Annals of Long Term Care

Introduction

Alcohol and drug dependence are two of the leading causes of disability in the world.1 However, the full extent of substance abuse in older patients is unknown.2 Despite the common occurrence and disability associated with substance use in older adults, these problems often go undiagnosed in this population.3 There is a myth fueled by age-related bias that substance use disorders occur in young and middle-aged adults but not in the elderly.4 As the number of older adults increases, the scope of mental health problems—including substance abuse—will increase.5 As elderly persons with substance abuse age and develop dementia, clinicians will be confronted with treating patients with these problems. We present a case of substance abuse in a person with dementia and discuss diagnosis and treatment in the older population.
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The Case
Mrs. R, a 78-year-old widowed female living at home with a full-time, 24-hour-a-day home health aide, presented for an evaluation at a geriatric psychiatry office. She had become increasingly more forgetful over the past two years and had been diagnosed with dementia of the Alzheimer’s type. For the past six months she was noted to appear more anxious by her family. She was sleeping erratically, was restless, and exhibited increasing psychomotor activity. She had a labile mood and would cry on and off for no reason. She was agitated at times and tried to strike her family members on one occasion. She exhibited some referential beliefs, as well as paranoid delusions regarding the home health aide stealing from her. She had no prior psychiatric history. She had a medical history significant for hypertension, which had worsened recently and required the addition of ramipril to her standing atenolol.

Both Mrs. R and her family denied any history of substance use or alcohol use in recent history, but did report that the patient was always concerned with her weight and had a remote history of using diet pills up to 20 years earlier; they denied recent use. She was seen by her private medical doctor two months earlier for the above symptoms and had a negative medical work-up. She was started on sertaline 50 mg daily six weeks earlier and quetiapine 25 mg at bedtime about two weeks earlier for her worsening symptoms. Her Mini-Mental State Examination score was 20/30 with poor short-term memory and recall.

Mrs. R presented with her son and her home health aide for the evaluation. The aide stated that during the past six months the patient would ask her to take her to a local health food store where she would buy “vitamins”; the family was not aware of this taking place. The family went to the patient’s home to examine the pills and found them to contain ephedrine. Mrs. R stated that she was taking them for weight loss. The family was instructed to remove the pills from her possession.

For the next few weeks Mrs. R’s symptoms were unchanged, with some worsening paranoia requiring an increase in her quetiapine dose. Her home health aide then found additional pills in her purse. The family thoroughly searched the house and found several stashes of well-hidden ephedrine pills that were then removed. The aide was instructed not to take the patient to any pharmacies or health food stores, and all medications were closely monitored, supervised, and administered by her family. Within one month, the patient improved greatly, was sleeping well, was no longer anxious, and had no psychotic symptoms.