case, Dr. Hashmi also noted that superimposed amnesia and hospital-induced delirium played a large role following the 93-year-old’s hospital stay two years prior. The condition often goes unnoticed and can start rapidly — within a few hours or days after hospitalization.

“It can take a person up to a year to return to normal after experiencing hospital-induced delirium,” says Dr. Hashmi. “And adding multiple medications too quickly only compounds the problem.”

He adds that, in this case, COVID pandemic social restrictions have played a large role in the patient’s wellness.

“For lots of aging patients, depression and anxiety have increased during the pandemic. This has a direct negative impact on memory. Many can’t see their family or friends. And for most of them, socialization is one of the highlights in their lives,” Dr. Hashmi notes. “I actively talk with my patients about navigating technology and virtually checking in with family members, friends and grandchildren. Connecting virtually, though not face-to-face, still delivers joy and connection.”