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Behavioural disturbance and visual hallucinations in a 78 year old man
  1. David W Schultza,
  2. Graham G Lennoxc,
  3. James W Ironsideb,
  4. Charles P Warlowa
  1. aDepartment of Clinical Neurosciences, bNeuropathology Laboratory, Western General Hospital, Edinburgh, UK, cDivision of Clinical Neurology, Queen’s Medical Centre, Nottingham, UK
  1. Dr David W Schultz, Department of Neurology, Flinders Medical Centre, Bedford Park, South Australia 5042.

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Case presentation

This 78 year old widower was referred for hospital admission in late September with shortness of breath. He was an ex-smoker and had a past history of chronic obstructive airways disease and ischaemic heart disease, having had a myocardial infarction 12 years earlier. He was experiencing weekly attacks of angina at rest and with exertion. His regular medications included bronchodilators, diuretics, and digoxin, and he had also recently been started on a course of prednisolone with omeprazole cover, for a presumed exacerbation of chronic obstructive airways disease.

On examination, he was apyrexial and not short of breath at rest. Although having evidence of chronic obstructive airways disease, there was no evidence of any acute respiratory compromise. He was in atrial fibrillation at a rate of 80/minute and had an aortic systolic murmur but no evidence of cardiac failure. No neurological abnormality was noted.

Shortness of breath did not seem to be a significant problem in hospital. Blood gases disclosed mild hypoxaemia and hypercapnia on air similar to previous recordings, and echocardiography confirmed moderate aortic stenosis with normal left ventricular function. However, the sheltered accomodation from which he was referred refused to accept him back. It then became apparent that the main reason for his referral to hospital was because of concern about his recent behaviour at home. He had been living in a warden controlled residence for the previous 6 months, and had recently become disruptive, especially at night.

He often became anxious and called out the warden or his general practitioner (GP) many times each week. A similar pattern of behaviour was noted during his hospital stay, often needing reassurance at night. He had seen psychiatrists intermittently during the past 5 years. When he was first seen, he was assessed as having a prolonged grief reaction after his wife’s …

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