My Father Went Down the Rabbit Hole

Abstract

After treatment, this elderly gentleman with apparent depression rapidly became cognitively impaired and began hallucinating, eventually ending up in the psychiatric ward. This case provides insight into the complexities that may arise in the clinical evaluation and pharmacologic management of often-evolving cognitive, behavioral, and sleep-related changes in elderly individuals. This case additionally emphasizes the importance of sleep in emotional and mental stability, as well as the importance of physicians being well versed in the adverse effects of prescribed and over-the-counter medications. Mirtazapine can induce restless legs syndrome and periodic limb movements in sleep, conditions that can fragment sleep and interfere with cognition. Use of pramipexole has been shown to cause compulsive and impulsive behaviors in patients with restless legs syndrome, Parkinson disease, and multiple system atrophy. Donepezil can cause hallucinations in patients, which can be difficult to distinguish from hallucinations caused by dementia or Charles Bonnet syndrome; in these cases, establishing a timeline is integral in discovering the etiology.