Post on 17-Jul-2015
Case Discussion20 April 2015
Dr. Ravi Soni, DM-SR IIDepartment of Geriatric Mental Health,K.G.M.U. Lucknow
Demographics of the patient
Patient
Mr. QA, a 65 year old married Muslim male, retired
primary school teacher, belonging to rural
background from safipur, Sandila admitted to
Department of Geriatric Mental Health in April 2015.
Reason for admission:
Diagnostic evaluation and management
Informants 1. Wife Mrs Bano ali, Homemaker, illiterate
Living with the patient since marriage [45 years]
Carer since onset of illness and well wisher of patient
Patient of DM, HTN, Arthritis knee joint, depression
Not reliable and inadequate information: she lacks perceptiveness to notice subtle
behavioral changes and she is not able to give consistent account of illness in
chronological order
2. Son: Mr Assif ali, 40 years old, married, inter pass, private accountant
Patient of chronic kidney disease and had kidney transplantation before 15 years
Appears to be of sound mind, able to give coherent and consistent account of
illness in chronological order. Reliable and adequate information provided
Illness Characteristics
Insidious onset
Progressive and continuous course
Total duration of illness – four years?
Increased symptoms severity for last 4 months
Chief Complaints
As reported by wife:
Forgetfulness
Easy irritability and aggression
Suspiciousness that his belongings has been
stolen
Not sleeping at night
Not able to take proper care of himself
Stress
1. Retirement in June 2012.
2. Youngest son is having some incurable kidney
disease for which he had kidney transplant
History of Presenting Illness
QA was FTC of bipolar affective disorder for last more than 35
years. [exact duration not available]
Before four years, from the year of 2011, family members started
noticing that pt was forgetting his belongings after placing them
somewhere, for which he was making thorough search and asked
family members to help in finding them.
The frequency of this forgetfulness later on increased.
Gradually he was also forgetting recent events and activities. He
started forgetting conversation with family member and then he
repeatedly spoke the same matter again and again.
Continued… His forgetfulness has increased to such a severity that he started blaming
family members for his lost belongings. He was suspicious that they have
been stolen by one of the family member.
Patient has also became easily irritable over minor matters. He started
yelling over wife when he was resisted from doing something. [that was also
a part of his past bipolar illness, but the severity was reported as increased]
In June 2012, patient retired from his job as a school teacher. After which
family members have noticed that he was remaining alone most of the
time. Interaction was decreased. Most of the time he was in bed, not taking
any interest in household activities and managing money.
Continued… Feb. 2013 patient had a stroke with right sided
hemiparesis. He was in confusion and delirium for 5 to 6 days.
He has improved from the weakness completely within next 4 months, but his forgetfulness was present.
The severity of the forgetfulness was not increased suddenly after stroke but it was progressing at slow rate as per interview with son.
Sleep disturbance has became major issue because he was not sleeping properly.
He used to sleep for 2 to 3 hours initially and then starts collecting his belongings and placing at different place. He started moving here and there at night, repeatedly awakening his wife and asked to go outside.
Continued… According to youngest son, the symptoms have increased
from January 2015. He has noticed worsening in Forgetfulness Sleep disturbance Aggression Taking personal care Daily activities
Patient also has difficulty in controlling urination for last 4 months
He was not able to go outside of house alone because he became confused and forgot the way back to home twice
Had developed difficulties in eating properly He became confused with day, time and surroundings
sometimes, although he indentifies family member properly
Activities of daily living Instrumental activities: summary of past 4 years
Difficult to evaluate because he was a patient of bipolar illness therefore he was always under supervision of someone.
Even though son has given history regarding difficulty in managing in finances after retirement.
He was operating mobile phone independently before 3 years but now he is not able to dial a number though he can receive a call. He has lost 5 cell phones in last 3 years
He can not be trusted for shopping of any kind because he forgets what to buy and loses all money whatever given to him
He can not travel alone and needs assistance For last 2 years he was given medications by a family member.
Previously he was able to take drugs on his own.
Basic ADLs: According to son1. Occasional mistakes in wearing clothes for last 3 years
before stroke. Difficulty in buttoning shirt.
2. Difficulty in controlling urination for last 6 months
3. Able to eat from a plate but eating manners have been lost like he eats fast and spoils the floor. He tries to eat many food items together for last 4 moths.
4. Previously he used to wash his plate after eating but for last 3 months he does not do that.
5. Now he is not punctual in his bathing time.
Negative history
Perceptual disturbances
Prominent disinhibition
Obsessive-compulsive
symptoms
Substance abuse
Prominent s/o depression
Sugar / carbohydrate
craving, Hyperphagia
Weight gain
History of head trauma
Repeated falls
Gait abnormality or difficulty
No H/O seizure, loss of
consciousness, high grade
fever
Past HistoryBipolar affective disorder, mania
First episode in 1980?, admitted to psychiatric nursing home in Kanpur, given 8 ECTs, improvedOn drug default relapse, more than 15 episodesMaximum symptoms free interval without drugs is 4 monthsSymptoms worsen with change of season, worsening is reported during winter and springHe was always on drugs, last treatment details are as follows: Tab. Torvate 500 twice a day Tab. Ativan 2 mg at night Tab. Vintel-AM ABF
Family History Family of low-middle socio-economic status, joint family, consisting of 7
members including two sons and three daughters until 15 years before after which both children got married and separated
Currently patient and his wife live alone in sandilla There is cordial relation between family members and patient used to be
head of family, but any major decision would be taken by jointly with advices of both sons [patient was not allowed to make decision on his own after the bipolar illness started]
They have their own 3 Pucca house one in sandilla, one in dubagga LKO, one in unnao.
Average family income from all sources is usually 35 k Patient is a pensioner and receives 18 k per month There is no history of psychiatric disorder in first degree relatives of patient
Personal History Early development: not known Adolescent sexual history: not known Occupational history: stable Social relations: Poor [after psychiatric illness] Substance use: no substance use Marital history: child marriage at the age of 14
years Wife came to live with him after 5 years of marriage Well adjusted before psychiatric illness No history of extramarital affair Repeated marital disharmony because of bipolar illness 5 children, 2 sons and 3 daughters
Premorbid Personality Social relation: poor after illness, not having close friends,
rarely attend social gatherings Intellectual activities, hobbies, & interests: no specifics Mood: bright, cheerful, optimistic Character:
Attitude toward work & responsibility: hard working Interpersonal relationship: confident, trusting relatioships Standards in moral, religious, social and health matters: not a
religious person Energy & initiative: most of the adult life spent in illness Fantasy life: not elicited Impression: disturbed because of the illness
Physical examination
Vital Signs, General Exam, CVS, RS, GI, GU and MS : WNL
Cranial nerves were normalMotor System: Bulk, tone, power and reflexes were normal
bilaterally.Plantars were flexorsSensory System: WNLCoordination: normalSkull and spine: normal
Mental status examination
General appearance and behavior
Well kempt, tidy, mesomorphic. Walks with slow steps, tremulousness
is seen in upper limbs
Psychomotor activity is within normal range
Patient retains social smile
Eye contact is established and sustained. Rapport easily established.
Cooperative
MSE continued….
Attentive with appropriate dressing, grooming
Facial expressions decreased in range and looked tense
Speech and language:
Spontaneous, relevant, coherent speech which was loud
Tone, volume and pressure – no change in tone, volume and
prosody
Naming, repetition, reading and writing normal
Phonation, articulation WNL
Some disturbance in fluency and comprehension [? Attention
problems]
MSE continued…. Conscious and oriented to place and person but not to time Attentive, east to arouse but not sustained Serial subtraction 100-7: 2/5 DF/DB: DF: 4/5, DB: 3/5
Affect and Mood:Affect: apprehensiveSubjective: euthymicObjective: AnxiousRange: decreasedIntensity: normalStability: normalDiurnal variation: absent
MSE continued….
Thinking: Stream: Reaction time: normalIntensity: audibleSpeed: retardedProductivity: decreasedEase of speech: spontaneousVolume: normalPitch, tone and fluctuations: normal
Form: relevant, coherent, absence of any formal thought disorderPossession of thought:
Obsession, compulsion, thought alienation absent
Content: Dominant preoccupations absentIdeas of theft present occasionallyOvervalued ideas, delusions absentPhobias and somatization absent
MSE continued….Perception:
Sense distortion: absentSense deceptions: absentContent: absentOther psychotic phenomena: absent
Memory: Immediate: unimpairedRecent: impairedRecent past: impairedRemote: somewhat impaired
Intelligence: above averageGeneral fund of knowledge: satisfactoryArithmetic intelligence: satisfactoryAbstract intelligence: impaired
Judgment: Test, social and personal judgment: poor
Insight: absent
IN SUMMARYProgressive cognitive decline over 4 yearsADL: [katz index and lawton’s IADL]
IADL impaired.Basic ADL Moderate impairment
Behavior: [NPI]Delusions, Agitation, Anxiety, Irritability, SNBD
Cognition: [MMSE, CDT]Amnesia, Attention and Concentration difficulties, Visuospatial impairment, Executive Dysfunction
CDR: 1 Mild impairmentGDS: Global stage 4Hachinski Ischemic score: 4
Patient has drawn rat and CDT
Copy made by patient
Investigations Routine WNL CT Scan: MRI Brain:
MRI Brain Diffuse cerebral atrophy with ischemic demyelination Gliosis in left frontal region in periventricular location with
dilatation of ipsilateral frontal horn.
CT scan head plain
Diffuse cerebral atrophy
DiagnosisProvisional:
Dementia of Alzheimer’s type, late onset with BPSD
D/D:
1. Mixed dementia, Alzheimer’s and Vascular
2. Vascular dementia
3. Fronto-temporal dementia
TreatmentTelma [40] ABFDonep [5] 1 ODQutan [50] 1 HSMeganeurone OD plus 1 ODCalcium 1 ODSatchet calcirol 1/wkAmlong [10] in evening
When patient was admitted he was taking valproate and ativan. Gradually valproate and ativan have been withdrawn
Progress in WardPatient was not sleeping for more than 2 hours initially,
but now we have managed sleep to 4 hours at night. As such there is no improvement in cognition and
behavior.Urinary problems have improved after urology
reference.Tremors in hands have increased recently.
THANKS FOR YOUR PATIENCE!
Language algorithm for the diagnosis of cortical dementias
FTD:Frontotemporal behavioral variant: fvFTD
1. Abulia-amotivational subtype2. Disinhibition subtype3. Obsessive subtype
Primary Progressive AphasiaSemantic Dementia: ftFVD
Associated MND/ALS/Parkinsonism/PSP
AD FTD
First Symptoms Memory loss Apathy, poor judgment/insight, hyperreligiosity, speech/language
Mental State Episodic memory loss Frontal/exe language, spares drawing
Neuropsych Initially normal Apathy, disinhibition, hyperorality, euphoria, depression
Neurologlical Initially normal PSP/CBD ovelap, vertical gaze palsy, axial rigidity, dystonia, alien hand
GTC seizure Late in disesase Not reported
Imaging Entorhinal cortex and hippocampal atrophy
Frontal and temporal atrophy. Post parietal lobule spared