Running head: CLINICAL CASE STUDY 1
Clinical Case Study
56 Year Old Black Male with Alcohol Induced Alzheimer’s Disease, Alcoholism and
Substance Abuse
CLINICAL CASE STUDY
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Chief Complaint:“I’m here because she is trying to get me in trouble and put me away!”
HISTORY OF PRESENT ILLNESS (HPI)
Mr. W. is a 56 year old black male with ongoing symptoms of alcohol induced Alzheimer’s
disease with recent exacerbation from a 3 week long drinking binge of beer and vodka. Mr. W. is
accompanied today by his wife who is his caregiver. Mr. W. states that he did not drink any
alcohol and his wife is lying to get him into trouble and take his money. Mr. W. states “All she
has ever wanted was my money and she is trying to have me put away so she can get rid of me”.
Wife states he has no memory of his drinking and has been very” belligerent” to her and the
family and it is getting worse. At times she states he becomes violent and she is scared for her
safety. She also states there is now a 2 year old grandchild in the home and she does not know
how much longer she can put up with his drinking.
Mr. W. has a long history (37 years) of domestic violence and verbal abuse with his wife and
children. Wife states that Mr. W. has become increasingly easily agitated and is sneaking out of
the house and driving the car to get alcohol. His driver’s license has been suspended due to
numerous DUI”s. She states she tries to disable the car and hide the keys but he manages to find
the keys and fix the car. She says he also calls his brother or friends to come and get him or bring
him alcohol. She has taken away his cell phone but then he goes to the neighbor’s house and uses
their phone.
Most recent episodes include Mr. W. climbing out a 2 story window of his home and sitting on
the roof and yelling at neighbors and family members. Mrs. W. also states that he is urinating out
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the window and exposing himself to people. She states he recently went into her closet and took a
bunch of her clothes and stabbed them with a knife and defecated on them. She also states he is
now yelling at the toddler and throwing things at the wall. He recently took $3000 out of the
checking account and cannot account for the money. He has lost 12 pounds since his last visit one
month ago and is not sleeping at night. He does nap for short periods of time during the day. She
feels he is noncompliant with his medications and refuses to let her help him. Mrs. W. does also
mention that he is starting to drop things and stumble when he walks, she was not sure if this
relates to his alcohol consumption or if there is an underlying problem.
PAST PSYCHIATRIC HISTORY
Mr. W. has a long history of domestic violence and being verbally abusive to his family. He has
been hospitalized 4 times in the past at Camden Clark Memorial Hospital on the behavioral health
unit for up to 30 days at a time. Most recent hospital admission was 1 year ago. Mr. W. states he
is unaware of any hospitalizations in the past. He also states he has never been “mean” to his
family. Mrs. W. states that she feels he has suffered from depression and anxiety most of their
marriage but was never diagnosed or treated. She states he has also spent time in jail due to
domestic violence and assault on a police officer. She also states that he has said in the past that
he has heard voices telling him to drink alcohol and gamble. He states he was told by the voices
that he would win the lottery. He states he thinks he did win the lottery years ago but his wife
spent the money. She denies he won the lottery.
SUBSTANCE USE HISTORY
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Alcohol use started when he was 12 years old and he states he has consumed alcohol ever since
then but does not see a problem with that. He drank a case of beer every 2 days. Sometimes (2
times a week) he would drink a couple of shots of vodka. He also has a history of cocaine use and
Percocet abuse. Mrs. W. states he smoked pot as a teenager into adulthood and would still do it if
he could get it. Last usage of pot was 1year ago that she knows of. She also states he has smoked
cigarettes since he was 13. He currently smokes a pack of cigarettes a day. Mr. W. states he does
not currently smoke or drink. Mrs. W. states she thinks he currently drinks about 1-2 6 packs a
day.
PAST MEDICAL/SURGICAL HISTORY
Mr. W. has a history of hypertension and hyperlipidemia and BPH. He has had no surgeries in the
past. He has had several broken bones in his hands from hitting walls and people. He was in a
MVA in 1978 where he sustained a broken right femur. He also sustained a head injury in 2000
from being thrown from a horse. He was on life support for 2 weeks. On occasion, he also
suffers from Gout in his left great toe which he feels he is having a flare up of it now. He is
scheduled for a hearing test and an eye exam in one week. Wife stated he always has the
television turned up loud. She also states that he says people are talking too loud in conversations
and he often puts his hands over his ears. She states she is worried he is hearing voices but won’t
admit it.
CURRENT MEDICATIONS
Abilify 5 mg by mouth daily in the morning.
HCTZ 25mg by mouth daily in the morning
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Aricept 5mg by mouth daily in the morning
Pravastatin 40mg by mouth daily at bedtime
Trazadone 50mg by mouth at bedtime
ALLERGIES
Sulfa, cats.
FAMILY PSYCHIATRIC HISTORY
Mr. W. was adopted at age 5. He was in foster care from birth. He does know who his birth
mother is. Mrs. W. states that his adopted mother suffered from depression, adopted father had no
history of psychiatric illness. Mrs. W. states birth mother had mental health issues, she thinks she
was bipolar. She also states that birth mother was an alcoholic and drank while pregnant and had
no prenatal care. Birth father is unknown. Grandparents are not known. No known biological
siblings but one adopted brother who has no psychiatric problems or substance abuse and is a
successful business owner.
SOCIAL HISTORY
Mrs. W. does not recall hearing anyone mention about any complications at birth. She also states
she has not heard anything about his childhood before the age of 5 due to him being in foster
care. He was born in Marietta Ohio and taken by the state at age 3 weeks. To her knowledge he
has no biological siblings. Birth mother died at age 26 from suicide. His highest level of
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education is 10th grade he does have a GED. Mr. W. states he struggled in school and did not get
along well with others and was often suspended. He states he had a few friends and was
considered the class clown. He is presently unemployed. He was fired from his job 1 year ago for
coming to work drunk and embezzlement. He lives with his wife and 2 year old grandson. His
children live at the home on and off. He is not social with friends and only goes to the store to get
beer, gamble or to a doctor appointment. He lives in a single dwelling 2 story home on .5 acres in
the city. He has several industrial plants near his neighborhood. He has no pets. He does admit to
having an abusive relationship with his wife and he states it was mostly because of her greed for
money. He has had past legal problems as a young man for battery against a policeman. He states
his financial situation is bad due to his wife stealing all of his money. Mrs. W. States there is no
military history. Mr. W. denies any sexual abuse.
Review of Systems
General: Reports a 3 pound weight gain over the past 2 week and thinks it’s from his drinking
along with the increased abdominal girth. Wife is fearful it is his liver failing.
Neurological: Denies any LOC alterations, positive for problems with cognition, motor and
sensory abnormalities. He states that people are talking too loud and often covers his ears during
a conversation. He does admit to hearing voices in the past. Gait is unsteady and he is dropping
items. He does experience problems with concentration and memory on a daily basis.
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HEENT: Denies headaches. Describes vision as poor, needs new glasses. Denies pain, blurred
vision and visual problems other than when trying to read. Denies obvious hearing loss, vertigo,
earaches, infection or discharge. Last dental exam is unknown
Neck and Lymphatics: Denies lumps, swollen glands, goiter, or other thyroid enlargement or
pain.
Chest and Lungs: Denies dyspnea, cough, sputum, hemoptysis, wheezing, asthma, bronchitis,
emphysema, pneumonia, tuberculosis, or pleurisy.
Cardiac: Denies known heart disease, cardiac murmurs and is positive for hypertension. Denies
history of rheumatic fever, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, chest
pain, or palpitations.
Peripheral Vascular: Denies peripheral numbness, paresthesia’s, and coldness of extremities.
Denies intermittent swelling, claudicating, cramps, varicose veins, or thrombophlebitis.
Hematologic: Denies bruising or bleeding. No history of blood transfusions.
Gastrointestinal (GI)/Abdominal: Occasional heartburn, denies any difficulty swallowing,
or food intolerance. No complaints of abdominal discomfort but positive for increased abdominal
girth for the past month of about 1 inch. Denies liver and gall bladder disease, jaundice, or
hepatitis.
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Urinary: Positive for polyuria and Nocturia. Denies any dysuria, hematuria, urgency, hesitancy,
incontinence, infections, or stones.
Genital: Denies infections or discomfort.
Musculoskeletal: Positive for bil knee and ankle joint pain and stiffness. Denies any arthritis,
muscle pain or cramps in upper extremities or hips. No complaints of back pain. He complains
of pain and swelling in his left great toe
Skin, Hair, Nails: Positive for red itchy rash on back, denies any lumps, dryness, color
changes, or changes in hair. Nails are brittle and break easily.
Hematological: Denies any abnormal bleeding.
Endocrine: Denies known thyroid problems, neck swelling or discomfort, temperature
intolerance, excessive sweating, diabetes, excessive thirst, hunger, and palpitations.
Physical Examination
General: Mr. W. is 6 feet 0 inches 174 pounds BMI 23.6.
Vital signs: Blood pressure 146/70, heart rate 80, and respiratory rate 20.
MENTAL STATUS AND ASSESSMENT
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Mr. W. is a 56 y/o confused black man that looks older than stated age. He is oriented to place
and season only. MMS score 17 and PHQ-9 score 3 (See attached). He is appropriately dressed
for the season and appears clean and no smell of body odor noted, hair is short and neatly
combed. ETOH odor present. His gait into the room was unstable and wife was holding him by
the arm. His eye contact during the exam was minimal and he looked at the floor most of the
interview only looking up to argue with wife. He carries a beverage with him and he dropped it
several times. He is argumentive but stays seated and listens to the conversation. His affect was
constricted and tense and he often fidgeted in his seat, facial expressions through most of the
interview were strained and he often “rolled his eyes” while his wife was speaking. Most of the
emotion demonstrated during the interview was anger at what his wife was saying about his
drinking and behavior. He disagrees with almost everything his wife states that he is doing and
repeatedly states she is trying to get him in trouble. His mood today is “pissed off” per Mr. W.
and answers are loud and with a sharp tone. Mrs. W. states that his mood is unpredictable and
often explosive when confronted. He denies any thoughts of self-harm or harm to others…he
states he “just wants to be left alone” in his “man cave”. His speech is clear but broken up at
times when he feels unsure of an answer. His thinking is irrational and clouded. He states he was
never mean to his family and denies throwing things against the wall. His thought content and
judgement is abnormal, he feels it is still ok to drink, urinate out of the window, expose himself to
neighbors and defecate on his wife’s clothes and stab them with a knife. He also feels that he has
won the lottery in the past but his wife spent the money. Mrs. W. states he “sits and dwells” on
how she is stealing his money and is keeping him a prisoner in his home by not letting him use
the phone. He often asks her the same question repeatedly. He seems to be worse at night. He
does state he has heard voices telling him to drink and gamble and that his wife is out to steal his
money. He denies visual hallucinations. He also states he feels he can manage the bills but has no
idea what bill he has to pay. His insight is poor, he feels he can take care of his self and pay bills,
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but has no recollection of what bills he owes and cannot account for $3000.00 missing from his
bank account.
Given the neurotoxic effects of alcohol and the inexorable increase in per capita consumption,
future generations may see a disproportionate increase in alcohol-related dementia. This could
be compounded by the effects of increasing use of recreational drugs such as ecstasy, whose
long-term effects on cognition are still uncertain. Detection of these cases could be improved by
the use of screening tests like the Michigan Alcohol Screening Test combined with tools such as
the Lifetime Drinking History interview. There is a need to develop tools for assessment of
alcohol-related cognitive impairment. It is always difficult to motivate change in public behavior
when there is a delay between the risk-taking behavior and the onset of complications. Need
reference here.
Laboratory Data
He has not had any recent lab work done. Last lab work done was 2 years ago. Pt is due for an
appointment with PCP in 1 week and will have results forwarded to me. Pt states that he is very
fearful of needles and usually passes out. Lab work that I would order is a CBC, CMP, TSH,
FLP, Hemoglobin AIC, PSA, Uric Acid level, UA w/micro, vitamin B12, folate and Thiamine,
urine drug screen. The reason I would order these tests are to check liver function due to alcohol
consumption, Also to check electrolytes, Also look for gout, due to complaints of big toe hurting
at times. I would do a TSH to check thyroid function to rule out and thyroid disease. He also has
a family history of diabetes. He would have a PSA done due to his age. Also since the patient is
over 50, I would have him get an EKG and chest x-ray due to tobacco use.
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Routine laboratory studies are necessary for the purposes of screening for concurrent
disease states, ruling out organicity, and establishing baseline values of functioning.
Thyroid disease and other endocrine abnormalities can present as a mood disorder and
Cancer and infectious diseases can present as depression (Kaplan & Sadock, 2007).
According to WEBMD, there is a severs chance someone with a history of gout will have flare
ups while on HCTZ
According to DiPiro, (pg. 820) vitamin B12, folate and thiamine should be checked for
Alzheimer’s and alcohol use.
Psychiatric Summary
Mr. W. is a black 56 y/o male that is educated on a 9th grade level but has obtained his
GED. He is suffering severe mood swings and aggression towards his family and the
neighbors, He has been recently exposing himself to people and sneaking out of the
house to purchase beer. If he cannot leave the house he calls a friend or relative to go get
him beer and bring in to him at his home. He has been forgetting things more often and
loosing common items such as a cup and his “Cheese it “box where he stores things he
does not want other people to see. He has also become increasingly paranoid about being
in trouble and going to jail. He is also experiencing more paranoia towards his wife and
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feels she is trying to steal all of his money. Wife and family are becoming more
concerned about the fact that his memory is getting worse, his drinking is becoming more
on a daily basis and now he is exposing himself to people from the window of his home.
And, the fact that he is taking a knife and shredding and defecating on his wife’s clothes
is disturbing to them. Mr. W. Denies doing this act and also denies hearing any auditory
hallucinations. Mr. W. dies not recall much of his childhood due to his present condition.
But his wife states his life was chaotic and he was in foster care and drank a lot as a
teenager. She denies hearing him talk about sexual or physical abuse. Mr. W. does not
feel he has any problems and that his drinking is in control and everyone is making up
these stories to hurt him and get him in trouble. He feels his mood is always “pissed off”
due to people “getting in his business”. He states he would like a divorce so he can live
his life how he wants to. During the interview Mr. W. is easily distracted by any
movement outside of the windows and puts his head down and pretends he does not hear
the questions being asked and then becomes agitated when asked the same question
several times.
Diagnosis According to: DSM V
ICD-9 Code: 291.2 Alcohol induced persisting dementia
ICD-9 Code: 305.00 Alcohol Use Disorder, severe
ICD-9 Code: 303.9 Alcohol Dependence
History of broken right femur 1978.
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History of head injury in 2000.
History and current episodes of Gout
Tobacco use
The DSM-5 (formerly DSM-IV TR) is produced by the American Psychiatric Association and
is utilized as a diagnostic tool for psychiatry.
Plan:
Safety
At this time he is a risk for harm to himself and others, he is unable to make rational
decisions. I spoke with the wife about documenting his outbursts and keep a cell phone near
to call police and record the episode. We discussed about Mr. W. not being left alone in the
home and making the window in his bedroom very hard to open. Also possibly keeping a
urinal in that room for him would maybe decrease his need to urinate out the window. We
also discussed about keeping the grandchild away from him. We also discussed the need to
keep the car disabled or putting the keys in a very remote area and switch locations often
According to the National Institute on Aging….think prevention, adapt the
environment, and minimize danger. Some example to help the wife: install smoke alarms
and carbon monoxide detectors in or near the kitchen and all sleeping areas. Check
their functioning and batteries frequently. Avoid the use of flammable and volatile
compounds near gas appliances. Do not store these materials in an area where a gas
pilot light is used. Install secure locks on all outside doors and windows. Hide a spare
house key outside in case the person with Alzheimer's disease locks you out of the house.
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Alcohol/Substance Abuse
We discussed the need for no alcohol in the home and limiting/eliminating ways for patient
to get it. Talk to local stores and explain the situation and ask them not to sell it to him.
Limit his cell phone usage. Talk to neighbors, friends and family about the health risks the
patient is experiencing. I also recommended that the wife seek help through AA, NA and
According to The National Institute of Health: Autopsy evaluations suggest that up to
78% of individuals with diagnosed alcoholism demonstrate some degree of brain
pathology. Neuroimaging and neuropathological evidence show prominent white
matter loss (most notable in the prefrontal cortex, corpus callosum, and cerebellum)
and neuronal loss in the superior frontal association cortex, hypothalamus, and
cerebellum. The frontal lobes of individuals with diagnosed alcoholism appear
particularly susceptible to damage, with evidence of markedly decreased neuron
density, volume shrinkage, and altered glucose metabolism and perfusion”. Also,
another hypothesis is that thiamine (vitamin B1) deficiency is primarily responsible for
the development of ARD. Individuals with alcohol use disorders are at particularly high
risk of thiamine deficiency, not only from poor dietary nutrition but because alcohol
directly compromises thiamine metabolism. (NIH)
According to DiPiro (pg. 1003), Alcohol-Attributable deaths report 80,374 U.S. citizens
with medium and high average daily alcohol consumption die each year because of
alcohol related causes, including collisions and cirrhosis of the liver
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Medications.
I reviewed his medications with his wife and agree with the above; however I would
increase the Aricept to 10 mg a day to see if the dementia symptoms stabilize. I would stop
the HCTZ due to the risk of causing more gout episodes, and allergy to sulfa. And start
Lisinopril because it is kidney friendly and he has a family history of diabetes and he has
not had blood work done in a while. Also, I would stop the Pravachol until his blood work
results are in due to his use of alcohol, I would want to see what liver functions are.
According to Stahl, the dose of Aricept can be increased to 10 mg and there is the
possibility to increase to 23mg if needed and the patient tolerates it well. I would only
change one medication at time so I can assess the efficacy or side effects of that change.
Due to his symptoms, I would look into increasing the trazadone and Abilify later. I
would stop the HCTZ due to his episodes of gout. Also Stahl mentions to closely monitor
glucose levels as Abilify can increase the risk of diabetes, Diabetic Ketoacidosis and
weight gain.
Diagnostic Studies
I would order the above lab work and suggest that an EKG be performed for being on
Abilify and due to the patient’s age and not having a good family history medical
background. I would also recommend a screening colonoscopy and lung CT due to his
history, race, age and current usage of tobacco.
According to Stahl (2014), Abilify can cause hypotension, dizziness and dry mouth. There
is also a chance of tachycardia from Abilify according to Rxlist.com
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The American College of Gastroenterology recommends that African Americans have
colorectal screening starting at age 45.
The recommendations are based on a careful review of several studies that looked at
low-dose CT screening. The most significant was the National Lung Screening Trial
(NLST). This study included more than 50,000 people aged 55 to 74 who were current or
former smokers with at least a 30 pack-year history of smoking (equal to smoking a pack
a day for 30 years, or 2 packs a day for 15 years). The NLST found that people who got
low-dose CT had a 20% lower chance of dying from lung cancer than those who got
chest x-rays. However, other trials found no benefit from screening.(The American
Cancer society)
Education
We talked about the importance of sleep for Mr. W. and for his wife. I advised the wife to
visit the website “National Sleep foundation” which gives great tips for Alzheimer patients
and the “sun downing “ episodes and how to reduce them. Keep a regular schedule, keep
him exposed to as much light as possible during the day and at night keep the room as dark
as possible, avoid caffeine. We discussed the importance of following through on safety
plans and making sure the car is only drivable when she can drive it. We talked about her
getting more information on this disease and keeping in close contact with his PCP. We
also discussed the signs and symptoms of alcohol cirrhosis and the dangers of him
continuing to drink.
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According to National Institute of health (NIH) Epidemiological studies suggest that
individuals with Alcohol related dementia (ARD) typically have a younger age of onset
than those with other forms of dementia, are more likely to be male, and often are
socially isolated.
Support System
We also talked about talking with the local police department and local stores that sell beer
about his situation to keep everyone informed so they can assist her if needed. We
discussed about her starting church. Keeping in touch with family members and allowing
time for her by having someone come into sit with him a few times a week. She also has
agreed to join an AA group and take her husband.
According to DiPiro, (pg. 822 table 38-4) there is an abundance of resources for
caregivers of persons with Alzheimer’s Dementia.
Therapy
He is currently not in any therapy and is refusing to speak to a therapist. With his level of
understanding and memory impairment, I’m not sure therapy would be beneficial, but is
certainly an option. I recommended an adult day program that specializes in Alzheimer
disease. I recommend Mrs. W. seek counselling to help deal with the alcoholism, past
domestic violence and her depression. Also, an Alzheimer support group for caretakers. I
will obtain a release of information from the patient to be able contact the PCP for
continuity of care. I do feel he would benefit from art therapy and music. I also advised
Mrs. W. to get some word puzzle books just to have him to try to concentrate on something
and advised her to try and play checkers with him if possible.
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Health information privacy protections under HIPAA requires written authorization from
individuals to release medical information (U.S. Department of Health and Human
Services, 2003).
According to the National Institute on Aging, there are a number of support groups for
caregivers across the nation.
According to everydayhealth.com, different non-pharmacologic therapies can help with
stress or depression such as music, art, pet and religious therapy.
Monitoring
BMI monthly for 3 months then quarterly, blood pressure at each visit, fasting glucose,
Hemo A1C, fasting lipids within 3 months and then annually, CBC frequently during the
first few months. Monitor weight. EKG baseline and annually. Perform a MMS exam as
needed for change in mental status.
Due to metabolic effect of atypical antipsychotics it is important to monitor BMI, lipids,
glucose and blood pressure. It is important to check CBC due to possible drug induced
leucopenia/neutropenia (Stahl, 2014)
According to the Journal of Psychiatric Research, a Mini Mental Status Exam is a
practical method for grading the cognitive state of the patient for the clinician
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He will follow-up with this provider in 1 week to have blood work done and discuss further
screening testing such as a prostate exam, colonoscopy and chest x-ray.
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References:
American Cancer Society Retrieved from internet July 7, 2015
http://www.cancer.org/cancer/news/new-lung-cancer-screening-guidelines-for-heavy-smokers
American College of Gastroenterology retrieved from internet July 7, 2015
http://gi.org/guideline/colorectal-cancer-screening/
British Journal of Psychiatry retrieved from the internet July 8, 2015
http://bjp.rcpsych.org/content/193/5/351.full
DiPiro, J.T. (Ed). (2014). Pharmacotherapy: a pathophysiologic approach (9th ed.). New York, New York:
McGraw-Hill/ Medical.
Everyday Health, Retrieved from internet June 10th 2015
http://www.everydayhealth.com/alzheimers/non-medical-alzheimers-therapy.aspx
Journal of Psychiatric Research retrieved from the internet July 8, 2015
http://www.journalofpsychiatricresearch.com/article/0022-3956(75)90026-6/abstract
National Institute on Aging Retrieved from internet on June 22, 2015
https://www.nia.nih.gov/alzheimers/publication/home-safety-people-alzheimers-disease/what-alzheimers-
disease
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National Institute of Health Retrieved from the internet June 22, 2015
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580328/
Rxlist.com retrieved from internet on July 7, 2015
http://www.rxlist.com/abilify-drug/side-effects-interactions.htm
Sadock, B.J. (2014). Kaplan & Sadocks’s synopsis of psychiatry: behavioral sciences/clinical psychiatry
(Eleventh edition). Philadelphia: Wolters Kluwer.
Retrieved from the internet on June 25, 2015
http://sleepfoundation.org/ask-the-expert/sleep-and-alzheimers-disease/page/0/1
Stahl, S. M. (2014). Stahl’s essential psychopharmacology: the prescriber’s guide. 5th Edition, Cambridge,
UK; New York: Cambridge University Press.
U.S. Department of Health and Human Services retrieved from internet July 8, 2015
http://www.hhs.gov/ocr/privacy/hipaa/understanding
WEBMD Retrieved from internet on July 8, 2015
http://www.webmd.com/drugs/2/drug-5310/hydrochlorothiazide-oral/details/list-sideeffects
