CCS Interactive Case 8

Question 1

75 y/o M, presents to office w/gradual onset of forgetfulness, difficulty with ADLs and money management, wandering behavior, paranoia. No other medical problems, non-alcoholic, good diet, family hx of dementia. Afebrile, HDS.

Ddx?

Answer 1

Alzheimer dementia, vascular dementia, Parkinson’s disease, Lewy body dementia, frontal lobe dementia, reversible dementia (eg, B12 deficiency, hypothyroidism, depression, alcohol-related, NPH)

Question 2

Exam?

Answer 2

Complete physical exam

Question 3

Labs?

Answer 3

CT/MRI head
B12
TSH

Question 4

Rx Alzheimer Disease?

Answer 4

Cholinesterase inhibitors (i.e., donepezil, rivastigmine, galantamine) can improve cognitive function by impoving acetylcholine transmission

Memantine (NMDA receptor antagonist) is also effective, consider as adjunctive

Vitamin E if no heart disease (?)

Question 5

Rx psychotic features?

Answer 5

Atypical antipsychotics

Question 6

Rx depression/anxiety/insomnia?

Answer 6

SSRI - depression
Buspar - anxiety
Sleep hygiene

Question 7

Other

Answer 7

Counsel patient and family, cognitive rehab, occupation therapy, support groups, good nutrition and medication compliance, no driving, medic alert bracelet, advance directives

Question 8

Sequence

Answer 8

Complete physical exam
Order (routine): CBC, BMP, LFTs, TSH, B12, head CT or MRI of brain
Location: home
Clock: appointment in 3-7 days, labs return WNL, patient arrives
Order: donepezil, vitamin E, olanzapine, counseling
Location: home
Clock: schedule in 6 weeks
Case ends
Final orders: none
Dx: Alzheimer disease