Poll: Call It What It Is! Inattention and Fluctuating Cognition in a 97-Year-Old With Heart Failure

Mr. M is a 97-year-old male with multiple chronic conditions (heart failure with reduced ejection fraction [HFrEF], sick sinus syndrome [s/p dual chamber permanent pacemaker], bilateral sensorineural hearing loss, macular degeneration, type 2 diabetes mellitus, diabetic peripheral neuropathy, benign prostatic hyperplasia, h/o prostate cancer) who was referred to a skilled nursing facility (SNF) after a complicated hospital course where he was discharged with a new diagnosis of HFrEF.

Chief Complaint:
Upon arrival to the SNF, Mr. M was noted to be alert but not oriented. He had no specific complaints. He was not able to follow a conversation, disoriented with an incoherent speech. No family available at bedside for obtaining collateral information. Report from the nurses state his current condition was noted in the hospital.

Pertinent negative past medical history: No history of prior diagnosis of minor or major neurocognitive disorders, no prior traumatic brain injury, no seizure disorder.

Pertinent Geriatric Conditions:
Polypharmacy: yes
Fall: no recent falls
Genitourinary: chronic Foley catheter
Nutrition: moderate protein calorie malnutrition, swallowing precautions
Sleep: difficulty initiating and maintaining sleep
Pain: none
Mood: stable.


Cardiovascular Non-Cardiovascular
Amlodipine 5-mg daily
Carvedilol 3.125 mg twice daily
Hydralazine 50-mg three times daily
Isosorbide dinitrate 30-mg three times daily
Losartan 50-mg daily
Spironolactone 25-mg daily
Famotidine 20-mg daily
Finasteride 5-mg daily
Lidocaine topical patch daily
Lidocaine URO -Jet jelly for comfort with Foley catheter
Melatonin 5-mg at bedtime
Metformin 1000-mg daily
Multivitamin daily
Niacinamide 500-mg twice daily
Tamsulosin 0.4 mg at bedtime

Temperature: 98.1 Degrees F.
Pulse: 72 bpm
Blood pressure: 137/75 mmHg
Weight: 160 lbs. (decreased from 168 lbs. prior 1-month ago)

Physical Exam:
General: arousable but sleepy, not able to have any full conversations. 
Head, Eyes, Ears, Nose, and Throat (HEENT): oral mucosa dry; conjunctivae - pink, sclera clear
Neck: supple, no jugular vein distention (JVD)
Cardiovascular: s1s2 regular rate
Chest: clear to auscultation
Abdomen: soft, BS+
CNS: Normal upper and lower extremity strength
Extremities: no edema

Current Diet:
Frazier free water protocol - a recommendation by speech therapy
Upright eating with assistance
Food consistency: nectar-like (mildly thickened); free water was thickened

Pertinent Laboratory Data:
Hemoglobin 10.3 g/dL
Sodium 142 mEq/L
Potassium 4.7 mEq/L
Creatinine 1.23 mg/dL
Urea nitrogen 37 mg/dL
Glomerular filtration rate 54.4 mL/min
Albumin 3.1 g/dL

Transthoracic Echocardiogram:
Normal left ventricle size with markedly reduced systolic function; left ventricle ejection fraction = 29%
Mild right ventricular enlargement with moderately reduced right ventricle function
Moderate mitral regurgitation, mild aortic and tricuspid regurgitation


  1. Slooter AJC, Otte WM, Devlin JW, et al. Updated nomenclature of delirium and acute encephalopathy: statement of ten Societies. Intensive Care Med 2020;46:1020-22.
  2. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113:941-48.
  3. Marcantonio ER. Delirium in hospitalized older adults. N Engl J Med 2017;377:1456-66.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Implantable Devices, EP Basic Science, Acute Heart Failure

Keywords: Heart Failure, Sick Sinus Syndrome, Pacemaker, Artificial, Macular Degeneration, Diabetes Mellitus, Type 2, Paraneoplastic Polyneuropathy, Prostatic Hyperplasia, Polypharmacy, Neurocognitive Disorders, Mental Status and Dementia Tests, Cognition, Aged, Aged, 80 and over, Geriatrics

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