The Case of Frank Mills

Frank Mills is a 94-year-old widower who has been in your practice for many years. He is a retired army colonel, businessman, and college teacher with many awards and mementos on his walls in his continuing care retirement home. He requires daily support from the aides and nursing staff. He has cerebrovascular disease (CVD), hyperlipidemia, prostate cancer, glaucoma, and recurring deep venous thrombophlebitis (DVT). His diffuse degenerative lumbar arthritis with spinal stenosis has progressed and contributed to chronic back ache, leg weakness, gait instability with several recent falls, and bladder atony requiring an indwelling bladder catheter. His CVD is diffuse, with a history of transient ischemic attacks, scattered small deep lacunar infarcts, and whitematter disease on magnetic resonance imaging. The CVD contributes to his gait slowness and instability. He receives bicalutamide (Casodex) and leuprolide (Lupron) treatments from an oncologist, and his prostate-specific antigen (PSA) has been low. He has not had a recurrence of his DVT or new transient ischemic attacks in the last couple years while on warfarin. His international normalized ratio is kept at around 2.0 and he has not suffered significant bleeds. For years his hyperlipidemia has been controlled with atorvastatin. His sight is declining significantly in spite of frequent ophthalmology consultations and adjustments of his glaucoma management. His mild chronic memory deficit has been more evident in recent months.

The nursing director notifies you that Mr. Mills is not eating as well as usual, and he has lost about 5 lbs in 60 days. The fitness center director reports that he is not the usual enthusiastic exercise participant he had previously been.