An Older Woman With Progressive Confusion, Hallucinations, and Myoclonic Jerking

A Case Series in Geriatrics

Mark E. Williams, MD


May 12, 2011

In This Article

The Case

A 72-year-old woman with a complex medical and psychiatric history presents in your office with a 1-month history of irritability, slowing of movements, poor concentration, and tremor. Confusion and hallucinations have been increasing for 2 weeks.

Her symptoms began about 5 weeks ago with generalized dizziness, increased irritability, decreased concentration, and slowness of motion. Approximately 2 weeks ago her husband noticed a fine tremor of her hands, visual hallucinations, and increased confusion and forgetfulness. Yesterday she developed difficulty walking and standing and started to jerk her upper and lower extremities.

Her medical history is notable for hypertension, gastroesophageal reflux, collagenous colitis, irritable bowel syndrome, prior thyroidectomy for hyperthyroidism with subsequent hypothyroidism and hypoparathyroidism, bipolar disorder II, depression, and anxiety.

She is currently taking the following medications:

  • Amlodipine 10 mg daily

  • Bismuth subsalicylate as needed

  • Calcitriol 25 mcg every other day

  • Calcium citrate 1000 mg twice daily,

  • Duloxetine 60 mg twice daily

  • Escitalopram 20 mg daily

  • Esomeprazole 40 mg daily

  • Iamotrigine 25 mg every morning and 100 mg at bedtime

  • Magnesium oxide 400 mg twice daily

  • Mesalamine 800 mg 3 times a day

  • Metoprolol-XL 50 mg daily

  • Quetiapine 50-100 mg at bedtime

  • Simethicone 1 tablet 3-4 times daily

  • Tramadol 50 mg every 8 hours

Her family history is only remarkable for breast cancer in her mother.

On physical exam, the patient is noted to be a well-nourished, hyperactive woman with fluctuations in her level of consciousness. Vital signs are normal. There are no skin lesions or evidence of trauma. The gaze is conjugate and the extraocular movements are full with no nystagmus. Pupillary reflexes are normal. Fundoscopic examination shows flat optic discs and good venous pulsations. The oral cavity shows moist mucous membranes and a normal tongue with a dark coloration; the uvula elevates in the midline. Her neck is supple with a well-healed thyroidectomy scar. There is no neck tenderness and no lymphadenopathy. The lungs are clear to percussion and auscultation bilaterally. Cardiac examination was normal. The abdomen showed mild tenderness in the right lower quadrant without guarding. Bowel sounds were present. Black stool was noted on rectal exam but was negative for occult blood. Neurologically, the patient is not orientated to time, person, or place. Comprehension and attention are poor. The patient responds in single-word answers with a normal voice volume and no dysarthria. On motor exam, patient has 4/5 muscle strength throughout with normal muscle bulk, increased tone with rigidity throughout, and frequent myoclonic jerks. Intention tremor was noted throughout exam. Hyperreflexia was noted symmetrically in both the upper and lower limbs. The plantar responses were extensor.

You admit the patient to the hospital. Basic laboratory studies, including thyroid function tests, are normal, and brain imaging shows no masses or acute processes. An EEG demonstrates moderate encephalopathy but is without seizures or spikes.