Psychiatry Case Challenge: A 60-Year-Old Woman With Sleep Problems and Odd Behavior

Donald M. Hilty, MD, MBA; Jose Feliberti, MD


May 15, 2023


The telepsychiatrist considered medical issues, including medication problems (eg, pain medication), delirium, hypothyroidism, and other conditions. The telepsychiatrist also considered psychiatric conditions and substance abuse.

The patient's mood, level of stress, and support seemed within reason. Medically, she appeared stable. In addition, the complaints were consistent but short-term (ie, 3 months rather than 1-2 years).

Alcohol use became a concern upon hearing the history from the daughter, as well as review with the patient, found the following compared with diagnostic criteria[1]:

  • The patient was not always able to limit the amount of alcohol she consumed.

  • The patient wanted to reduce her drinking.

  • The patient felt a strong urge to drink alcohol.

  • The patient was failing to fulfill certain obligations and was very self-critical.

  • The patient was reducing social and work activities and hobbies.

  • The patient's progressive isolation

  • The patient was developing a tolerance to alcohol.

  • The family history of alcoholism

Substance use disorders (SUDs) are prevalent in medical and psychiatric populations and can lead to disastrous clinical outcomes; divorce; employment termination; recidivism; and burnout for patients, families, and providers in all settings.[2,3] An estimated 20.8 million people in the United States live with an SUD, which is similar to the number of individuals who have diabetes and more than the number of people who have all cancers combined.[4] SUD in the elderly is common but not diagnosed.

Patients with psychiatric disorders also have a high prevalence of comorbid SUDs. The comorbidity prevalence of any lifetime SUD and lifetime mental illness is roughly 50%, according to the National Comorbidity Survey.[5] Furthermore, the prevalence of individuals with co-occurring disorders is dramatically elevated, from a baseline of 3%-4% of those living in the community to 40%-60% in mental health treatment settings and 50%-60% in substance abuse treatment settings. SUD can result in dementia; this patient is starting to show signs of it with memory problems.

Disastrous medical and psychiatric outcomes are related to SUDs and comorbidities.[6] Comorbidities of SUDs include the following:

  • Unintentional injuries

  • Exacerbation of medical conditions (eg, diabetes, hypertension, cardiovascular disease, poor sleep)

  • Exacerbation of neuropsychiatric conditions (eg, depression, anxiety)

  • Exposure to infectious diseases (eg, HIV, hepatitis C)

  • Reduced and altered effectiveness of medications

  • Increased risk for suicide and homicide

The gradual progression of cortical thinning that occurs with aging is accentuated by alcohol consumption. White-matter hyperintensities, also referred to as "leukoaraiosis," are often found on CT or MRI in older patients (Figure 2).

Figure 2.

The prevailing view is that these intensities are a marker of small-vessel vascular disease. In clinical practice, these are indicative of cognitive and emotional dysfunction, particularly in the aging population, such as the patient in this case. These are often associated with demyelination and axonal loss, reduced glial density and atrophy, cortical thinning/atrophy, ischemic damage, and hypoxia/hypoperfusion.


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