# Clinical Cases: Neurocognitive Disorders ## Case 1: Delirium ### Patient Demographics - **Age:** 78 years old - **Sex:** Male - **Occupation:** Retired engineer ### Chief Complaint Per nursing staff: "He's confused and trying to pull out his IV. He was fine yesterday." ### History of Present Illness The patient is a 78-year-old man admitted 3 days ago for elective right hip replacement surgery. The surgery was performed on hospital day 2 and was uncomplicated. On post-operative day 1, nursing staff noted an acute change in mental status. The patient became agitated during the night, attempting to climb out of bed and stating he needed to "get to work" and "they're coming for me." He did not recognize his wife when she visited and accused nursing staff of trying to poison him. His level of alertness fluctuates throughout the day - he was somnolent and difficult to arouse during morning rounds but became agitated and combative in the evening. Pre-operatively, the patient was described by his family as cognitively intact, living independently with his wife, managing his own finances and medications, and volunteering at a local museum. He has no history of psychiatric illness or cognitive impairment. ### Medical History - Hypertension - Type 2 diabetes mellitus - Benign prostatic hyperplasia - Osteoarthritis - Mild hearing loss (uses hearing aids) ### Medications (Current) - Oxycodone 5 mg q4h PRN for pain - Diphenhydramine 25 mg PRN for sleep (received 2 doses) - Famotidine 20 mg BID - Metoprolol 50 mg BID - Metformin 1000 mg BID (held) - Tamsulosin 0.4 mg daily ### Mental Status Examination **Appearance:** Elderly man in hospital gown, disheveled, Foley catheter and IV in place **Behavior:** Variable - during examination was picking at IV tubing and bed sheets; intermittently agitated; poor eye contact **Speech:** Disorganized, mumbling, sometimes incoherent **Mood:** Unable to assess **Affect:** Fearful, suspicious, irritable **Thought Process:** Disorganized, tangential, difficult to follow **Thought Content:** - Paranoid content ("they're trying to kill me") - Disoriented to place (thinks he's at work) - Unable to assess for suicidal or homicidal ideation due to disorganization **Perceptions:** Appears to be responding to visual hallucinations (reaching for things not present, startled by unseen stimuli) **Cognition:** - Attention severely impaired: Cannot spell WORLD backward, cannot count backward from 20 - Orientation: Knows name only; disoriented to place (thinks he's at his old workplace), date (states it's 1987), and situation - Memory: Unable to register 3 words - Fluctuating level of consciousness - alternates between hyperalert and somnolent **Insight:** None - does not recognize he is confused **Judgment:** Severely impaired ### Assessment with CAM (Confusion Assessment Method) **Feature 1 - Acute Onset and Fluctuating Course:** YES - Acute change from baseline (was cognitively intact pre-operatively) - Mental status fluctuates throughout the day **Feature 2 - Inattention:** YES - Cannot spell WORLD backward - Easily distracted, cannot maintain conversation **Feature 3 - Disorganized Thinking:** YES - Incoherent, tangential speech - Illogical flow of ideas **Feature 4 - Altered Level of Consciousness:** YES - Fluctuates between hyperalert/agitated and lethargic **CAM Result:** POSITIVE for delirium (Features 1 + 2 + 3 and 4) ### Diagnostic Workup **Laboratory Studies:** - CBC: WBC 12.4 (elevated), Hgb 10.2 - CMP: Na 148 mEq/L (elevated), BUN 32, Cr 1.4 (elevated from baseline 1.0), glucose 186 - UA: Positive for leukocyte esterase, nitrites, WBC >50 - Blood cultures: Pending - TSH: 2.1 (normal) **Imaging:** - CT Head: No acute intracranial abnormality - Chest X-ray: No infiltrate ### Diagnosis **Delirium Due to Multiple Etiologies (F05)** **DSM-5 Criteria Met:** A. Disturbance in attention and awareness (reduced ability to focus, sustain, shift attention) B. Develops over short period (hours), represents change from baseline, fluctuates C. Additional cognitive disturbance (disorientation, memory, language, perception) D. Not better explained by pre-existing NCD, does not occur in coma E. Evidence of medical etiology (UTI, dehydration, medications) **Subtype:** Mixed (alternating hyperactive and hypoactive features) **Identified Contributing Factors:** 1. Urinary tract infection 2. Dehydration/hypernatremia 3. Medications: Oxycodone (opioid), Diphenhydramine (anticholinergic) 4. Post-operative state 5. Sensory deprivation (hearing aids not used in hospital) 6. Sleep deprivation 7. Unfamiliar environment ### Treatment Plan **Treat Underlying Causes:** - Start empiric antibiotics for UTI (ciprofloxacin or alternative based on local resistance patterns) - IV fluid resuscitation for hypernatremia and dehydration - Discontinue diphenhydramine (anticholinergic) - Reduce/taper oxycodone, transition to scheduled acetaminophen with PRN low-dose opioid - Optimize glucose control **Non-Pharmacological Management:** - Ensure hearing aids are in place - Reorientation: Place clock and calendar at bedside, have family photos visible - Consistent nursing staff when possible - Minimize room changes - Preserve sleep-wake cycle: Minimize nighttime interruptions, open blinds during day - Early mobilization as orthopedics allows - Remove Foley catheter as soon as possible - Have family present during daytime hours - Avoid physical restraints **Pharmacological Management (for agitation/safety):** - Haloperidol 0.5-1 mg PO/IM PRN for severe agitation (low dose given age) - Monitor QTc - Avoid benzodiazepines (would worsen confusion) **Monitoring:** - CAM assessment every shift - Daily reassessment of medications - Electrolytes daily until normalized - Fall precautions **Expected Course:** - Delirium typically resolves in days to weeks once underlying causes addressed - Full cognitive recovery expected given intact baseline - Counsel family about fluctuating course --- ## 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 --- ## Case 3: Lewy Body Dementia ### Patient Demographics - **Age:** 71 years old - **Sex:** Male - **Occupation:** Retired architect ### Chief Complaint Per wife: "He sees children in our living room who aren't there, and he's been acting out his dreams so violently he fell out of bed." ### History of Present Illness The patient is a 71-year-old man whose wife reports 18 months of progressive cognitive changes, visual hallucinations, and behavioral disturbances. The cognitive symptoms began with difficulty with spatial tasks - he got lost driving, had trouble reading blueprints (his professional expertise), and struggled with the TV remote. Memory problems are present but not as prominent as the spatial difficulties. The hallucinations began approximately 10 months ago. He sees detailed images of small children playing in the house, often in the evening. He sometimes talks to them and becomes distressed when his wife tells him they're not real. He also reports seeing his deceased brother sitting in a chair. The hallucinations are vivid and fully formed, not vague shapes. His wife reports dramatic fluctuations in his mental status - some days he's nearly his old self, other days he seems confused and "far away." These fluctuations occur even within the same day. For several years before cognitive symptoms, his wife noticed he was acting out his dreams - yelling, punching, and kicking in his sleep. He once fell out of bed while "fighting someone" in a dream. She started sleeping in a separate room for safety. In the past 6 months, she's noticed he moves more slowly, shuffles when he walks, and his handwriting has become small and cramped. ### Mental Status Examination **Appearance:** Elderly man, masked facial expression, mild tremor at rest **Behavior:** Cooperative but slow to respond, stares off at times, attention waxes and wanes during interview **Speech:** Hypophonic (soft), slow rate **Mood:** "Okay" (impoverished response) **Affect:** Flat, limited range **Thought Process:** Slow but linear when engaged **Thought Content:** - Describes visual hallucinations of children in matter-of-fact way - Some insight that hallucinations may not be real - No paranoid delusions - No suicidal ideation **Perceptions:** Well-formed visual hallucinations of people (children, deceased relatives), occurring especially in evening **Cognition:** - Attention: Fluctuates markedly during examination - MoCA: 20/30 - Visuospatial: 0/5 (severely impaired - could not copy cube, very poor clock) - Memory: 3/5 (relatively preserved) **Insight:** Partial - acknowledges some problems but inconsistent **Judgment:** Impaired ### Physical/Neurological Examination **Motor Findings:** - Bradykinesia (slow movements) - Cogwheel rigidity bilateral upper extremities - Shuffling gait with reduced arm swing - Mild resting tremor, left > right - Postural instability (positive pull test) ### Diagnosis **Major Neurocognitive Disorder with Lewy Bodies, Probable (G31.83 + F02.81)** **Core Clinical Features (2 of 3 required for "probable"):** 1. **Fluctuating cognition:** YES - marked variations in attention and alertness 2. **Recurrent visual hallucinations:** YES - detailed, well-formed images of children 3. **REM sleep behavior disorder:** YES - dream enactment with violent movements **Supportive Clinical Features:** - Parkinsonism: Present (bradykinesia, rigidity, tremor, gait changes) - Severe neuroleptic sensitivity: Not yet tested (AVOID typical antipsychotics) **Timing Criterion:** - Dementia developed before parkinsonism became prominent (distinguishes from Parkinson's disease dementia) ### Treatment Plan **CRITICAL - Medication Precautions:** - **AVOID typical antipsychotics (haloperidol, etc.)** - severe neuroleptic sensitivity can cause life-threatening rigidity, autonomic instability - If antipsychotic needed for severe psychosis, only low-dose quetiapine or pimavanserin **Cognitive Symptoms:** - Donepezil 5 mg at bedtime (cholinesterase inhibitors may help cognition and hallucinations) - Titrate to 10 mg in 4-6 weeks **Visual Hallucinations:** - If not distressing and patient has insight, may not require treatment - If distressing: Low-dose quetiapine 12.5-25 mg at bedtime - Consider pimavanserin (FDA-approved for Parkinson's psychosis) **REM Sleep Behavior Disorder:** - Melatonin 3-6 mg at bedtime (first line, well-tolerated) - Ensure safe sleep environment (mattress on floor, remove sharp objects) - If melatonin insufficient, low-dose clonazepam 0.25-0.5 mg **Parkinsonism:** - Mild symptoms - no treatment unless functionally limiting - If treatment needed, low-dose carbidopa-levodopa (may worsen hallucinations) **Safety:** - Driving cessation - Fall precautions (PT evaluation, remove tripping hazards) - Supervision due to fluctuating cognition **Follow-up:** - Neurology/Movement disorders clinic in 6 weeks - Close monitoring for medication side effects - Family education about neuroleptic sensitivity - provide letter for medical emergencies --- ## Image Attribution ![Neurocognitive Disorders Brain Imaging](case_01_image.jpg) *Image: MRI brain imaging comparing normal aging, Alzheimer's disease with hippocampal atrophy, and vascular dementia with white matter changes. Source: Radiopaedia. Used for educational purposes under Creative Commons license.*