Apply information from the Aquifer virtual case studies to answer the following questions:
• What is the CC in the case studies? What are important questions to ask the patients to formulate the history of present illness and what did the patients tell you?
• What components of the physical exams are important to review in the cases? What are pertinent positive and negative physical exam findings to help you formulate your diagnosis?
• Which differential diagnosis is to be considered with each case study? What was your final diagnosis?
Attached are both case scenarios' summary.
Internal Medicine 18: 75-year-old male with memory problems
You are working in the internal medicine clinic today with Dr. Irving. She asks you to evaluate Mr. Caldwell, a 75-year-old male, who is here today with his daughter because of concerns about his memory raised at his last visit.
1. Focused history
2. Cognitive assessment
3. Functional evaluation
You go to the exam room and introduce yourself to Mr. Caldwell. He responds, "Happy to meet you. This is my daughter Kathy."
After you've greeted them both briefly, you begin asking Mr. Caldwell questions about his memory.
"Oh, I have the same memory problems as any 75-year-old. Occasionally, I forget my keys or forget something at the grocery store. But I still remember my wedding day and I still remember my grandchildren's names. I'm not doing any worse than any of my friends."
"Well, my wife used to manage the money until she died two years ago. I have trouble with the numbers in my checkbook and trouble figuring out my medications so Kathy takes care of these things for me now."
After this initial questioning, you proceed with your cognitive evaluation.
The MoCA test is administered to Mr. Caldwell. He achieves a score of 17, suggesting moderate impairment.
Based on Mr. Caldwell's score, how would you classify his memory loss? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
· A. Delerium
· B. Depression
· C. Major neurocognitive disorder
· D. Mild neurocognitive disorder
· E. Normal aging
> The correct answer is C
Mr. Caldwell has a score of 17 and by his history has problems in at least one DSM-5 cognitive domain. In addition, some of his instrumental activities of daily living like managing his medications and finances are now not possible. He is classified as having Major Neurocognitive Disorder (C).
Major Neurocognitive Disorder
The main subtypes of major neurocognitive impairment that classify as forms of dementia are as follows:
· Alzheimer disease
· Vascular disease / dementia
· Lewy body dementia
· Frontotemporal lobar degeneration
The additional subtypes are as follows:
· Parkinson disease
· Traumatic brain injury
· Prion disease
· Huntington disease
· Substance/medication use
· Other medical condition
· Multiple etiologies
The DSM-5 estimates that the prevalence of major neurocognitive disorder (which they use congruently with the term dementia) vary across ages.
The prevalence of Major Neurocognitive Disorder is approximately 1-2% at age 65 and as high as 30% by age 85.
The prevalence of Mild Neurocognitive Disorder ranges from 2-10% at age 65 and from 5-25% by age 85.
Development and Course:
When due to neurodegenerative conditions like the common forms of dementia, the onset of symptoms is usually insidious and gradual. Later in life if may be difficult to distinguish normal aging from prodromal phases of Mild Neurocognitive Disorder. In addition, given the high prevalence of other medical conditions in older individuals, the symptoms of these conditions often go unnoticed or are overlooked due to the coexisting problems.
Age is the most common risk factor since increased age leads to greater neurodegenerative and cerebrovascular disease. Females are also more prone to developing these conditions, although this may be due to their overall increased lifespan.
After Mr. Caldwell grants you permission, you ask his daughter a couple of questions about his activities of daily living:
"Have you noticed that your father has any trouble with his memory?"
"I definitely think he's having some trouble. He has a lot more trouble remembering new information. He's right, he does remember things that happened a long time ago, like his wedding, and he knows all of his grandkids. However, last week he forgot what he needed at the store and he has missed some bills and occasionally forgets his medications."
"Is he able to prepare his own meals?"
"Dad makes his own meals and eats well – he was always the cook in the family. He can do his laundry and take care of the house. He doesn't drive or get out much because he doesn't have a car and he has some trouble with his balance because of his knee pain, so my husband and I or our kids take him on most of his errands."
Functional Assessment: Activities of Daily Living
Activities of daily living (ADLs) are divided into two subcategories: basic and instrumental (IADLs)
· bathing and toileting
· maintaining personal hygiene
· managing finances
· managing transportation
· preparing food
· managing medications
The patient's family members may be very helpful with this information.
Which of the following basic or instrumental ADLs are likely to be affected early in the course of dementia? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
· A. Bathing
· B. Doing laundry
· C. Dressing
· D. Managing finances
· E. Managing medications
Now that you have gained some information about Mr. Caldwell's memory, you take a second to review his medical history with Mr. Caldwell and his daughter:
2. Occasional insomnia
Social history / habits
Social history / habits:
· retired high school librarian
· lives at home alone
· widowed for 2 years
· 2 close friends in his apartment complex
· never smoked
· occasional alcohol around holidays only, never excessive.
1. Hydrochlorothiazide 25 mg by mouth once a day.
2. Amlodipine 5 mg by mouth once a day.
3. Lorazepam 2 mg by mouth before bed as needed for insomnia (takes 2-3 times/week).
4. Acetaminophen 500 mg – two tablets by mouth three times per day.
5. Lovastatin 40 mg by mouth once a day.
Avoid Polypharmacy, Especially in Older Adults
Review the medication list at every visit to ensure the most appropriate and least number of medications are being prescribed.
Polypharmacy is a common problem among older patients and can result in avoidable adverse drug events.
Don't forget to include over-the-counter medications, supplements, and herbal remedies
You have completed your initial assessment of Mr. Caldwell's memory problems, so you move on to other important and common issues to assess in the geriatric patient, such as fall risk assessment:
He responds, "no," and his daughter agrees. However he does say that he occasionally feels "unsteady".
"Well, I'm not dizzy and I don't feel lightheaded. It's just this feeling that I could trip and fall. I think part of it is because my knees bother me from the arthritis. I have to be more careful where I step and pay more attention to my feet."
"It's hard to say. It may be worse when I wake up in the morning, or if I have to get up in the middle of the night."
"Yes, I had my hearing tested last month, and it was fine."
Screening for Hearing and Vision Deficits
While hearing and vision impairment may contribute to fall risk in older patients, routine hearing and visual acuity screening in people over 50 years old is not currently recommended by the U.S. Preventive Services Task Force.
Vision: In 2016 it was concluded that current evidence is insufficient to assess the balance of benefits and harms of visual acuity screening in the improvement of outcomes in older adults. (Grade I statement.)
Which of the following items from Mr. Caldwell's history increases his risk of falling in the next year? Select all that apply.
The best options are indicated below. Your selections are indicated by the shaded boxes.
· A. Cognitive impairment
· B. History of hyperlipidemia
· C. Knee osteoarthritis leading to difficulty ambulating
· D. Polypharmacy
· E. Use of acetaminophen
· F. Use of lorazepam
> The correct answers are A, C, D, F
Mr. Caldwell's risk factors for fall include:
· Cognitive impairment (A)
· Self-reported gait disturbance from osteoarthritis (C)
· Use of more than four prescription medications (D)
· Use of lorazepam (F)
· Use of hydrochlorothiazide (a diuretic)
History of hyperlipidemia (B) is a risk factor for coronary artery disease, but not for falling. Use of acetaminophen (E) can cause hepatic failure in high doses but is not a risk factor for falling.
Fall Risk Factors
The more risk factors a patient accumulates, the more likely he or she is to fall.
According to the CDC, risk factors for falls can be divided into Intrinsic and Extrinsic categories as outlined below:
· Advanced age
· Previous falls
· Muscle weakness
· Gait and balance problems
· Poor vision
· Postural hypotension
· Chronic conditions including arthritis, stroke, incontinence, diabetes, Parkinson
· Cognitive impairment
· Fear of falling
· Lack of stair handrails
· Poor stair design
· Lack of bathroom grab bars
· Dim lighting or glare
· Obstacles and tripping hazards
· Slippery or uneven surfaces
· Psychoactive medications
· Improper use of assistive device
You move on to ask Mr. Caldwell about urinary incontinence:
"Do you ever notice leaking urine?"
"Well, since you mention it, I do. It's been going on for a year or two now and hasn't changed much."
"When do you notice it?"
"I can't always predict when it's going to happen. It's not when I sneeze or cough — my wife used to have that problem. Usually it's when I have a full bladder or sometimes right after I empty my bladder. I also have a hard time starting the stream sometimes, and sometimes more comes out after I think I'm done."
"Do you need to get up to urinate at night?"
Make sure to assess for this during your interviews, because patients often will not volunteer this information. Incontinence is a common problem in older patients and is often multifactorial.
A symptom diary can be very helpful in assessing the severity of incontinence. This involves tracking when incontinence occurs and whether it seems to be triggered by specific times of day, beverages, medications, or other circumstances.
From the history provided, what type of incontinence do you suspect Mr. Caldwell exhibits? Choose the single best answer.
The best option is indicated below. Your selections are indicated by the shaded boxes.
· A. Functional incontinence
· B. Overflow incontinence
· C. Stress incontinence
· D. Urge incontinence
> The correct answer is B
Mr. Caldwell's description of difficulty starting the stream suggests "hesitancy," and his description of more coming out when he thinks he's done suggests "dribbling"-both of which are consistent with overflow incontinence (B), possibly due to benign prostatic hypertrophy.
He specifically denies trouble when coughing or sneezing which rules out stress incontinence (C), makes no mention of either rushing to "make it in time" (D) or physically not being able to get to the toilet when he needs to go (A).
You are now ready to examine Mr. Caldwell. Kathy asks Mr. Caldwell if she should leave, and he requests for her to stay.
Prior to performing the physical exam, you consider specific elements that may be helpful in the assessment of the syndromes you have reviewed so far.
· Mini mental state exam or other neurocognitive assessment
· Complete neurological exam
· Depression screening
· Joint exam for abnormalities
· Cardiovascular exam, including examination for bruits and orthostatic vital signs
· Complete neurologic exam, especially focused on proprioception and strength
· Walking speed (normal is 15 feet in < 7 seconds)
· Men: Prostate exam to assess for hypertrophy or nodules
· Women: Complete pelvic exam to assess for atrophy, pelvic floor muscle weakness or pelvic masses
You re-enter the room once Mr. Caldwell is ready and begin the exam.
Orthostatics: Lying BP 124/75, pulse 82; Standing BP 132/72, pulse 76.
HEENT: Sclerae anicteric. No conjunctival pallor. Mucous membranes moist.
Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmurs/rubs/gallops. No carotid bruits. Extremities warm, 2+ pulses, no edema.
Chest: Clear to auscultation bilaterally, no wheezes/rales/rhonchi.
Abdomen: Soft, non-tender, non-distended, no organomegaly.
Musculoskeletal: Mild crepitus in knees bilaterally. No knee effusions or warmth. No joint line tenderness. Get Up and Go test takes 18 seconds. Patient has an antalgic gait, favoring left leg. Does not need to use arms to rise from a seated position. Does not appear unsteady.
Neurologic: Cranial nerves II-XII grossly intact. Strength 4+/5 in bilateral upper and lower extremities. Grip strength 5/5 bilaterally. Reflexes 2+ throughout. Normal heel-knee-shin, rapid alternating movement, and finger-nose-finger. Normal Romberg. Sensation is intact in upper and lower extremities to light touch.
Mr. Caldwell's physical exam is normal except for his Get Up and Go test. You realize that, in addition to his major neurocognitive disorder, Mr. Caldwell is at high risk for falling.
"Get Up and Go" Test
Instructions for patient:
Get up (without armrests, if possible), stand still for a moment, walk forward 10 feet, turn around and walk back to chair, turn and be seated.
A normal time ranges from 8-12 seconds. Patients who take greater than 14 seconds to complete this are at higher risk for falls.
In addition, the assessor should make note of sitting balance, transfers from sitting to standing, pace and stability of walking, and ability to turn without staggering.
You tell Mr. Caldwell he can get dressed and you will come back with Dr. Irving.
When you leave the room, you feel like you have formulated a plan for what to do about Mr. Caldwell's fall risk. However, you are still unsure about how to approach his major neurocognitive disorder.
Major Neurocognitive Disorder (Dementia) Subtypes
Review the different subtypes of major neurocognitive disorder.
Alzheimer dementia (AD) accounts for 75% of cases of major neurocognitive disorder. It usually presents as gradual memory loss, with specific difficulties in short-term memory and in learning new facts. Patients may have a family history of AD. It is caused by amyloid plaques and neurofibrillary tangles in the brain, which can only be confirmed at autopsy. However, the clinical diagnosis is up to 90% accurate. AD should be considered a terminal illness; average life expectancy after diagnosis is about six years.
Lewy body dementia (LBD) is another common cause of major neurocognitive disorder. It is caused by the deposition of Lewy bodies in the nuclei of cerebral cortical neurons. LBD is characterized by fluctuations in memory and cognition, visual hallucinations, and parkinsonism. "Parkinsonism" refers to resting tremor, bradykinesia, rigidity and postural instability that are typically associated with Parkinson disease but can be caused by other disorders.
Vascular dementia classically manifests as step-wise deterioration in memory. It is thought to be due to damage from discrete vascular events, such as strokes or transient ischemic attacks (TIAs). Patients have other vascular risk factors and evidence of past stroke on exam or imaging. The presentation and course of vascular dementia is very heterogenous due to differences in extent, severity, number, and location of the vascular lesions.
Frontotemporal dementia (FTD) is characterized by dementia associated with behavior/personality changes and language impairment. FTD is typically used to describe a group of disorders that have different causes, but all types involve atrophy of the frontal and temporal lobes, which is thought to be the cause of symptoms. It is a common cause of major neurocognitive disorder in individuals younger than 65.
Recall from prior that other subtypes of major neurocognitive disorder include Parkinson disease, Huntington disease, traumatic brain injury, HIV, prion disease, substance/medication use, and cases of multiple etiologies.
Evaluating For Reversible Causes Of Major Neurocognitive Disorder
All patients with concern for cognitive impairment should be screened for depression. This condition is common in older adults and may be mistaken for cognitive impairment. There are several validated screening tools like the Patient Health Questionnaire 2 or 9 and the Geriatric Depression Scale.
The American Academy of Neurology (AAN) recommends screening for B12 deficiency with a B12 level and a complete blood count as well as screening for hypothyroidism with a TSH level. Other potential tests are detailed below.
Hypothyroid or hyperthyroid conditions can contribute to cognitive impairment.
Vitamin B12 and Complete Blood Count
While both folate and B12 deficiencies can cause macrocytic anemia, only B12 deficiency can cause posterior column disease and cognitive impairment. As part of the evaluation for vitamin B12 deficiency, the AAN also recommends a complete blood count.
Complete Metabolic Panel
While some metabolic abnormalities can lead to memory impairment there is no clear evidence that this test is useful or cost-effective so it should not be routinely sent. Examples of electrolyte issues that could cause cognitive symptoms include:
Hypercalcemia leading to confusion, psychiatric disturbances, and memory loss, particularly in older patients, and hyponatremia leading to mental status changes in older adults.
Rapid Plasma Reagin (RPR) and HIV
Screening for these conditions is not routinely recommended unless the patient is high risk due to sexual history or travel.
Thiamine (Vitamin B1)
In patients with a history of alcohol abuse or those who are not receiving adequate nutrition, it is also reasonable to consider thiamine deficiency. In the U.S., thiamine deficiency is most commonly seen in patients with alcohol use disorder and typically causes Wernicke-Korsakoff syndrome. Wernicke syndrome is characterized by nystagmus or other ocular abnormalities, gait abnormalities, and memory loss with other mental status changes. It develops over days. Korsakoff syndrome includes retrograde and antegrade amnesia. These syndromes are part of a spectrum of disorders.
The question of whether to obtain imaging, such as a head CT or MRI in the workup of dementia is also controversial. The AAN recommends a non-contrast head CT or MRI as part of the routine workup. In theory, this imaging would help exclude other contributing pathologies such as stroke, subdural hematoma, normal pressure hydrocephalus, and an intracranial mass.
You present your findings to Dr. Irving and explain that you would like to evaluate for reversible causes of major neurocognitive disorder by ordering a TSH, B12 level, and a complete blood count.
Dr. Irving tells you that she administered a PHQ-9 questionnaire to Mr. Caldwell at his last visit and that did not show any evidence of depression, which can lead to cognitive impairment.
She also reminds you it is very important to review a patient's medications and consider the impact they may be having on the patients symptoms. Mr. Caldwell is taking hydrochlorothiazide, which can cause clinically significant hyponatremia, especially in older patients. Hyponatremia can cause mild memory deficits and could increase Mr. Caldwell's risk for falls as well. For this reason she recommends checking a basic metabolic panel as well.
All medications can have unwanted side effects, but older patients are at higher risk for many reasons.
1. Older adult patients are often on multiple medications that interact.
2. With aging, there are physiologic changes affecting pharmacokinetics and pharmacodynamics.
3. Poor nutritional intake and renal or liver impairment can cause problems with metabolism of medications.
4. Drug clearance may be decreased by an age-associated decline in renal function.
5. As older patients lose muscle mass relative to fat, the volume of distribution of many drugs increases and patients may require lower doses of drugs.
· Poor nutritional intake and renal or liver impairment can cause problems with metabolism of medications.
· Drug clearance may be decreased by an age-associated decline in renal function.
· As older patients lose muscle mass relative to fat, the volume of distribution of many drugs increases and patients may require lower doses of drugs.
It's important to consider all of these factors before prescribing a medication to an older patient. In particular, reviewing the appropriateness and indications for opioids, anxiolytics, and any medications with anticholinergic properties should be done at each visit.
You discuss the diagnosis of major neurocognitive disorder as follows:
"Well, I figure you are trying to find out if there is something wrong with me. I guess you might be concerned about my memory. I know I have some forgetfulness and need assistance with certain things, but I figured it was just me getting old."
"Just make it easy for me to understand. I’m a big picture kind of guy."
You say "Okay. Unfortunately, the news may not be what you want to hear, I’m afraid. Based on your testing you have dementia, or what we call dementia." You pause for a few moments to allow him time to process this news. Kathy appears tearful, and Mr. Caldwell just looks at you silently.
Then Mr. Caldwell asks: "Is this Alzheimer's dementia?"
"Well, it's not what I wanted to hear, but I'm not totally surprised. Kathy and I have been worried about this. I guess it might just take a little time to sink in."
"It can sometimes be difficult to tell. Some people do find that memory declines as they age. However, that typically doesn't interfere with their ability to perform their daily activities. Because your dad is having trouble with his finances and his grocery shopping, his memory loss is more severe and qualifies as dementia. In addition, the test that your father did last week, called the mini-mental state exam, helps to confirm our diagnosis."
You add, "This is a lot to take in; what other questions do you have?" Kathy asks for more information about Alzheimer’s dementia. Dr. Irving refers them to the Web site of the Alzheimer's Association.
You plan that Mr. Caldwell will follow up in clinic in 2-4 weeks after he has had his home-safety evaluation and physical therapy. You plan to address the discussion of medications at that time.
You are in clinic with Dr. Irving two weeks later when Mr. Caldwell and Kathy return for a follow-up visit.
You review his chart and find all of the labs you checked returned normal.
Dr. Irving asks you to go into the room and see how things are going with Mr. Caldwell. She will come in later to discuss follow-up of Mr. Caldwell's Alzheimer’s dementia.
You greet Mr. Caldwell and Kathy:
"Mr. Caldwell, it's great to see you! How is it going with the physical therapist?"
"Good to see you again! It's going pretty well. She has been out to the house twice. We're working on leg exercises, and I do them every day for 20 minutes, even when she's not there. I haven't noticed a big difference in my balance yet, but I do feel a little stronger. And it's nice to have the company."
"Kathy how did the home-safety evaluation go?"
"They were great. They came and took away a few slippery rugs I'd been trying to get Dad to get rid of. They are going to come back out and help us get some bars in the bathroom, and they set up some night lights for Dad. I think it was really helpful."
"How have you been sleeping without the lorazepam?"
"OK, I think. The first few nights it was hard to fall asleep, and it still takes me longer, but I feel less groggy in the morning. I'd rather have it back, but if you think it's important to stay off it, then I will."
Dr. Irving now joins you to discuss the possibility of initiating medication for Mr. Caldwell's Alzheimer’s dementia.
"Using medications to treat patients with Alzheimer’s dementia is controversial. There are two types of medications that are typically used." She continues to describe the indications and side effects of cholinesterase inhibitors and memantine concluding, "Your dad's Alzheimer’s dementia is moderate, so we would consider prescribing medication for him at this point."
"I'd like to get a little more information about these drugs and talk it over with Kathy a little more," Mr. Caldwell says.
Although there are no medications to cure Alzheimer’s disease or other forms of dementia, there are several medications that may be used to help slow the progression of cognitive and functional decline.
Cholinesterase inhibitors (ex: donepezil, rivastigmine, and galantamine)
· Indications: Used for patients with dementia of any severity – mild, moderate, or severe
· Effectiveness: There may be small, beneficial effects in cognitive and functional performance, though the clinical significance of these effects is unclear
· Common side effects: Nausea, vomiting, and diarrhea, but these usually get better if people keep taking the medications
· Indications: Moderate or severe Alzheimer’s dementia
· Effectiveness: Studies have shown small improvements in cognition but the clinical significance is unclear
· Common side effects: Dizziness, possibility of confusion and hallucinations
There is some research that demonstrates the potential for cognitive and functional performance may be better if memantine and a cholinesterase inhibitor are used together, but once again the clinical significance remains unclear.
These medications all cost more than $150 per month if paid for out of pocket. However, with insurance coverage the cost is much lower.
For each of these medications, treatment decisions should be individualized and consider drug tolerability and cost.
· There are ongoing studies on various supplements including vitamins for treatment or prevention of dementia. So far, the available research has been disappointin
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