Case discussion of a patient of Alzheimer's disease

1. Case
Discussion
20 April 2015
Dr. Ravi Soni, DM-SR II
Department of Geriatric Mental Health,
K.G.M.U. Lucknow

2. Demographics of the patient
Patient
 Mr. QA, a 65 year old married Muslim male, retired
primary school teacher, belonging to rural
background from safipur, Sandila admitted to
Department of Geriatric Mental Health in April 2015.
Reason for admission:
 Diagnostic evaluation and management

3. Informants
1. Wife Mrs Bano ali, Homemaker, illiterate
Living with the patient since marriage [45 years]
Carer since onset of illness and well wisher of patient
Patient of DM, HTN, Arthritis knee joint, depression
Not reliable and inadequate information: she lacks perceptiveness to notice subtle
behavioral changes and she is not able to give consistent account of illness in
chronological order
2. Son: Mr Assif ali, 40 years old, married, inter pass, private accountant
Patient of chronic kidney disease and had kidney transplantation before 15 years
Appears to be of sound mind, able to give coherent and consistent account of
illness in chronological order. Reliable and adequate information provided

4. Illness Characteristics
 Insidious onset
 Progressive and continuous course
 Total duration of illness – four years?
 Increased symptoms severity for last 4 months

5. Chief Complaints
As reported by wife:
 Forgetfulness
 Easy irritability and aggression
 Suspiciousness that his belongings has been
stolen
 Not sleeping at night
 Not able to take proper care of himself

6. Stress
1. Retirement in June 2012.
2. Youngest son is having some incurable kidney
disease for which he had kidney transplant

7. History of Presenting Illness
 QA was FTC of bipolar affective disorder for last more than 35
years. [exact duration not available]
 Before four years, from the year of 2011, family members started
noticing that pt was forgetting his belongings after placing them
somewhere, for which he was making thorough search and asked
family members to help in finding them.
 The frequency of this forgetfulness later on increased.
 Gradually he was also forgetting recent events and activities. He
started forgetting conversation with family member and then he
repeatedly spoke the same matter again and again.

8. Continued…
 His forgetfulness has increased to such a severity that he started blaming
family members for his lost belongings. He was suspicious that they have
been stolen by one of the family member.
 Patient has also became easily irritable over minor matters. He started
yelling over wife when he was resisted from doing something. [that was also
a part of his past bipolar illness, but the severity was reported as increased]
 In June 2012, patient retired from his job as a school teacher. After which
family members have noticed that he was remaining alone most of the
time. Interaction was decreased. Most of the time he was in bed, not taking
any interest in household activities and managing money.

9. Continued…
 Feb. 2013 patient had a stroke with right sided
hemiparesis. He was in confusion and delirium for 5 to 6
days.
 He has improved from the weakness completely within
next 4 months, but his forgetfulness was present.
 The severity of the forgetfulness was not increased
suddenly after stroke but it was progressing at slow rate
as per interview with son.
 Sleep disturbance has became major issue because he
was not sleeping properly.
 He used to sleep for 2 to 3 hours initially and then starts
collecting his belongings and placing at different
place. He started moving here and there at night,
repeatedly awakening his wife and asked to go
outside.

10. Continued…
 According to youngest son, the symptoms have increased
from January 2015. He has noticed worsening in
 Forgetfulness
 Sleep disturbance
 Aggression
 Taking personal care
 Daily activities
 Patient also has difficulty in controlling urination for last 4
months
 He was not able to go outside of house alone because he
became confused and forgot the way back to home twice
 Had developed difficulties in eating properly
 He became confused with day, time and surroundings
sometimes, although he indentifies family member properly

11. Activities of daily living
 Instrumental activities: summary of past 4 years
 Difficult to evaluate because he was a patient of bipolar illness therefore
he was always under supervision of someone.
 Even though son has given history regarding difficulty in managing in
finances after retirement.
 He was operating mobile phone independently before 3 years but now
he is not able to dial a number though he can receive a call. He has lost
5 cell phones in last 3 years
 He can not be trusted for shopping of any kind because he forgets what
to buy and loses all money whatever given to him
 He can not travel alone and needs assistance
 For last 2 years he was given medications by a family member.
Previously he was able to take drugs on his own.

12. Basic ADLs:
 According to son
1. Occasional mistakes in wearing clothes for last 3 years
before stroke. Difficulty in buttoning shirt.
2. Difficulty in controlling urination for last 6 months
3. Able to eat from a plate but eating manners have been
lost like he eats fast and spoils the floor. He tries to eat many
food items together for last 4 moths.
4. Previously he used to wash his plate after eating but for last
3 months he does not do that.
5. Now he is not punctual in his bathing time.

13. Negative history
 Perceptual disturbances
 Prominent disinhibition
 Obsessive-compulsive
symptoms
 Substance abuse
 Prominent s/o depression
 Sugar / carbohydrate
craving, Hyperphagia
 Weight gain
 History of head trauma
 Repeated falls
 Gait abnormality or difficulty
 No H/O seizure, loss of
consciousness, high grade
fever

14. Past History
Bipolar affective disorder, mania
First episode in 1980?, admitted to psychiatric nursing
home in Kanpur, given 8 ECTs, improved
On drug default relapse, more than 15 episodes
Maximum symptoms free interval without drugs is 4
months
Symptoms worsen with change of season, worsening is
reported during winter and spring
He was always on drugs, last treatment details are as
follows: Tab. Torvate 500 twice a day
Tab. Ativan 2 mg at night
Tab. Vintel-AM ABF

15. Family History
 Family of low-middle socio-economic status, joint family, consisting of 7
members including two sons and three daughters until 15 years before
after which both children got married and separated
 Currently patient and his wife live alone in sandilla
 There is cordial relation between family members and patient used to be
head of family, but any major decision would be taken by jointly with
advices of both sons [patient was not allowed to make decision on his own
after the bipolar illness started]
 They have their own 3 Pucca house one in sandilla, one in dubagga LKO,
one in unnao.
 Average family income from all sources is usually 35 k
 Patient is a pensioner and receives 18 k per month
 There is no history of psychiatric disorder in first degree relatives of patient

16. Personal History
 Early development: not known
 Adolescent sexual history: not known
 Occupational history: stable
 Social relations: Poor [after psychiatric illness]
 Substance use: no substance use
 Marital history: child marriage at the age of 14
years
 Wife came to live with him after 5 years of marriage
 Well adjusted before psychiatric illness
 No history of extramarital affair
 Repeated marital disharmony because of bipolar illness
 5 children, 2 sons and 3 daughters

17. Premorbid Personality
 Social relation: poor after illness, not having close friends,
rarely attend social gatherings
 Intellectual activities, hobbies, & interests: no specifics
 Mood: bright, cheerful, optimistic
 Character:
 Attitude toward work & responsibility: hard working
 Interpersonal relationship: confident, trusting relatioships
 Standards in moral, religious, social and health matters: not a
religious person
 Energy & initiative: most of the adult life spent in illness
 Fantasy life: not elicited
 Impression: disturbed because of the illness

18. Physical examination
Vital Signs, General Exam, CVS, RS, GI, GU and MS :
WNL
Cranial nerves were normal
Motor System:
Bulk, tone, power and reflexes were normal
bilaterally.
Plantars were flexors
Sensory System: WNL
Coordination: normal
Skull and spine: normal

19. Mental status examination
General appearance and behavior
 Well kempt, tidy, mesomorphic. Walks with slow steps, tremulousness
is seen in upper limbs
 Psychomotor activity is within normal range
 Patient retains social smile
 Eye contact is established and sustained. Rapport easily established.
 Cooperative

20. MSE continued….
 Attentive with appropriate dressing, grooming
 Facial expressions decreased in range and looked tense
 Speech and language:
 Spontaneous, relevant, coherent speech which was loud
 Tone, volume and pressure – no change in tone, volume and
prosody
 Naming, repetition, reading and writing normal
 Phonation, articulation WNL
 Some disturbance in fluency and comprehension [? Attention
problems]

21. MSE continued….
 Conscious and oriented to place and person but not to time
 Attentive, east to arouse but not sustained
 Serial subtraction 100-7: 2/5
 DF/DB: DF: 4/5, DB: 3/5
Affect and Mood:
Affect: apprehensive
Subjective: euthymic
Objective: Anxious
Range: decreased
Intensity: normal
Stability: normal
Diurnal variation: absent

22. MSE continued….
Thinking: Stream:
Reaction time: normal
Intensity: audible
Speed: retarded
Productivity: decreased
Ease of speech: spontaneous
Volume: normal
Pitch, tone and fluctuations: normal
Form: relevant, coherent, absence of any formal thought disorder
Possession of thought:
Obsession, compulsion, thought alienation absent
Content: Dominant preoccupations absent
Ideas of theft present occasionally
Overvalued ideas, delusions absent
Phobias and somatization absent

23. MSE continued….
Perception:
Sense distortion: absent
Sense deceptions: absent
Content: absent
Other psychotic phenomena: absent
Memory:
Immediate: unimpaired
Recent: impaired
Recent past: impaired
Remote: somewhat impaired
Intelligence: above average
General fund of knowledge: satisfactory
Arithmetic intelligence: satisfactory
Abstract intelligence: impaired
Judgment: Test, social and personal judgment: poor
Insight: absent

24. IN SUMMARY
Progressive cognitive decline over 4 years
ADL: [katz index and lawton’s IADL]
IADL impaired.
Basic ADL Moderate impairment
Behavior: [NPI]
Delusions, Agitation, Anxiety, Irritability, SNBD
Cognition: [MMSE, CDT]
Amnesia, Attention and Concentration difficulties,
Visuospatial impairment, Executive Dysfunction
CDR: 1 Mild impairment
GDS: Global stage 4
Hachinski Ischemic score: 4

25. Patient has drawn rat and CDT

26. Copy made by patient

27. Investigations
 Routine WNL
 CT Scan:
 MRI Brain:

28. MRI Brain
 Diffuse cerebral atrophy with ischemic demyelination
 Gliosis in left frontal region in periventricular location with
dilatation of ipsilateral frontal horn.

29. CT scan head plain
 Diffuse cerebral
atrophy

30. Diagnosis
Provisional:
Dementia of Alzheimer’s type, late onset with BPSD
D/D:
1. Mixed dementia, Alzheimer’s and Vascular
2. Vascular dementia
3. Fronto-temporal dementia

31. Treatment
Telma [40] ABF
Donep [5] 1 OD
Qutan [50] 1 HS
Meganeurone OD plus 1 OD
Calcium 1 OD
Satchet calcirol 1/wk
Amlong [10] in evening
When patient was admitted he was taking valproate
and ativan. Gradually valproate and ativan have
been withdrawn

32. Progress in Ward
Patient was not sleeping for more than 2 hours initially,
but now we have managed sleep to 4 hours at night.
As such there is no improvement in cognition and
behavior.
Urinary problems have improved after urology
reference.
Tremors in hands have increased recently.

33. THANKS FOR
YOUR
PATIENCE!

34. Language algorithm for the diagnosis of cortical dementias

35. FTD:
Frontotemporal behavioral variant: fvFTD
1. Abulia-amotivational subtype
2. Disinhibition subtype
3. Obsessive subtype
Primary Progressive Aphasia
Semantic Dementia: ftFVD
Associated MND/ALS/Parkinsonism/PSP

36. AD FTD
First Symptoms Memory loss Apathy, poor
judgment/insight,
hyperreligiosity,
speech/language
Mental State Episodic memory loss Frontal/exe language, spares
drawing
Neuropsych Initially normal Apathy, disinhibition,
hyperorality, euphoria,
depression
Neurologlical Initially normal PSP/CBD ovelap, vertical gaze
palsy, axial rigidity, dystonia,
alien hand
GTC seizure Late in disesase Not reported
Imaging Entorhinal cortex and
hippocampal atrophy
Frontal and temporal atrophy.
Post parietal lobule spared