A 76-year-old woman is brought to the physician by her son. He is concerned that his mother, who was previously outgoing, does not want to leave her home. She lives alone and works as a part-time volunteer at a local library. Although she continues to work shelving books, she has stopped attending her weekly meetings at a senior center where she socialized with friends. The patient also seems quieter and more difficult to engage in conversation when he calls her on the telephone. One week ago, he found her sitting on a chair pulled up close to the television. She did not notice his presence immediately but then smiled and nodded as if following the conversation. He became concerned when she asked about her grandchild's upcoming birthday party even though he had just told her the details. Her past medical history is significant for hypertension. The patient reports that her sleep and appetite are fine. She does not use tobacco, alcohol, or illicit drugs. Her medications include valsartan and hydrochlorothiazide. Which of the following is the most likely diagnosis?

Question

A 76-year-old woman is brought to the physician by her son.  He is concerned that his mother, who was previously outgoing, does not want to leave her home.  She lives alone and works as a part-time volunteer at a local library.  Although she continues to work shelving books, she has stopped attending her weekly meetings at a senior center where she socialized with friends.  The patient also seems quieter and more difficult to engage in conversation when he calls her on the telephone.  One week ago, he found her sitting on a chair pulled up close to the television.  She did not notice his presence immediately but then smiled and nodded as if following the conversation.  He became concerned when she asked about her grandchild's upcoming birthday party even though he had just told her the details.  Her past medical history is significant for hypertension.  The patient reports that her sleep and appetite are fine.  She does not use tobacco, alcohol, or illicit drugs.  Her medications include valsartan and hydrochlorothiazide.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: This patient's clinical features are most consistent with presbycusis, or age-related hearing loss, which has resulted in progressive social withdrawal. Presbycusis is a gradual, symmetrical, sensorineural hearing loss that affects more than 50% of adults by age 75 and can significantly impair quality of life. Patients typically withdraw from their social lives and may stop leaving home to avoid conversations. Their social interactions deteriorate and they often must listen to the radio or television at high volumes. Physical examination may show no abnormalities except for the hearing loss itself. Although audiometry is used to confirm the diagnosis, the whispered voice test, a simple procedure that can be performed in the office without equipment, can be used. In this test, the examiner stands behind the patient and whispers letters/numbers while occluding the non-tested ear. Repeating 3 out of 6 letters/numbers correctly is passing. Progressive social withdrawal may contribute to feelings of depression and low self-esteem. However, apart from decreased motivation to socialize, this patient does not exhibit features of major depression (ie, >5 of following 9 symptoms: depressed mood, anhedonia, sleep disturbance, appetite disturbance, psychomotor abnormalities, impaired concentration, fatigue, guilt, suicidality) (Choice C). Most patients with presbycusis benefit from the use of hearing aids, which should decrease social isolation. (Choice A) Delirium is a reversible, acute confusional state involving fluctuating levels of consciousness and inattention. It is most commonly seen in elderly patients with medical illness. (Choice B) Dementia involves an irreversible, global deterioration in cognitive abilities and functioning, which frequently includes short-term memory problems, impaired communication skills, and a decline in activities of daily living. Although this patient could be experiencing very early signs of dementia, there is insufficient information to support this diagnosis. (Choice D) Although the prevalence of presbycusis increases with age, progressive social isolation should not be attributed to normal aging. Appropriate diagnosis and treatment with a hearing aid should reverse this patient's social withdrawal and improve her quality of life. Educational objective: Hearing loss due to presbycusis is one of the most frequent causes of social withdrawal and isolation in the elderly. It must be differentiated from depression and dementia. Screening can be accomplished through simple hearing tests performed in the office. References: Hearing loss and depressive symptoms in elderly patients. (http://www.ncbi.nlm.nih.gov/pubmed/22212622)

A 76-Year-Old Woman Is Brought to the Physician by Her