NU674 Unit 10 Revised Evaluation, Late-Onset AUD Example

The Recital Fall: A Revised Psychiatric Evaluation of Late-Onset Alcohol Use Disorder in a 66-Year-Old Retired Piano Teacher, With a Ledger of What Changed Since the Term's First Evaluation

[Student Name]

Purdue University Global

NU674: PMHNP Diagnosis and Management Across the Lifespan Clinical I

Unit 10 Revised Psychiatric Evaluation

[Instructor Name]

[Date]

The patient is composite; dates, scores and details are bracketed.

Identifying Data and Sources

Mrs. [N.], [66], widowed, retired high school music teacher who still gives a few private piano lessons, lives alone. Referred by her primary care clinician after her daughter called. Sources: the patient, her daughter by phone with consent, and primary care records including a recent emergency visit.

Chief Complaint

"My daughter thinks I have a drinking problem. I think I have a grief problem."

History of Present Illness

Her husband of [38] years died of heart failure [two] years ago. Before his death she drank "a glass of wine with dinner on weekends." In the first months after, she began having wine in the evenings "to get to sleep." Over the past year this has increased to about a bottle a day, beginning in the afternoon. She has stopped playing piano for pleasure, gives fewer lessons, and says evenings are "the worst part of the day." [Three] weeks ago, at a recital given by a former student, she fell on the steps of the hall, bruising her hip; the emergency department noted a blood alcohol level of [0.11] percent. She was embarrassed and has not left the house much since.

She reports low mood, poor sleep with early waking, reduced appetite and loss of interest, which she attributes to grief. She denies suicidal thoughts, intent or plan. She has tried to cut down twice and "managed a week" each time. She reports morning shakiness that settles after her first drink.

Screening and Scales

AUDIT: [24], in the range suggesting possible dependence. The AUDIT was developed in a WHO collaborative project to detect hazardous and harmful drinking and has been validated across settings (Saunders et al., 1993). PHQ-9: [15]. Columbia screen: negative. MoCA: [25], with points lost on delayed recall.

Collateral

Her daughter reports that her mother "was never a drinker," that the change began after her father's death, and that she found empty bottles in the recycling hidden under newspapers. She has noticed her mother repeating stories on the phone in the evenings.

Medical History

Hypertension on lisinopril. Osteopenia. No known liver disease; GGT [78] U/L and MCV [101] fL on recent tests.

Mental Status Examination

Well dressed, with a bruise on her left forearm. Cooperative, slightly defensive at first, then tearful when speaking about her husband. Speech normal. Mood "sad and tired." Affect sad, reactive. Thought process linear. No suicidal ideation. No perceptual disturbance. Mild tremor of outstretched hands at [10:00]. Oriented. Insight partial: sees grief clearly, drinking less so. Judgment fair.

Differential Diagnosis

1. Alcohol use disorder, moderate to severe, late onset. She describes drinking more than intended, unsuccessful attempts to cut down, continued use despite a fall, reduced activities, and withdrawal tremor relieved by drinking.

2. Major depressive disorder versus alcohol-induced depressive disorder. Her depressive symptoms began with bereavement and have worsened with drinking; whether they persist after a period of abstinence will help distinguish them.

3. Prolonged grief. Her yearning and avoidance two years after the death may meet criteria and will be reassessed as drinking is addressed.

4. Mild cognitive impairment versus alcohol-related cognitive effects. Recall deficits and evening repetition may reflect intoxication; cognition will be retested after abstinence.

The diagnosis she offered, grief, is part of the answer; the drinking she has been using to manage grief is now the more urgent part.

Why Late-Onset Drinking Deserves Its Own Attention

Older adults are more sensitive to alcohol because of changes in body composition and metabolism, and drinking interacts with common medications and with falls, which reviews highlight as specific risks in this age group (Blow & Barry, 2012). Late-onset problem drinking often follows a loss such as bereavement or retirement and is frequently missed because older adults are not asked (Kuerbis et al., 2014). Her fall is the kind of consequence that brings the problem to light. In her case the problem had been visible to her daughter for months, but it took an injury in public for anyone to name it, and the evaluation treats that delay as part of the history rather than a failing of the family.

Her Own Account of the Drinking

Asked to describe an ordinary day, she said she wakes at [05:00], cannot get back to sleep, and waits for the light. Mornings are manageable; she walks to the shop and sometimes practices scales. The first glass comes "around three, when the house gets too quiet," which was when her husband used to come home from his workshop. By evening she has finished most of a bottle and falls asleep in front of the television. She said the wine "makes the house feel less empty for a few hours," and then, after a pause, "and then it makes it emptier." When asked what she would want if the drinking stopped, she said she would like to play for her grandchildren at Christmas without her hands shaking. That goal was written into the plan in her words, since a reason she chose is more likely to carry her through withdrawal than one offered to her.

Plan

1. Withdrawal risk: given daily heavy drinking and morning tremor, a medically supervised withdrawal plan with her primary care clinician, with a withdrawal scale, rather than stopping abruptly at home alone.

2. Treatment for alcohol use disorder: discussion of naltrexone once liver tests are reviewed, and referral to an older adult outpatient program.

3. Grief: referral to a bereavement group and grief-focused therapy once she is stable.

4. Reassess mood and cognition after [four] weeks of abstinence.

5. Falls: home safety review, and discussion with her daughter about support during withdrawal.

Ledger: What Changed Since My First Evaluation of the Term

1. Collateral. First evaluation: none. This evaluation: daughter by phone, which supplied the hidden bottles and the evening confusion.

2. Substance screening. First: one question, "Do you drink?" This one: the full AUDIT, completed with her.

3. Mental status language. First: interpretive words such as "guarded." This one: observations, such as the tremor with its time of day.

4. Differential. First: a single diagnosis. This one: four, each with the finding that will separate it.

5. Cognition. First: not assessed. This one: a MoCA, with a plan to repeat it.

6. Plan order. First: listed by diagnosis. This one: ordered by risk.

References

Blow, F. C., & Barry, K. L. (2012). Alcohol and substance misuse in older adults. Current Psychiatry Reports, 14(4), 310-319. https://doi.org/10.1007/s11920-012-0292-9

Kuerbis, A., Sacco, P., Blazer, D. G., & Moore, A. A. (2014). Substance abuse among older adults. Clinics in Geriatric Medicine, 30(3), 629-654. https://doi.org/10.1016/j.cger.2014.04.008

Saunders, J. B., Aasland, O. G., Babor, T. F., de la Fuente, J. R., & Grant, M. (1993). Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption: II. Addiction, 88(6), 791-804. https://doi.org/10.1111/j.1360-0443.1993.tb02093.x