Case Scenario

A 75-year-old woman had been living in a nursing home for several years. She had moderate dementia and took citalopram for severe anxiety. She often shouted that she was dying, prompting her physicians to add quetiapine to her treatment regimen to modify her disruptive behavior. One day, she woke up quieter than usual and said her head felt like it was exploding. Her nurse was concerned and contacted her physician. When the physician visited her later that day, she told him, “I feel dizzy, my head is exploding, and I'm going to die.” The physician told her to “calm down” and asked the nurse to administer a dose of lorazepam and the quetiapine earlier than scheduled. When the nurse visited the patient a few hours later, the patient was calm but obtunded. The patient was transported by ambulance to the hospital. Non-contrast head computed tomography found a large cerebral hemorrhage. The patient died a few hours later.

Clinical Commentary

According to the Joint Commission, diagnostic overshadowing is “the attribution of symptoms to an existing diagnosis rather than a potential co-morbid condition.”¹ Overshadowing, most common in patients with mental disabilities, originates from physicians' cognitive biases and leads to assumptions about a patient that preclude an appropriate diagnostic approach and treatment plan. People with psychiatric disabilities are more likely to have underlying medical conditions, including a far higher incidence of cerebrovascular and cardiovascular disease, arthritis, and diabetes mellitus. Physicians who focus on psychiatric issues may become myopic and not appreciate the underlying causes of new symptoms in these patients.¹