report

1. 1
Mental Health Consultation
Patient Name: P
Date: 12/6/99
Comprehensive history can be found elsewhere in this chart and will not be repeated here.
Reasonfor Referral: Dr. S asked me to reevaluate Mrs. P because of a “decline in her
cognition, ADLs, and feeding”. On 11/30/99 Dr. S discontinued Aricept, Salicylate and Zoloft to
determine if any these medications were playing a role in Mrs. P’s cognitive impairment. She
was started on Lopressor in July 1999. It improved her cardiac functioning significantly.
Consequently, Dr. S continued it.
During the past year she has had “intermittent syncopal episodes” which were preceded by
“diaphoresis and dizziness” and during which she became “limp and unresponsive for as long
as five minutes” at times vomiting followed.
Background Information:
 Admitted to G in 1996 with left leg numbness and weakness. Had a history of “decreased
cognition and falling”. Neuroimmaging (CT scan, MRI) showed “significant diffuse central
cortical atrophy with prominence of all the ventricles especially the lateral ventricles…
numerous white matter hyperintensities scattered throughout both cerebellar and cerebral
hemispheres… most likely due to chronic arteriosclerotic microischemic events” no acute
findings. Nevertheless, her symptoms were thought to be due to a CVA and small vessel
disease. She suffers from chronic HTN.
Findings:
 Although I have chatted briefly with Mrs. P on numerous occasions during the past year, I
have not had any extended contact with her since 10/12/98. Consequently, I found the
change in her mental status quite striking. She was in bed at mid-afternoon, vacantly staring
at the television. Her warm engaging manner and spontaneity were gone, replaced by
apathy, a flat affect, profoundly slowed thinking and dysarthric speech. I also thought I
detected slight right-sided facial flattening. She denied subjective feelings of depression but
the general tone and content of her speech was rife with references to frustration and
discouragement. She had recently been thinking about whether or not to give up on PT and
any hope of improvement in the use of her leg, as well as, relief from intermittent pain. Her
appetite “ has never been too good” and she sleeps “OK, if I get my two nerve pills”. She c/o
“feeling tired all the time”. Memory impairment was marked, much worse than a year ago.
There were no signs of delirium.
 I don’t think the change in her mental status was in anyway related to her medications. I
suspect that the change in mental status reflects a progression of her Binswanger’s like
subcortical arteriosclerotic dementia and possibly a new lacunar stroke. Nearly all of the
textbook signs are evident in her presentation. Subcortical arteriosclerotic encephalopathy is
a vascular dementia involving the small penetrating vessels supplying the deep white matter

2. 2
of the cerebral hemispheres. It occurs in elderly individuals with a history of chronic
hypertension. A gradually progressive course with dementia and personality change is
typical. Neuropsychiatric findings include memory impairment, poor judgment, lack of
spontaneity, perseveration, psychomotor slowing, general dilapidation in cognitive
functioning, apathy and at times stroke associated anxiety and/or depression. Gait problems
and falls, weakness, ataxia, rigidity, dysarthria, parkinsonism and urinary incontinence are
frequent neurological signs. This type of small-vessel VaD and lacunar state commonly co-
occur. TIAs and stroke-like episodes are common features of this disease process.
 Mrs. P shows an admixture of stroke related depression and anxiety, as well as, apathy. I
think the falls, weakness and upper extremity tremor which she c/o just prior to her 1996
admission were all s/s of the above described disease process. The recent episodes of
unresponsiveness may have been manifestations of the “stroke-like episodes” often seen in
this type of VaD. She was seen by cardiology…I’m not sure what the outcome was. The
facial flattening and the sudden onset of some of the signs suggest the possibility of lacunar
stroke. We should expect her mental status to fluctuate…common in this disease.
Diagnosis: 1.) VaD – progressing subcortical arteriosclerotic encephalopathy.
2.) Post stroke depression. 3.) R/O lacunar stroke.
Recommendations:
1. Because she seems to have some depression and to a lesser extent anxiety blended with
her apathy, I suggest restarting her on Zoloft gradually increasing the dose to 100mg qd.
She just briefly mentioned pain; if it is a significant problem better control would
mood.
2. Staff should help her compensate for her memory loss by:
(1) helping her to create a memory log including:
a. autobiographical information
b. facts about the facility
c. a detailed daily schedule
d. a calendar with scheduled appointments, activities, etc.
e. a things to do list
f. a list of important names with identifying information.
(2) Repeating all important information/instructions many times each day. Try to use the
same simple words and phrases each time.
3. Try to identify events and interactions, which seem to improve her mood and weave more
of them into her daily routine. Engage her in as many self-esteem enhancing activities as
possible.
___________________________
Drew Chenelly, Psy.D. Date:
Licensed Clinical Psychologist