Ms. Clark is a white, married female living with her husband and until recently worked as a volunteer at a church food pantry.  She stopped her volunteer activity due to an inability to remember what days and what time of day she was to work.  She also had apparent difficulty finding her way to familiar and close destinations.  She was evaluated in her primary care provider’s office with the findings of problems with immediate and recent memory, word finding difficulties, confirmation of her orientation deficits, and inattention to simple tasks.  She was also  generally disorganized and newly neglectful of her appearance. 

She has a history of osteoporosis, osteoarthritus, and a remote history of depression surrounding the death of a daughter, their only child.  Medications include acetaminophen, estrogen, calcium with vitamin D and multi-vitamin.  Her physical exam is unremarkable except for her mental status exam revealing the deficits described above.  Her Mini Mental Status Exam was 18/30.

1. What diagnosis seems most likely?
2. What specific screening and investigations would help confirm the diagnosis?
3. What management issues do you anticipate?
4. What guidance would you provide the patient and her husband?

The husband and Mrs. Clark are told she likely has Alzheimer’s dementia.  They return to clinic on month later due to concern about a change in her personality, restlessness, early morning insomnia, loss of memory, poor concentration, difficulty in swallowing and a loss of interest in usual activities.  These symptoms have gradually become worse since her last visit.  She complains of poor memory and expresses concern about why she is there and what will happen next.  Her physical examination, neurological examination, and laboratory workup are all within normal limits.  Because of her apparent memory deficits and inability to function independently, her husband requests that she be placed in a nursing facility.  Upon admission to the nursing facility, the evaluation  by her new attending  suggests she is primarily suffering from major depression with anxiety.  She is started on Paroxetine 10 mg qAM and gradually increased to 30 mg a day.  Additionally, she requires Lorazepam 0.25 mg PO bid and 0.5 mg.  After four weeks of  these medications , she shows remarkable improvement.  She becomes independent with her basic ADLs, participates well in group activities and activity therapy, and stops complaining about poor memory.  Evaluation of her cognitive functioning shows  she is now  well oriented and has regained insight and judgement. She  scores 24/30 on the Mini Mental Status Exam.  She continues to improve and a month later is discharged home.

1. What are her primary psychiatric diagnoses?
2. What management strategies would you employ in her follow-up as an outpatient?
3. What is her prognosis for continued functional independence?

Ms. Clark is followed over the next year with no appreciable change in her cognitive capacity.  She is tapered off  Lorazepam after six months and off of  Paroxetine after one year, with no reoccurrence of her major depression with anxiety.   Over the next two years, her memory, orientation, language skills, insight and judgment all progressively deteriorate.  Her Mental Status Exam is 16/30 at the end of this time.  She is diagnosed with probable Dementia of the Alzheimer’s Type.  She is able to participate in a limited discussion concerning her diagnosis and prognosis.  She states that she wants to be kept at home as long as possible.  She also declines any intervention for life-threatening nutritional compromise or infection ,  should either arise.  She requests to be made a “Do Not Resuscitate” and only to be hospitalized for the limited objectives of an easily reversible problem or for her comfort.

Her husband is able to maintain her in the home over the next two years with the help of church volunteers.  She suffers a fall with an intertrochanteric fracture and is admitted for surgical pinning.  She returns to her home with home health care. However, she never resumes adequate oral intake of food or fluid and is enrolled in home hospice.  She succumbs in her home three months later.