A 50-year-old male was brought by his wife with complaints of forgetfulness, difficulty communicating, and needing assistance with daily activities over the past 5 years. His symptoms had been progressively worsening. On examination, he had low MMSE scores, impaired speech and language skills, and decreased responsiveness. Brain MRI showed cerebral and cerebellar atrophy and white matter changes. He was diagnosed with probable major neurocognitive disorder due to Alzheimer's disease with superimposed delirium. He was started on cholinesterase inhibitors and memantine for his dementia along with antipsychotics to address behavioral issues.

1. CASE PRESENTATION
Presenter : Dr. Vidit Singh
Senior Resident
Department of Psychiatry
Manipal Tata Medical College
Jamshedpur

2. Sociodemographic Data
A 50-year-old male, Hindu by religion, resident of Jamshedpur, used to
work as a Foreman, belonging to middle socio-economic stratum, was
brought to the hospital by his wife who has been living with him for
the past 27 years.
The information given by the informant is continuous, consistent,
adequate, verifiable and hence reliable.

3. Presenting Complaints:
According to patient
when asked about his
complaints he didn’t reply
According to informant
Forgetfulness - for 5 years, increased since the last 2 years
• Difficulty in communication - for 2 years
• Needs assistance in doing daily activities - for 1 year
• Irritability
• Suspicious behaviour
• Talking irrelevantly
-since last 6 months

4. History Of Presenting Illness:
• Onset – Insidious
• Progress – Deteriorating
• Course – Continuous
• Symptoms started 5 years ago
Forgetfulness
Difficulty in communication.
Needs assistance in doing daily activities.
Irritability.
Suspicious behaviour.
Talking irrelevantly.

5. Negative History
• No h/o head injury with loss of consciousness and/or vomiting
• No h/o seizures
• No h/o fever with altered sensorium or dog bite
• No h/o recurrent episodes of giddiness, loss of consciousness, or slurred
speech.
• No h/o sudden onset of weakness of limbs, deviation of mouth, blurring of
vision.
• No h/o constipation, cold or heat intolerance.
• No h/o reversal of sleep wake cycle.

6. • No h/o any gait disturbance, urinary incontinence.
• No h/o difficulty swallowing & emotional lability.
• No h/o disinhibition, stereotypical, antisocial behaviour, lack of impulse
control.
• No h/o overfamiliarity, talking high of self, excessive speech.
• No h/o of pervasive low mood, reduced energy levels or decreased
interest in activities.
• No h/o suicidal ideation or attempts.
• No h/o frequent checking, washing behaviour, fear of contamination or
repeated thoughts which are out of his control.
• No h/o pending legal issues.

7. Treatment History
September 2022 -
December 2022
January 2023 – March
2023
April 2023 – June 2023
DRUGS Rivastigmine 3mg
Donepezil 5mg
Memantine 5mg
Vitamin B complex
Donepezil 5mg
Memantine 5mg
Atorvastatin 10mg
Clopidogrel 75mg
Donepezil 10 mg
Memantine 5 mg
Citicoline 500mg
Ginkgo Biloba 60mg
Piracetam 800mg
Vinpocetine 5mg
SYMPTOMS Forgetfulness persisted
and progressing
Forgetfulness
Difficulty in
communication
Assistance in daily
activities persisted
symptoms improving but
inadequate relief
reported
SIDE EFFECTS Excessive sedation - -

8. 7th July 2023 to 17th July 2023 From 17th July 2023 till
Hospital admission
During Hospital Stay
DRUGS Amisulpiride 150 mg
Lorazepam 1mg
Quetiapine 200mg
Trihexyphenidyl 2 mg
Quetiapine 600 mg
Amisulpiride 300 mg
6 ECTs Given
SYMPTOMS • Forgetfulness
• Difficulty communication
• Needs assistance in daily
activities
• Irritability
• Suspicious behavior
• Irrelevant talk
• Irritability
• Suspiciousness
• Irrelevant talk
• Irritability
• Suspiciousness
• Irrelevant speech
SIDE EFFECTS Tremors Tremors

9. Past history
Past History Medical illness :
No History Of Diabetes Mellitus, Hypertension, Asthma,
TB, Epilepsy, Jaundice, Thyroid Abnormalities.
Past H/O of mental illness :
No H/O Mental Illness In The Past.

10. Family history
70
75

11. • Belongs To Middle Socio-economic Status Family.
• Family Type : Nuclear Family.
• Born out of Non - Consanguineous Marriage.
• First In Birth Order.
• Father – Illiterate, Farmer Mother – Housewife
• 3 Younger Sisters And 2 Younger Brothers
• Patient used to work as a Foreman and is currently on voluntary retirement
• No History of psychiatric illness in family.
• Family relationships were cordial.
• There were no conflicts between any of the family members.
• Well maintained relationships with good interaction with parents, wife, sisters
and brothers.
• No h/o Dementia in family.
Family History

12. Personal History
Birth And Developmental History :
Mother’s antenatal period is unavailable as informant was wife.
Perinatal and Post-natal History :
unavailable as informant is wife.
Childhood Health and Adjustment :
unavailable as informant is wife.

13. • Educational history : Completed intermediate
• Occupational history :
• Had been working as a Foreman in Tata Steel for the past 20 years,
had taken Voluntary Retirement 4 years ago
• Marital history :
Married for the past 27 years, satisfactory marital life
Had 2 children: son died at the age of 3 years, details not known;
daughter 24 years, with profound IDD with epilepsy.

14. Pre-morbid Personality
• Social relations are well maintained.
• General mood-calm and composed.
• Responsible at work.
• Believes in God.
• Hobbies and interests are reading newspaper, books, watching news.
• Good hygienic standards.
• No h/o any fantasies.
• Takes mixed diet, occasionally drinks alcohol once or twice in a month.
• Sleeps by 11 pm wakes up by 7 am.

15. MMSE on 26/07/2023
• MMSE on day of admission was 3/30.
• MSE on day of admission -could not be elicited as pt is
unco operative and unable to comprehend the
questions asked.

16. Kirby’s Examination on 28/07/2023
• General reaction and posture:
 Spontaneous acts
 patient is tidy.
 Patient eats food volutarily when placed in front.
 Patient dresses himself with assistance.
 Behaviour towards the examiner
 Apathetic.
 Voluntary postures
 Patient is comfortable
 Behaviour is constant.

17. • Facial movement and expression
 Patients expressions are mask like and perplexed.
 Facial expression is constant.
• Eyes and pupil
 Eyes are open.
 Gives attention to the examiner with evasive gaze.
 Blinging of eyes present.
 Patient responding to sudden movement of hand towards
the patient eye.
 Response of pupils to painful sensory stimulus and corneal
reflex present.

18. • Reaction to the examiners questions and tests
 Patient is responding to simple commands like “show your
tongue” after multiple attempts.
 No negativism, automatic obedience, echolalia, echopraxia.
• Muscular reactions
 No regidity of limbs.
 No urinary or fecal incontinence.

19. • Emotional responsiveness
 No emotional response when family members speak or
when personal facts are told.
 Patient is responding to unexpected stimulus like clapping
sound.
• Speech
 No spontaneous speech.
 Patient is making effort to speak.

20. • Writing
 When patient is offered a pencil and paper to write his
wishes, he wrote only his name.
• Vitals
 PR- 78/min.
 BP – 120/80 mmHg.
 Temperature – Afebrile.
 RR- 18/min.

21. • MMSE score on 15/08/2023 was 3/30.
• As pt is uncooperative for mse kirby examination was done.
Kirby’s Examination on 15/08/2023:
• General reaction and posture:
 Spontaneous acts
 patient is tidy.
 Patient eats food volutarily when placed in front.
 Patient dresses himself with assistance.
 Behaviour towards the examiner
 Apathetic.
 Voluntary postures
 Patient is comfortable.
 Behaviour is constant

22. • Facial movement and expression
 Patients expressions are mask like and perplexed.
 Facial expression is constant.
• Eyes and pupil
 Eyes are open.
 Gives attention to the examiner with evasive gaze.
 Blinging of eyes present.
 Patient responding to sudden movement of hand towards
the patient eye.
 Response of pupils to painful sensory stimulus and corneal
reflex present.

23. • Reaction to the examiners questions and tests
 Patient is responding to simple commands like “show your
tongue” after multiple attempts.
 No negativism, automatic obedience, echolalia, echopraxia.
• Muscular reactions
 No regidity of limbs.
 No urinary or fecal incontinence.

24. • Emotional responsiveness
 No emotional response when family members speak or
when personal facts are told.
 Patient is responding to unexpected stimulus like clapping
sound.
• Speech
 No spontaneous speech.
 Patient is making effort to speak.

25. • Writing
 When patient is offered a pencil and paper to write his
wishes, he wrote only 3 letters of his name latter scribbled.
• Vitals
 PR- 78/min.
 BP – 120/80 mmHg.
 Temperature – Afebrile.
 RR- 18/min.

26. Summary
• A 50-year-old male, literate, married, Hindu by religion, used to work as s Foreman
was brought by his wife with presenting complaints of forgetfulness for 5 years and
increased since last 2 years, difficulty in communication, needs assistance in daily
activities for 2 years. Irritability, aggressiveness, suspicious behaviour for 6 months
– insidious in onset, deteriorating in nature with no obvious precipitating factor
with no h/o head injury, seizures, fever with altered sensorium, with no h/o
recurrent episodes of giddiness, loss of consciousness/slurred speech, no h/o
sudden onset of weakness of limbs/ deviation of mouth/blurring of vision. No h/o
constipation, diarrhoea, cold/heat intolerance, no h/o reversal of sleep wake cycle,
no h/o any gait disturbance/ urinary incontinence, no h/o spastic paralysis of limbs
accompanied by tremors, rigidity and choreoathetoid movements, no h/o antisocial
behaviour/lack of impulse control behaviour.

27. No h/o difficulty in swallowing and emotional lability, and no h/o pervasive low
mood, ideas of hopelessness or worthlessness, no h/o talking to self, laughing
to self, no h/o suicidal ideation or attempts, no h/o overfamiliarity/talking high
of self, no h/o repetitive behaviour, no h/o any substance abuse, no h/o any
legal issues. With no past history of mental illness with no h/o DM/ HTN/TB,
Asthma/ Epilepsy or thyroid abnormalities with well-adjusted premorbid
personality with physical examination revealing no abnormalities and systemic
examination revealing patient is conscious, speech is non-fluent, poor verbal
comprehension, repetition relatively intact, naming, writing and spelling are
impaired and MMSE score was 3/30 revealing difficulty in orientation, deficit in
registration, attention and calculation, recall, in language he named only one
object, unable to follow written instructions and difficulty copying. Kirby's
revealing patient is restless, moving around, and frequently picking things
around, apathetic, mask like, perplexed, with constant facial expression,
responding to simple commands, decreased emotional responsiveness, no
spontaneous speech, vitals are in normal range.

28. Diagnostic formulation
A 50 year old male, Literate, belonging to middle socio economic status, Hindu by religion,
resident of Jamshedpur, brought with complaints of Forgetfulness – for 5 years increased
since 2 yrs, difficulty in communication for 2 yrs, needs assistance in daily activities for 1
year, irritability, suspicious behaviour, irrelevant talk since last 6 months with no history
suggestive of CJD, Huntington’s, Parkinsonism with systemic examination and MMSE
revealing disturbance in orientation, memory, attention, calculations, learning capacity and
language with speech revealing impaired verbal comprehension, repetition relatively intact,
naming, writing and spelling are impaired, speech revealing possible mixed transcortical
aphasia and agraphia, Kirby's revealing patient is restless, moving around, and frequently
picking things around, seeing something that don’t exists, apathetic, mask like, perplexed,
with constant facial expression, responding to simple commands, decreased emotional
responsiveness, no spontaneous speech, vitals are in normal range.

29. Provisional Diagnosis
ICD 10 - DEMENTIA IN ALZHEIMERS DISEASE WITH EARLY ONSET WITH DELIRIUM SUPERIMPOSED ON
DEMENTIA.
DSM-5 POSSIBLE MAJOR NEUROCOGNITIVE DISORDER DUE TO ALZHEIMERS DISEASE (331.9).
Points in favour:
 Decline in cognitive function.
 Age less than 65 years.
 Restlessness and signs suggesting of visual hallucinations
 Absence of clinical evidence like hypothyroidism, Vitamin B12 deficiency, autoimmune disease,
normal pressure hydrocephalus.
 Absence of sudden onset of hemiparesis/sensory loss/ visual disturbances/ incoordination of gait
earlier in illness.
Points against:
 No family history of dementia
 MRI findings- Mild diffuse cerebral and cerebellar volume loss- likely metabolic in nature with deep
white matter ischemic changes.

30. Differential Diagnosis
DEMENTIA IN ALZHEIMERS DISEASE ATYPICAL OR MIXED TYPE,
(MIXED ALZHEIMERS AND VASCULAR ) –ICD10 (F00.2.x1) WITH
DELIRIUM SUPERIMPOSED ON DEMENTIA (F05.0)
• Points in favour
 Decline in cognitive function
 Restlessness and signs suggesting of visual hallucinations
 MRI finding - Mild diffuse cerebral and cerebellar volume loss- likely metabolic in
nature with deep white matter ischemic changes.
• Points against
 No h/o sudden impairment of consciousness/ fleeting paresis or visual loss.

31. Management Plan
• Admit the patient.
• Baseline hematological and radiological investigations.
• Neuropsychological testing.
• Psychopharmacological Intervention
• Psychosocial Intervention

32. Blood Investigation
Recent Investigations That Are Already Done
 Vit B12 – With In Normal Range.
 Thyroid Function – Normal.
 Ana Profile – Negative.
 VDRL – Negative.
 NACO – Nr.
 EEG – Normal Awake Record.
 Lipid Profile – Normal.
 LFT And RFT – Normal
 CBC - Normal

33. MRI done on July 8, 2023
• Mild diffuse cerebral and cerebellar volume loss- likely metabolic in nature with
deep white matter ischemic changes.
• Multifocal small chronic lacunaes Vs non-specific white matter hyperintensities at
bilateral fronto – parietal, mid parietal, posterior parietal and parieto-occipital
white matter as well as at the left high posterior parietal subcortical white matter
extending into the bilateral centrum semiovale regions.
• No evidence of acute ischemic event.
• Mild deviation of bony nasal septum to the left side with a septal spur on the left.
• Minimal mucosal thickening at the bilateral ethmoidal sinuses.

34. Non Pharmacological/ Psychosocial
Intervention
• Psychoeducation.
• Behavioural management.
• Environmental modifications.
• Care Giver Support.

35. Pharmacological Intervention
• Based on course and MMSE scores the Dementia is severe and advanced
stage.
• Trial with Cholinestrase Inhibitors for 3-6 mnths to look for benefit.
• Tab Donepezil start at 5 mg at bed time for a month and increase upto 10
mg.
• Tab Memantine start with 5mg and increase to 10 mg.
• Citicoline, Ginkgo Biloba, Piracetam, Vinpocetine etc may be added as
adjunctive treatment
• Olanzapine may be added with monitoring for metabolic symptoms and
parameters to address behavioural symptoms as well as sleep disturbance.
• Antipsychotic drugs like Aripiprazole may be added for the behavioural
symptoms

36. Prognosis
Good prognostic factors:
• Good family support.
• No h/o comorbidities.
Poor prognostic factors:
• Early age of onset.
• Low MMSE score at the time of
admission.
• Requiring support for activities
of daily living.

37. Thank you