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