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

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Case #3 Neurocognitive Disorders

Decision Point One

Major frontotemporal neurocognitive disorder (FTNCD)

Decision Point Two

Begin Citalopram 20 mg orally daily

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RESULTS OF DECISION POINT TWO Client returns to clinic in four weeks

Mr. Wingate’s son returns with Mr. Wingate and informs you that the Citalopram had to be stopped because his father developed nausea, vomiting, and became confused and irritable. These symptoms began approximately 1 week after starting the citalopram. During the hospitalization, it was discovered that Mr. Wingate’s sodium had decreased to 124 mEq/L. He also reported that his father had developed some type of “heart problem,” which they treated during his hospitalization.

Decision Point Three

Restart Citalopram at only 10 mg orally daily and increase to 20

mg in 7 to 10 days

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Guidance to Student

In the case of Mr. Wingate, he meets the diagnostic criteria for major

neurocognitive disorder as evidenced by a decline from a previous level of

performance in more than one cognitive domain—in this case, complex

attention and executive function. The decline is based on a

knowledgeable informant, as well as a clinician (the patient’s primary care

provider) who referred him to you, as well as substantial impairment in

another quanti�ed clinical assessment (the MMSE). Cognitive de�cits that

Mr. Wingate demonstrates interferes with independence in everyday

activities and he requires help with complex instrumental activities of

daily living (IADLs) such as medication management and paying bills.

Nothing in the scenario suggests that delirium could be responsible for

the cognitive decline, nor is anything in the scenario suggestive of another

mental disorder.

While one may be initially inclined to consider major neurocognitive

disorder due to Alzheimer’s disease (NDAD), probable Alzheimer’s would

require evidence of a causative genetic mutation either from family

history or genetic testing, and/or decline in memory and learning and at

least one other cognitive domain, steadily progressive, gradual decline in

cognition without extended plateaus, and no evidence of mixed etiology

(i.e., absence of other neurodegenerative or cerebrovascular disease, or

another neurological, mental, or systemic disease or condition likely

contributing to the cognitive decline. Similarly, while there is some

evidence of mild apathy, and decline in executive abilities, there is

insu�cient evidence of three or more behavioral symptoms that would

be needed to make a diagnosis of major frontotemporal neurocognitive

disorder (e.g., behavioral disinhibition, loss of sympathy or empathy,

perseverative, stereotyped or compulsive/ritualistic behavior, hyperorality

and dietary changes, or prominent decline in social cognition and/or

executive abilities) nor is there evidence of prominent decline in language

ability, in the form of speech production, word �nding, object naming,

grammar, or word comprehension that would suggest major

frontotemporal neurocognitive disorder.

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In Mr. Wingate’s case, there is clear evidence of �uctuating cognition, and

spontaneous features of Parkinsonism, which had their onset subsequent

to the development of cognitive decline. These symptoms, coupled with

the presence of a rapid eye movement sleep behavior disorder, are

suggestive of major neurocognitive disorder with Lewy bodies (MNDLB).

Diagnostic testing should focus on determining the presence of a

synucleinopathy.

If Mr. Wingate did have FTNCD, selective serotonin reuptake inhibitors

(SSRIs) can be used to treat behavioral symptoms in older adults with

FTNCD. However, they are used to treat symptoms such as disinhibition,

compulsive behaviors, irritability, depressive symptoms, carbohydrate

craving, and increased sexual drive- none of which Mr. Wingate appeared

to be exhibiting in the case.

If an SSRI was needed, citalopram was a poor �rst choice as Mr. Wingate

already had a baseline hyponatremia. The PMHNP should not prescribe

citalopram as it can worsen hyponatremia, and can cause QT

prolongation and increases the risk for cardiac arrhythmia. Dosing above

20 mg is also discouraged in elderly patients.

If modulation of Serotonin is required, then Trazodone may be a safer

choice in some patients, but further studies are needed to con�rm this.

Psychostimulants have been used with varying degrees of success in

treating the pervasive apathy which occurs in many patients with FTNCD.

Mr. Wingate is demonstrating apathy, and although the cause is from a

di�erent form of dementia, this strategy may still be bene�cial.

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