Psychiatry · Year 3 · from Psychiatry
Case 2: Major Neurocognitive Disorder Due to Alzheimer's Disease
Patient Demographics
- Age: 74 years old
- Sex: Female
- Occupation: Retired librarian
Chief Complaint
Per daughter: "Mom keeps asking the same questions over and over. She got lost driving to the grocery store she's been going to for 30 years."
History of Present Illness
The patient is a 74-year-old woman brought by her daughter for evaluation of progressive memory problems over the past 2-3 years. The daughter first noticed changes approximately 3 years ago when her mother began repeating stories within the same conversation and forgetting recent phone calls. Over the past year, symptoms have progressed significantly. She missed several bill payments (previously meticulous), got lost driving to familiar locations twice, and left the stove burner on overnight. She forgot a grandchild's birthday for the first time. She has difficulty following the plots of TV shows she used to enjoy and has stopped reading books, which was her lifelong passion.
The patient lives alone since her husband died 4 years ago. Her daughter visits weekly and has become increasingly concerned. She notes her mother's house is less clean than usual, there's expired food in the refrigerator, and she appears to be wearing the same clothes multiple times without washing them.
The patient minimizes concerns, stating "Everyone forgets things at my age." She becomes defensive when discussing her driving and insists she can manage on her own. She cannot recall specific instances of forgetting that her daughter describes.
Past Medical History
- Hypertension
- Hyperlipidemia
- Osteoporosis
- Remote history of depression following husband's death (resolved)
Family History
- Mother had "senility" in her 80s (likely dementia, unspecified)
- No other family history of dementia
Mental Status Examination
Appearance: Well-groomed elderly woman, appropriately dressed (though daughter notes outfit chosen by daughter)
Behavior: Pleasant, cooperative, defers to daughter for historical information
Speech: Normal rate, occasional word-finding pauses, circumlocution (describes "the thing you use to eat soup" instead of "spoon")
Mood: "I'm fine"
Affect: Pleasant but somewhat flat; minimal concern about memory issues
Thought Process: Linear but impoverished, concrete
Thought Content:
- Minimization of deficits
- No paranoid ideation
- No suicidal ideation
Perceptions: No hallucinations
Cognition:
- Montreal Cognitive Assessment (MoCA): 18/30
- Visuospatial/executive: 1/5 (could not complete trail-making, poor clock draw)
- Naming: 3/3
- Attention: 4/6
- Language: 2/3
- Abstraction: 1/2
- Delayed recall: 0/5 (recalled 0/5 words even with category cues)
- Orientation: 5/6 (incorrect date)
Clock Drawing Test: Drew circle, numbers clustered on one side, hands pointing to incorrect times
Insight: Poor - does not recognize severity of impairment
Judgment: Impaired - continues to drive despite getting lost
Diagnostic Workup
Laboratory Studies (rule out reversible causes):
- TSH: 2.8 (normal)
- Vitamin B12: 420 pg/mL (normal)
- CBC: Normal
- CMP: Normal
- RPR: Non-reactive
Neuroimaging:
- MRI Brain: Bilateral hippocampal atrophy out of proportion to age-related changes; generalized cortical atrophy most prominent in temporal and parietal regions; moderate periventricular white matter changes
Diagnosis
Major Neurocognitive Disorder Due to Alzheimer's Disease, Probable (F02.81)
DSM-5 Criteria Met:
Major Neurocognitive Disorder: A. Significant cognitive decline from previous level in one or more cognitive domains:
- Learning and memory: Severe impairment (0/5 delayed recall, cannot remember recent events)
- Executive function: Impaired (financial management, planning)
- Language: Mild impairment (word-finding difficulty)
B. Cognitive deficits interfere with independence in everyday activities (needs help with bills, driving unsafe, hygiene declining) C. Not exclusively in context of delirium D. Not better explained by another mental disorder
Probable Alzheimer's Disease:
- Insidious onset, gradual progression
- Early and prominent memory impairment
- No evidence of other neurodegenerative or cerebrovascular cause
- Supportive neuroimaging (hippocampal atrophy)
Severity: Moderate (requires assistance with IADLs; basic ADLs preserved)
Treatment Plan
Pharmacotherapy:
- Donepezil 5 mg at bedtime, increase to 10 mg after 4-6 weeks if tolerated
- Cholinesterase inhibitor for symptomatic cognitive benefit
- Monitor for GI side effects, bradycardia
- Consider adding memantine when progresses to moderate-severe stage
Safety Interventions:
- Driving evaluation and likely cessation - refer to occupational therapy for driving assessment
- Remove or disable stove when not supervised
- Medication management: Daughter to take over or use pill organizer with daily checks
- Medical ID bracelet in case of wandering
- Consider GPS tracking device
Supportive Services:
- Referral to social work for community resources
- Adult day programs for socialization and structure
- Home health aide evaluation
- Financial power of attorney documentation (while patient retains some capacity)
- Advance directive discussion
Caregiver Support:
- Alzheimer's Association resources
- Support group referral for daughter
- Discuss respite care options
- Education about disease progression and what to expect
Follow-up:
- Neurology/Psychiatry in 3 months
- MoCA annually to track progression
- Reassess driving status, living situation, and care needs at each visit