Dementia - Clinical Case Flashcards
70-year-old-man
* GP referred because of concerns about memory
* Accompanied by wife to clinic
* Patient denies any problems “I’m no worse than the average man over 70. My family worry too much. I have no idea why I’ve had to come here.”
Family says:
* Patient asks the same questions every day
* Makes mistakes with respect to taking medication
* Still drives, but could not find his way to son’s house last month, even though going for several years
* Will watch film/TV programme for the second time without realising
* Increasingly irritable
What is the differential diagnosis?
- Alzheimer’s Disease (AD)
- Vascular Dementia (VaD)
- Frontotemporal Dementia (FTD)
- Dementia with Lewy Body (DLB)
- Depression (Reversible)
- Delirium (Reversible)
70-year-old-man
* GP referred because of concerns about memory
* Accompanied by wife to clinic
* Patient denies any problems “I’m no worse than the average man over 70. My family worry too much. I have no idea why I’ve had to come here.”
Family says:
* Patient asks the same questions every day
* Makes mistakes with respect to taking medication
* Still drives, but could not find his way to son’s house last month, even though going for several years
* Will watch film/TV programme for the second time without realising
* Increasingly irritable
What examinations would you conduct?
MMSE (Mini Mental State Examination)
ACE (Addenbrooks Cognitive Assessment)
Neuropsychology assessment
70-year-old-man
* GP referred because of concerns about memory
* Accompanied by wife to clinic
* Patient denies any problems “I’m no worse than the average man over 70. My family worry too much. I have no idea why I’ve had to come here.”
Family says:
* Patient asks the same questions every day
* Makes mistakes with respect to taking medication
* Still drives, but could not find his way to son’s house last month, even though going for several years
* Will watch film/TV programme for the second time without realising
* Increasingly irritable
Upon examination:
* Head-turning sign
* Profound impairment of episodic memory, particularly in relation to recently learned material
* Episodic memory:
* memory for particular episodes in life
* dependent on the medial temporal lobes, inc the hippocampus
What investigations would you conduct next?
MRI
Lumbar puncture
70-year-old-man
* GP referred because of concerns about memory
* Accompanied by wife to clinic
* Patient denies any problems “I’m no worse than the average man over 70. My family worry too much. I have no idea why I’ve had to come here.”
Family says:
* Patient asks the same questions every day
* Makes mistakes with respect to taking medication
* Still drives, but could not find his way to son’s house last month, even though going for several years
* Will watch film/TV programme for the second time without realising
* Increasingly irritable
Upon examination:
* Head-turning sign
* Profound impairment of episodic memory, particularly in relation to recently learned material
* Episodic memory:
* memory for particular episodes in life
* dependent on the medial temporal lobes, inc the hippocampus
Upon investigation:
* Following MRI
* Elevated beta-amyloid in lumbar puncture
What is the most likely diagnosis
Alzheimer’s Disease
70-year-old-man
* GP referred because of concerns about memory
* Accompanied by wife to clinic
* Patient denies any problems “I’m no worse than the average man over 70. My family worry too much. I have no idea why I’ve had to come here.”
Family says:
* Patient asks the same questions every day
* Makes mistakes with respect to taking medication
* Still drives, but could not find his way to son’s house last month, even though going for several years
* Will watch film/TV programme for the second time without realising
* Increasingly irritable
Upon examination:
* Head-turning sign
* Profound impairment of episodic memory, particularly in relation to recently learned material
* Episodic memory:
* memory for particular episodes in life
* dependent on the medial temporal lobes, inc the hippocampus
Upon investigation:
* Following MRI
* Elevated beta-amyloid in lumbar puncture
How is Alzheimer’s Disease confirmed?
Post-mortem amyloid PET scan
78-year-old retired mechanic
* Attended clinic with son
* Able to do less than previously
* Seems very disorientated on some days but fine on others
* Memory not specifically an issue
Upon further interview:
* Stated that they had been having daily visual hallucinations. Seeing children/people in the room, sometimes walking, some blocking the stairs; not frightening; not individuals known to patient
Upon examination:
* Aware of recent news events
* No evidence of altered behaviour
* MMSE 28/30 Errors on ’attention’ (‘7’ subtractions; DLROW)
* No evidence of Parkinsonism
What is the most likely diagnosis?
Dementia with Lowy bodies
78-year-old retired mechanic
* Attended clinic with son
* Able to do less than previously
* Seems very disorientated on some days but fine on others
* Memory not specifically an issue
Upon further interview:
* Stated that they had been having daily visual hallucinations. Seeing children/people in the room, sometimes walking, some blocking the stairs; not frightening; not individuals known to patient
Upon examination:
* Aware of recent news events
* No evidence of altered behaviour
* MMSE 28/30 Errors on ’attention’ (‘7’ subtractions; DLROW)
* No evidence of Parkinsonism
You start the treating the patient with cholinesterase inhibitor (rivastigmine). How would you expect the patient to develop?
- Developed shuffling gait with reduced facial expression
- Hallucinations had decreased in response to treatment, with noted improvement in cognition
72-year-old man attending with his wife
* Wife noticed some problems with his memory e.g. he was uncertain as to what food he had earlier in the day
* At first visit scored quite highly on the MMSE at that point and it was felt that he did not have dementia
* Late last year, his wife had noticed that he had problems with speech and he was “speaking like a dyslexic.” “Where’s my blue chatter?” when he meant sweater
* Using the wrong words when saying things and his speech has deteriorated significantly since then
* She also thinks that he has had some difficulty with understanding speech
* He appeared angry and frustrated when he did not understand
* He has been rude on a number of occasions
* He abruptly left a meal with friends at 9 o’clock last weekend without having had dessert
* He did not ask his wife whether she wanted to accompany him back home, and she had to get a lift with a friend
* Apparently, he has also become obsessive about having bread and butter pudding every evening for the last two to three months
* With respect to personal hygiene, he is now washing himself much less than previously. Whereas before he would have a bath every day, he now washes once or twice a week and will not always wash his hands after going to the bathroom. He is still driving
* Appears symmetrical and his plantars were withdrawn. I could see no evidence of myoclonus or fasciculations.
What is the most likely diagnosis?
Frontotemporal Dementia
72-year-old man attending with his wife
* Wife noticed some problems with his memory e.g. he was uncertain as to what food he had earlier in the day
* At first visit scored quite highly on the MMSE at that point and it was felt that he did not have dementia
* Late last year, his wife had noticed that he had problems with speech and he was “speaking like a dyslexic.” “Where’s my blue chatter?” when he meant sweater
* Using the wrong words when saying things and his speech has deteriorated significantly since then
* She also thinks that he has had some difficulty with understanding speech
* He appeared angry and frustrated when he did not understand
* He has been rude on a number of occasions
* He abruptly left a meal with friends at 9 o’clock last weekend without having had dessert
* He did not ask his wife whether she wanted to accompany him back home, and she had to get a lift with a friend
* Apparently, he has also become obsessive about having bread and butter pudding every evening for the last two to three months
* With respect to personal hygiene, he is now washing himself much less than previously. Whereas before he would have a bath every day, he now washes once or twice a week and will not always wash his hands after going to the bathroom. He is still driving
* Appears symmetrical and his plantars were withdrawn. I could see no evidence of myoclonus or fasciculations.
What investigations would you use to confirm diagnosis?
Blood test
MRI
72-year-old man attending with his wife
* Wife noticed some problems with his memory e.g. he was uncertain as to what food he had earlier in the day
* At first visit scored quite highly on the MMSE at that point and it was felt that he did not have dementia
* Late last year, his wife had noticed that he had problems with speech and he was “speaking like a dyslexic.” “Where’s my blue chatter?” when he meant sweater
* Using the wrong words when saying things and his speech has deteriorated significantly since then
* She also thinks that he has had some difficulty with understanding speech
* He appeared angry and frustrated when he did not understand
* He has been rude on a number of occasions
* He abruptly left a meal with friends at 9 o’clock last weekend without having had dessert
* He did not ask his wife whether she wanted to accompany him back home, and she had to get a lift with a friend
* Apparently, he has also become obsessive about having bread and butter pudding every evening for the last two to three months
* With respect to personal hygiene, he is now washing himself much less than previously. Whereas before he would have a bath every day, he now washes once or twice a week and will not always wash his hands after going to the bathroom. He is still driving
* Appears symmetrical and his plantars were withdrawn. I could see no evidence of myoclonus or fasciculations.
Investigations:
* Blood tests all normal
* MRI showed extensive volume loss in temporal lobes and frontal opercula, more so on right
Do the investigations confirm your diagnosis?
Yes, this is Frontotemporal Dementia
