A 72-year-old man comes to the office accompanied by his daughter. She relates that he is not doing well and frequently does not answer his phone until noon. There was little food in the refrigerator when she visited recently. The patient appears to care less about his grooming and appearance lately and does not seem to be eating well. His wife died 2 years ago. After a period of mild depression immediately following her death, he felt better and has continued to live independently.
The patient says that he is doing fine. He admits to insomnia (frequent awakenings in the middle of the night) and not eating well. He spends his days playing cards with friends and watching televised sports and news programs. He has been to the emergency department twice in the last 8 months, once to be checked after a minor motor vehicle accident and once after suffering a shoulder injury in a fall. The patient appears to be his stated age on general examination. Blood pressure is 148/90 mm Hg and pulse is 84/min. BMI is 18 kg/m². His general examination is unremarkable. The patient scores 27/30 on the Mini-Mental State Examination. He has no suicidal ideation. There are no focal neurologic findings.
Laboratory results are as follows:
Which of the following is the most likely primary cause of the patient's decline?

Question

A 72-year-old man comes to the office accompanied by his daughter. She relates that he is not doing well and frequently does not answer his phone until noon. There was little food in the refrigerator when she visited recently. The patient appears to care less about his grooming and appearance lately and does not seem to be eating well. His wife died 2 years ago. After a period of mild depression immediately following her death, he felt better and has continued to live independently.
The patient says that he is doing fine. He admits to insomnia (frequent awakenings in the middle of the night) and not eating well. He spends his days playing cards with friends and watching televised sports and news programs. He has been to the emergency department twice in the last 8 months, once to be checked after a minor motor vehicle accident and once after suffering a shoulder injury in a fall. The patient appears to be his stated age on general examination. Blood pressure is 148/90 mm Hg and pulse is 84/min. BMI is 18 kg/m². His general examination is unremarkable. The patient scores 27/30 on the Mini-Mental State Examination. He has no suicidal ideation. There are no focal neurologic findings.
Laboratory results are as follows:

Which of the following is the most likely primary cause of the patient's decline?

Quizplus · Accepted Answer

This patient's history of recent accidents, in combination with an elevated mean corpuscular volume and a disproportionately increased aspartate aminotransferase, suggests an alcohol use disorder. Middle-of-the-night insomnia, decreased concern about appearance (poor self-care), and poor oral intake are common findings. Further evaluation of this patient should include questions about frequency, amounts, and complications of alcohol use. Although depression is also a concern, the patient's social engagement, interest in television programs, and lack of suicidal ideation make major depression less likely (Choice B). In patients in whom significant depression is present, both problems should be addressed concurrently. Approximately 30% of alcoholism encountered in individuals age >65 is late-onset in nature. Alcoholism in the aging population remains undiagnosed in >50% of cases. History of substance use, bereavement, depression, anxiety, disability, and pain are risk factors. Alcoholism may be difficult to recognize as signs and symptoms frequently mimic common pathologies seen in the elderly, and underlying comorbid conditions may distract the clinician from considering alcoholism as a diagnosis. (Choice A) Cognitive impairment can be associated with alcoholism and depression, but this patient's Mini-Mental State Examination score of 27/30 and his normal neurologic examination make this less likely. A score <24 is suggestive of dementia or delirium. (Choice C) The lack of systemic symptoms and a normal physical examination make the diagnosis of occult malignancy unlikely. (Choice D) Although this patient has a low BMI, he has no evidence of muscle wasting (eg, bitemporal wasting, atrophy in extremities) and has a relatively normal albumin, making nutritional deficiencies less likely. This patient's poor eating is likely secondary to his alcohol abuse. Educational objective: Alcoholism is often unrecognized in the elderly and is frequently accompanied by changes in sleep, poor oral intake, and decreased attention to self-care. Unexplained accidents, elevated mean corpuscular volume, and elevated liver function studies should prompt consideration of alcohol use disorder. __________ References: Alcohol use disorders in the elderly: a brief overview from epidemiology to treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/22575256) Patterns of alcohol and drug use among depressed older adults seeking outpatient psychiatric services. (http://www.ncbi.nlm.nih.gov/pubmed/21788921) Epidemiology of alcohol and drug use in the elderly. (http://www.ncbi.nlm.nih.gov/pubmed/23689545)

A 72-Year-Old Man Comes to the Office Accompanied by His