Mr. Lucien Davenport is a 69-year-old patient who has been your continuity clinic patient in your resident clinic for the last 3 years. He is originally from New Orleans, but he and his wife relocated to Louisville where their daughter lives following loss of their home in Hurricane Katrina. You typically see him every 3 to 4 months to maintain control of his diabetes (type 2) and his hypertension, hyperlipidemia, gout, and peripheral vascular disease. In the last year, he has missed a couple of regular appointments and not shown up despite rescheduling and calling him personally. When you call him to see why he did not come to clinic, you learn that his wife of 43 years died four months ago, and he promises to come back to clinic for his next regularly scheduled visit in a couple of months.
Before that visit appointment occurs, his daughter JoAnn brings Mr. Davenport to the ER for a gout flare. She asks to speak to the social worker in the ER due to her concerns about Mr. Davenport’s safety at home. The ER social worker records the concerns in her notes and moves his appointment with you up to the following week to both follow-up on his gout flare and talk to him and his daughter about how things are going at home.
Social worker additional history regarding home function states: Daughter privately reports (in hallway where she asked to speak without client, who is her Father) finding spoiled food out at home and finding stove left on for unspecified period at least once. Daughter reports that Father will not show her the checkbook or bills or give her access to the checking account shared with her Mother prior to Mother’s death, and finding collection notices piled at doorstep with uncollected mail. Daughter reports weight loss in Father and periods of confusion about year and whether Mother is still alive. Daughter reports finding liquor bottles all over the house and Father is not showering or shaving as usual. Daughter also reports she took the car keys away out of fear that Dad would drive and hurt himself or others. Daughter also reports that Father has a collection of guns in the house and that they are loaded. When encouraged to discuss her concerns with Father in front of Social Worker, Daughter refused, saying he would get angry and leave the ER. Social Worker advised Daughter of resources available with mental inquest warrant procedure and crisis line for Adult Protective Services if she is worried about her father’s imminent danger to self or others.
Client’s willingness to share and discuss his care with the daughter is assessed, and he refuses this permission. His level of education and financial situation were assessed. He has a 9th grade education and was employed previously as a maintenance man in the public school system in Louisiana and has been retired since relocating to Louisville. He and his wife had pensions that they lived on, and hers has been discontinued since her death 4 months prior. His pension with social security amounts to $2677 per month, and he lives in a small home that he and his wife purchased with insurance money following Katrina. Daughter lives a few miles away and is the only remaining family. His wife had a $30,000 death insurance benefit that was used to pay her funeral expenses and remaining healthcare bills after she died of a sudden stroke 4 months ago. The couple attended the local Southern Baptist church at the wife’s preference until her death, and he has not attended since. He has not identified a financial or medical surrogate decision-maker, and has no advanced directive in place. He refuses to discuss the possibility of planning for these during today’s interview.
Client reports to Social Worker that he has been “down” since his wife died and that she “used to cook and do the bills” and he has not “felt like doing any of that.” When asked about weight loss, he says he is eating, but not as well as when his wife was alive because “she was a great cook.” When asked about the financial consequences of not paying bills, he gets angry and says “I’m not a child, I’ll get to it, they aren’t even that behind” and then says his daughter needs to “mind her own business” and that “she wants my money so she doesn’t have to wait to inherit it, she has all of this credit card debt and is about to get kicked out of her apartment.” When asked who he could call if he was in crisis and needed someone to talk to, he said “I guess not my daughter since she’ll just get you guys to come lock me up and then take all my money!”
Social Worker assessed client with MoCA and received a score of 16, with some questionable lack of cooperation from client due to his frustration with interview. When offered a follow-up in-home visit, client refused. Client was given the phone numbers for local spouse bereavement groups and suicide hotline. Client was cooperative with medical staff during remainder of ER visit and was transported home by Daughter.
Mr. Davenport and his daughter, JoAnn, are sitting in the clinic room waiting for you. Mr. Davenport accepts your condolences on his wife and affirms that his foot is better with the treatment of his gout flare.
You called his pharmacy ahead of time after reading the social work note and find that he has not refilled his prescriptions in 2 months. His prescribed medications are: lisinopril, propranolol, atorvastatin, amlodipine, and allopurinol. His triage blood pressure is 185/101, and although his usual appearance is dapper, he is wearing clothes that look and smell dirty, and his hair and beard are not groomed.
You ask how things are going at home, and hear from him that things are “fine” and from his daughter that she is worried that he can’t take care of himself. He gets very angry with his daughter and tells her to leave the clinic room, which she does.
You discuss carefully with him that his medications have not been refilled and that his blood pressure is uncontrolled, and he admits to “not getting around to” picking up his medicine, plus “his daughter stole his keys and is driving the car all over and won’t give them back.” He insists he takes the medication sometimes, just is not good about taking them every single day at the same time. You ask about appetite, sleep, mood, and interest in daily activities and he states that he “used to just do all that with his wife and she was in charge of making sure everything went right” and that it is overwhelming to take care of everything himself. He does admit that he has “sometimes” been more forgetful lately, but says he just thinks it’s because of missing his wife and getting older anyway. You ask about leaving the stove on and he laughs and says “Probably the game was on and I just forgot about it.”
You ask about guns in the house and if he has ever thought about killing himself. He says not really, sometimes he feels “sorry for himself when he is drunk”, but he wouldn’t go through with it because his daughter would be the one to find him and that is not fair to her.
You administer the Mini-Cog assessment, and he scores a 2 with the clock as shown below when instructed to show the time 11:10
You discuss with him the possibility of depression or a medical problem that could be making memory problems worse, and bring into the discussion the need to control his blood pressure and other problems to decrease his risk of “mini-strokes” which would make things worse. He agrees to pick up his medication on the way home and use a pill box and alarm you write a prescription for to help him remember to take the meds. He also agrees to get some blood work done to check out how his overall health is doing.
You also ask him to visit the clinic’s social worker with his daughter for more memory and mood testing and discussion before coming back to see you the following week, and ask if he would be willing to do that. He agrees on the condition that if he does all of the testing and does well, he gets his car keys back from his daughter.
Lab testing: CBC shows mild leukopenia, normocytic anemia, and thrombocytopenia. Liver panel shows an AST of 210 with an ALT of 90, an albumin of 2.8, and a bilirubin of 1.9. Electrolytes show a BUN of 7 and a creatinine of 2.1 (baseline 1.8.) B12 and folate levels are normal, TSH and free T4 are normal, and RPR is nonreactive. Urinalysis shows 2+ protein and no casts, leukocyte esterase, nitrite, WBC or RBC. After he leaves, you talk briefly to the social worker in clinic, who recommends that home health get involved to set up a pill box and monitor medication use and adherence as a possibly less invasive intervention from the patient’s point of view that still allows assessment of the home environment and safety. She also recommends additional testing of decision-making capacity, which she can address when the patient follows up with her.