R.M. is an 83-year-old woman who presents to the geriatric care clinic for a routine visit. She is accompanied by her two oldest daughters. The patient was diagnosed with probable Alzheimer disease nine years ago when her children reported short-term memory loss and several cognitive manifestations. They noted that she was constantly misplacing her glasses, hearing aid, and keys and that, on several occasions, had placed familiar household items in illogical places-like the coffee pot in the refrigerator. They also reported that she had taken walks in the neighborhood where she had lived for nearly 45 years and got lost. Neighbors had helped her home on more than one occasion.

It was at about this same time that her children and friends also noticed several changes in her personality. She had become very quiet and passive and seemed to have lost all motivation and interest in everything that she had previously enjoyed, including her flower garden. A complete clinical workup with neuroimaging studies revealed no significant new medical conditions that were causing her neurologic manifestations. However, she scored only 25 out of a possible 30 points on a Folstein Mini-Mental State Examination. She was started on tacrine, but when adverse effects became intolerable (nausea, vomiting, and abdominal pain), her medication was changed to donepezil. Donepezil helped significantly with both memory and mood for several years.

Four years ago, family members noticed another significant change in the patient. Not only had previous manifestations become more severe, she also began developing new features of Alzheimer disease. She started having difficulty with numbers, could no longer balance her checkbook, and even forgot how to play bridge-a game that she had enjoyed for more than 60 years. She also began showing signs of poor judgment-one time leaving the house on a cold, winter morning without a coat and shoes, another time going to the store in her nightgown. Furthermore, there was a small kitchen fire that occurred when she forgot to turn off the stove. Fortunately, her neighbor had come over to check on her and put the fire out. At this time, she was again tested for new systemic disease, but no significant abnormalities were detected other than a mild case of iron deficiency anemia. A CT scan of the brain revealed moderate-to-severe cerebral atrophy in the temporal and parietal lobes bilaterally. Her Folstein Mini-Mental State Examination score had significantly decreased to 18/30. Shortly thereafter, the oldest daughter sold her mother's home and moved her mother in to live with her family. The two oldest daughters shared caregiving responsibilities and the youngest son also contributed significantly to his mother's safety and well-being.

Within the past six weeks, the patient has demonstrated multiple, sudden outbursts of anger. While shopping for groceries earlier this week with her second oldest daughter, the patient became separated, lost, confused, angry, and then violent when store employees and several customers tried to help her. Before she could be calmed, she had thrown several tomatoes at the store manager. She broke into a violent rage again at check-out when the grapes that she was purchasing fell out of the bag onto the floor. Within the last two weeks, she also began having occasional urinary accidents. Caring for their mother is now becoming unmanageable and the children are currently considering admitting their mother into a long-term nursing care facility.

• HTN X 20 years
• Episode of nephrolithiasis 2 years ago, stone passed without intervention, uric acid was primary component of stone
• Gout X 2 years
• Hypercholesterolemia X 6 months
• Plantar fasciitis of left foot X 3 months
• Occasional constipation

FH

• Both parents are deceased
• Father died from CVA
• Mother developed Alzheimer disease in her 70s
• Brother died from heart disease
• Sister also had Alzheimer disease, died 5 years ago at age 76

• Lives with daughter
• Has been widowed for 14 years (husband died from cancer)
• Does not smoke or drink alcohol

ROS

• No history of trauma or recent infection
• Patient reports occasional bladder incontinence
• No complaints of chest pain, shortness of breath, dizziness, joint pain, foot pain, or bowel incontinence

Medications

• Donepezil 10 mg po Q HS
• Allopurinol 100 mg po QD
• Pravastatin 40 mg po QD
• Lisinopril 20 mg po QD
• Ensure drinks PRN
• Ibuprofen 200 mg q4h PRN
• Docusate sodium 100 mg po BID

Co-trimoxazole → rash

PE and lab Jests

Gen

• Slightly confused but cooperative elderly woman in NAD
• Becomes less confused with slowly repeated questions and simple explanations
• The patient has a significant tic of the upper lip (2-3 twitches/minute)

Vital Signs

See Patient Case Table 38.1

• Pale and dry with senile lentigines
• Poor turgor
• Multiple minor ecchymoses noted on forearms; no other lesions or abrasions

HEENT

• Fundi WNL
• TMs intact
• Dentures present
• Buccal and pharyngeal membranes moist and without lesions or exudate

• Neck supple
• No thyromegaly or lymphadenopathy
• Trachea mid-line
• Carotid pulses full and equal bilaterally without bruits
• No JVD

Chest/lungs

• Mildly increased chest anteroposterior diameter with mild kyphosis
• Lungs clear to auscultation throughout

• RRR
• Normal S₁ and S₂
• No murmurs or rubs

Abdomen

• Soft, NT/ND, and symmetric with no apparent masses or hernias
• No scars, lesions, or bruits
• Bowel sounds present
• Tympany to percussion in all quadrants; no masses or organomegaly

Breasts

No masses, tenderness, discoloration, discharge, or dimpling

Normal external female genitalia

MS/Extremities

• No redness, swelling, or cyanosis
• Extremities warm bilaterally
• All peripheral pulses present and equal bilaterally
• No inguinal adenopathy
• With exception of left great toe, which was tender with movement, joints showed full, smooth ROM; no crepitus or tenderness
• Able to maintain flexion and extension against resistance without tenderness

• Pinprick, light touch, vibration intact
• Able to feel key in both hands with eyes closed, but unable to identify it as such
• Rapid alternating movements have deteriorated since the patient's last visit
• DTRs all 2+
• Negative Babinski sign bilaterally
• Gait slightly wide-based and awkward; unable to tandem walk
• No Romberg sign

Folstein Mini-Mental State Examination

The patient's examination score was 9/30

See Patient Case Table 38.2

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Clinical Values for Case Study Problem-Solving

Abbreviations

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Abbreviations