Table 1

Investigations and patient timeline

Time point/eventNovember 2016, initial assessmentDecember 2016Early February 2017, reassessmeFebruary 2017August 2017, reassessment
Review of systemsPatient reports constant hunger, feelings of isolation and dizziness on standing. Negative for pain, depression, Cardiovascular symptoms or dyspnoeaPatient still reports constant hunger, and feelings of isolation increased. Negative for dizziness, pain, depression, CVD Sx or dyspnoeaPatient reports hunger, increased isolation. Negative for pain, troubling hallucinations, depression, CVD Sx or dyspnoea.
Clinical course and physical examinationWeight loss >5 kg in 12 months and reduced muscle bulk diffusely. Kyphotic posture c/w Hx of hip fracture (2012). Ecchymosis widespread, acute ankle sprain. Cerebellar ataxia w. standing and walking c/w Hx excessive alcohol use.Sepsis and seizure following fall. Further weight loss of 6.5 kg in 2 months, diffuse wasting. Ecchymosis still present. Decreased alertness c/w delirium, gait stability and strength/function.Further weight loss of 11 kg in 5 months and severe, diffuse wasting. Healed rib fracture secondary to fall, immobilised with restraints. Decreased alertness. Ecchymosis still present. Unable to stand. Tardive dyskinesia, trunk dystonia to the right side, increased limb rigidity. Fetal posture in the supine position with hamstring contractures.
MMSE
SPPB
MNA-SF
Weight/BMI
Orthostatic BP and HR
Lying (0 min)
Standing (1 min)
Standing (3 min)
BIA SMI
Grip strength
(85 year+percentile.26)
21/30
5/12
10/14 (at-risk)
74.5 kg/23 kgm−2
Symptomatic—dizziness
120/50 mm Hg, 50 bpm
110/50 mm Hg, 62 bpm
108/48 mm Hg, 70 bpm
8.43 kgm−2
L—25 kg (45th percentile)
R—26 kg (40th percentile)
17/30
4/12
4/14 (Malnourished)
68 kg/21 kg/m2
not symptomatic
118/50 mm Hg, 56 bpm
126/60 mm Hg, 70 bpm
128/460 mm Hg, 68 bpm
7.8 kgm−2
L—20 kg (25th percentile)
R—17 kg (10th percentile)
13/30
0/12
0/14 (malnourished)
57 kg / 17.7 kg/m2
Unable to perform due to immobility


N/A
L—17 kg (15th percentile)
R—17 kg (10th percentile
PathologyTC: 4.7 mmol/L, LDL: 2.5 mmol/L, Vit. D: 58 nmol/LNo pathology results available for review by the research teamNo pathology results available for review by the research team
Recommendations to facility doctorReview need for aspirin, perindopril, atorvastatin, and mirtazapine.
Recommend vitamin D—1000 IU/day.
Flagged as high falls risk, malnourished and sarcopenic
Increase energy intake by an addition of high protein supplements and larger meal portions.
Review needs for aspirin
Discussed in the Intervention section
Implemented recommendationsRemoval of perindopril and atorvastatin. Vitamin D was not added, aspirin and mirtazapine not removedFood portions not increased, high energy supplements prescribed (1080 kJ/day)
  • Measured in kg/m2, <9.5 kg/m2 is considered Sarcopenic.27

  • December 2016, adverse event: patient sustained minor elbow wound from injurious fall in facility. Infected wound led to sepsis, resulting in seizure and hospitalisation. Sodium valproate added to prescription. Patient restrained and catheterised and subsequently developed UTI and delirium.

  • February 2017, adverse event: patient experienced injurious fall within facility resulting in several fractured ribs and required hospitalisation. Physical restraints implemented in the reclining chair. Following medications added to prescription over 5-month period; risperidone, buprenorphine (patch), oxycodone, paracetamol. Supra-pubic catheter placed. Several UTIs reported. Completely immobile and highly sedated.

  • BIA SMI, bioelectrical impedance skeletal muscle index; BMI, body mass index; BP, blood pressure; HR, heart rate; LDL, low density lipoprotein; MMSE, mini-mental state exam; MNA-SF, Mini-nutritional Assessment Short Form; SPPB, short physical performance battery; Sx, symptoms; TC, total cholesterol; UTI, urinary tract infection.