Assignment 2: Week 8 Practicum: Decision Tree (Due in Week 10)

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Case #3 Neurocognitive Disorders

BACKGROUND Mr. Charles Wingate is a 76-year-old Caucasian male who presents to your o�ce for an initial

psychiatric evaluation. He is accompanied by his eldest son, Mark, who lives with Mr. Wingate. Mr.

Wingate was referred to you by his primary care provider who has performed an extensive

diagnostic workup to rule out an organic basis for his changes in cognition. Mr. Wingate’s son

Mark has verbalized a concern that Mr. Wingate may have Alzheimer’s disease. When questioned,

Mr. Wingate states that he is unaware of anyone in his family ever having been diagnosed with

Alzheimer’s disease.

SUBJECTIVE Mr. Wingate states that he has always been “a little bit forgetful,” but he noticed that in his 60s

and 70s, it got worse. Mark states that “for the past 2 years, it has been getting worse. He doesn’t

even notice how bad his memory has become.” On at least two occasions, Mr. Wingate has gotten

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lost when he was driving to the grocery store. Mr. Wingate protested his disagreement with this

accusation stating, “but they were doing road construction, anyone could have gotten mixed up!”

While his son conceded to this, he pointed out that Mr. Wingate’s memory has caused some

other problems, such as errors with paying his monthly utility bills (at one point, the electric

company threatened to shut o� his electricity due to his nonpayment of the bill).

His son Mark also pointed out that the family is concerned for Mr. Wingate’s safety as he twice

left his keys hanging in the door and just two evenings ago, put food in oven and forgot about it

until the smoke detector in the kitchen began to alarm.

Mr. Wingate also has had a few issues with managing his medications. Speci�cally, he took too

many Norvasc tablets a few months ago, which resulted in hypotension and a fall. Since that time,

Mark’s wife has been setting up Mr. Wingate’s pills in pill boxes, but recently, multiple “missed

doses” have been noted.

Mr. Wingate states: “but those are my night pills that I miss—I’m always better at remembering

things in the morning.” Mark agrees, stating that Mr. Wingate’s cognition does vary throughout

the course of the day and appears to worsen in the evening. He also reports that his father

seems much less alert in the evenings, and more alert in the mornings.

Mr. Wingate reports that he has had poor sleep for “a long time now.” He does report that over

the past few months, he has been having what he describes as “very vivid nightmares.” His son

states that sometimes he is awakened by his father’s yelling during nightmares, and enters his

father’s room, and sees his father swinging or kicking in his sleep.

He reports that his appetite is “alright” and that his energy levels do �uctuate throughout the

course of the day. He states: “sometimes, I can concentrate really well; other times I can’t … it is

very frustrating!” Speci�c to substance use, Mr. Wingate notes that he used to enjoy a glass of

wine or two with dinner, but states that it just doesn’t interest him, anymore. Plus, he stated that

he notices that when he does drink, he develops slow muscle contractions.

Mr. Wingate’s son also shares a concern about his father’s abnormal movements. He states that

for about the last 6 months, his father has had problems with coordination. He states that he

raised these concerns with the family doctor who suggested it may be “late onset Parkinson’s

disease.” However, he was not treated because the symptoms were “not that bad.”

OBJECTIVE

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Mr. Wingate was overall calm and pleasant during the clinical interview. Throughout the clinical

interview, you notice that Mr. Wingate is not really involved in the discussion. He seems

somewhat indi�erent to the assessment and does not seem very concerned with what is being

discussed. He only protested when discussing how he got lost on his way to the supermarket and

his evening medication dose.

Review of systems and screening physical assessment were unremarkable, with the exception of

�ne resting tremors noted in both of Mr. Wingate’s hands. The psychiatric/mental health nurse

practitioner (PMHNP) also reviewed laboratory studies that were sent from Mr. Wingate’s primary

care provider; they were within normal limits with the exception of a serum sodium level of 130

mEq/L.

MENTAL STATUS EXAM Mr. Wingate is alert. He is oriented to person, place, and partially oriented to time (he knows that

it is morning, but cannot tell the hour). His speech is clear, coherent, goal directed, and

spontaneous. Mr. Wingate’s self-reported mood is “ok.” A�ect is somewhat constricted. His eye

contact is �eeting throughout the clinical interview. He denies visual or auditory hallucinations,

no overt delusional or paranoid thought processes appreciated. Judgment seems well preserved,

but insight appears impaired as he is having trouble understanding why his son brought him to

this appointment. Concentration and attention also appear impaired, which prompts the PMHNP

to perform a mini-mental status exam (MMSE) on Mr. Wingate.

RESULTS OF MMSE Score of 17, with primary de�cits in orientation; calculation; recall (he was unable to recall any of

the three items presented after 5 minutes); and he was unable to perform serial 7’s or spell the

word “WORD” in reverse, despite the fact that he is a high school graduate and attended 1 year of

college. He also needed prompting with the three-step command. His score suggests severe

cognitive impairment.

At this point, please discuss any additional diagnostic tests you would perform on Mr. Wingate.

Decision Point One

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BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE

FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE

PRACTITIONER (PMHNP) GIVE TO MR. WINGATE?

In your write-up of this case, be certain to link speci�c symptoms presented in the case to DSM–5 criteria

to support your diagnosis.

Major frontotemporal neurocognitive disorder (FTNCD)

(1.html)

Major neurocognitive disorder due to Alzheimer’s disease

(2.html)

Major neurocognitive disorder with Lewy bodies

(3.html)

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