DISCUSSION RESPONSE
konxidum
responsecasestudy1wk9.docxAn 80-year-old male Caucasian male brought to the clinic by his wife concerned about his “memory problems”. Per the wife, she has noticed his memory declining but has never interfered with his daily activities until now. He is unable to remember his appointments and heavily relies on written notes for reminder. Just last week, he got lost driving and was not found by his family until 8 hours later. He is unable to use his cell phone or recall his home address or phone number. He has become a “hermit” per his wife. He has withdrawn from participating with church activities and has become less attentive.
PMH: HTN, controlled
Prostate cancer 20 years ago
Dyslipidemia
SH: no alcohol or tobacco use; needs assistance with medications
PE: VS stable, physical exam unremarkable
Primary Diagnosis
AD is categorized into mild, moderate, and severe according to the signs and symptoms (Weller & Budson, 2018). In mild AD, signs include memory loss, confusion about familiar places, compromised judgment, and mood and personality changes (Weller & Budson, 2018). In moderate AD, signs include increased memory loss, shorter attention span, difficulty recognizing friends and family, difficulty organizing thoughts, delusions, and perceptual-motor problems (Weller & Budson, 2018). In severe AD, patients can no longer recognize friends and family and can no longer communicate (Weller & Budson, 2018). Weight loss, sleep disturbance, and lack of bladder and bowel control may also be present (Weller & Budson, 2018). This patient’s memory loss was starting to interfere with his activities of daily living. He was getting lost because he could not remember core memories such as his cell number or address. He was also becoming withdrawn.
As of today, an autopsy or brain biopsy is the only definitive way to diagnose AD (Weller & Budson, 2018). Upon clinical examination, the Mental Status Examination can reveal signs, symptoms, and severity (Weller & Budson, 2018). A lumbar puncture can reveal elevated levels of tau and phosphorylated tau in cerebrospinal fluid along with low amyloid levels (Weller & Budson, 2018). Imaging can assist in ruling out other treatable causes of cognitive decline (Weller & Budson, 2018).
Differential Diagnoses
1. Vascular Dementia: Vascular Dementia (VaD) is second only to AD in most common forms of dementia (Korzcyn, 2016). It can be brought on by focal cerebrovascular disease that occurs secondary to embolic vascular occlusion (Korzcyn, 2016). Diffuse cerebrovascular disease is most commonly brought on by hypertension (Korzcyn, 2016). Patients exhibit a progression of motor, cognitive, mood, and behavioral changes over about a five to ten-year period (Korzcyn, 2016). These changes were described from the wife. Along with hypertension, diabetes, coronary artery disease, osteoarthritis, and osteoporosis are underlying risk factors for vascular dementia (Korzcyn, 2016). The patient’s history of hypertension and hyperlipidemia also place him at risk for this disease.
2. Depression: Depression is a mental health disorder defined by mood and personality changes and loss of interest in what has always been important (Morimoto, Kanellopou, Manning, & Alexopoulos, 2015). Late-life depression is often accompanied by cognitive impairment (Morimoto, Kanellopou, Manning, & Alexopoulos, 2015). Episodic memory, visuospatial skills, verbal fluency, and psychomotor speed have been reported consistently in late-life depression (Morimoto, Kanellopou, Manning, & Alexopoulos, 2015). The wife described his behavior as withdrawn, less attentive, and with a loss of interest in usual church activities, which are all observations that would point to this as a potential diagnosis.
3. Vitamin B12 Deficiency: Low serum vitamin B12 levels are associated with neurodegenerative disease and cognitive impairment (Agarwal, 2011). Increased homocysteine levels in conjunction with low levels of folate and vitamin B12 have been found to correlate with decreased cognitive performance (Agarwal, 2011). For this reason, B12 supplementation has been shown to prevent or reverse cognitive decline (Agarwal, 2011). Mood changes, psychotic episodes, and cognitive impairment are all potential symptoms of an elderly patient that is B12 deficient (Agarwal, 2011). The wife had reported both mood and cognitive changes in the patient.
Potential Treatment Plan
Most recent research is discovering more about the mechanisms that alter amyloid and tau protein metabolism, inflammation, oxidative stress, and hormonal changes that produce neuronal degeneration in AD (Weller & Budson, 2018). Pharmaceutical intervention based on these discoveries are actively being developed (Weller & Budson, 2018). Symptomatic therapies include cholinesterase inhibitors and partial N-methyl-D-aspartate (NMDA) (Weller & Budson, 2018). Donepezil, rivastigmine, and galantamine are recommended therapies for mild, moderate, or severe AD (Weller & Budson, 2018). These therapies adjust the acetylcholine and glutamate neurotransmitters (Weller & Budson, 2018). Psychotropic medications are prescribed to help treat secondary symptoms, such as depression, agitation, or sleep disorders (Weller & Budson, 2018).
References
Agarwal R. (2011). Vitamin B₁₂ deficiency & cognitive impairment in elderly population. The Indian Journal of Medical Research, 134(4), 410–412.
Korczyn A. D. (2016). What is new in vascular dementia?. BMC Medicine, 14(1), 175. doi:10.1186/s12916-016-0726-z
Morimoto, S. S., Kanellopoulos, D., Manning, K. J., & Alexopoulos, G. S. (2015). Diagnosis and treatment of depression and cognitive impairment in late life. Annals of the New York Academy of Sciences, 1345(1), 36–46. doi:10.1111/nyas.12669
Weller, J., & Budson, A. (2018). Current understanding of alzheimer's disease diagnosis and treatment. F1000Research, 7, F1000 Faculty Rev-1161. doi:10.12688/f1000research.14506.1
