Introduction: This case involves a 91-year-old female, long-term care patient with advanced mixed dementia, multiple chronic conditions, and behavioral symptoms. Presented with an increase in behavioral symptoms, including screaming, yelling, agitation, pain, and distress, created significant challenges in assessment, diagnosis, and management in long-term care. Eventually, the patient was diagnosed with an acute ischemic event leading to a gangrenous toe. The acute ischemia in the presence of dementia complicated her presentation, as her pain-related behaviors were at risk of being misinterpreted and delayed in diagnosis, underscoring the need for a careful approach.
Case Description : A 91-year-old patient with advanced mixed dementia (FAST scale 7c), depression, uncontrolled type 2 diabetes with retinopathy, hyperlipidemia, hypertension, glaucoma, and osteopenia, had been admitted to skilled nursing for rehabilitation after a right tibial shaft fracture and remained in long-term care. After approximately eight months of stability, she developed worsening behavioral symptoms. Three weeks before hospitalization, clinicians frequently evaluated her due to escalating behaviors and reported leg pain. Initial workup ruled out acute injury, and symptoms were attributed to dementia until discoloration and necrosis appeared on her right second toe. Vascular studies revealed a right popliteal artery occlusion with an ABI of 0.36. In Emergency Department seen in consultation with Vascular Surgery. It was determined that, given her extensive comorbidities and frailty, revascularization was unlikely to improve her quality of life or extend her survival. The patient was placed on hospice care upon her return to the nursing facility, where she received improved pain management and comfort measures. She passed away peacefully two weeks after her hospitalization.
Discussion: Peripheral arterial disease (PAD), primarily resulting from atherosclerosis, affects 3–10% of adults in Western countries, with prevalence rising to 15–20% among the elderly. Chronic limb-threatening ischemia (CLTI) is a clinical syndrome defined by the presence of PAD in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Acute ischemic occurs more frequently in the elderly with risk factors like cardiovascular disease, peripheral artery disease (PAD), and diabetes, which is very common among nursing home residents. Studies suggest that among elderly patients with PAD, rates of acute ischemia events, including limb-threatening ischemia, increase significantly, although precise rates for nursing home residents are less documented. This case highlights the complexities of managing acute ischemia alongside behavioral disturbances in a dementia patient with multiple comorbidities.
