xamine Case 3: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the clientâ€s diagnosis and treatment.
At each Decision Point, stop to complete the following:
CASE STUDY 3
Case #3 Neurocognitive Disorders
Mr. Charles Wingate is a 76-year-old Caucasian male who presents to your office for an initial psychiatric evaluation. He is accompanied by his eldest son, Mark, who lives with Mr. Wingate. Mr. Wingate was referred to you by his primary care provider who has performed an extensive diagnostic workup to rule out an organic basis for his changes in cognition. Mr. Wingateâ€s son Mark has verbalized a concern that Mr. Wingate may have Alzheimerâ€s disease. When questioned, Mr. Wingate states that he is unaware of anyone in his family ever having been diagnosed with Alzheimerâ€s disease.
Mr. Wingate states that he has always been â€œa little bit forgetful,â€ but he noticed that in his 60s and 70s, it got worse. Mark states that â€œfor the past 2 years, it has been getting worse. He doesnâ€t even notice how bad his memory has become.â€ On at least two occasions, Mr. Wingate has gotten lost when he was driving to the grocery store. Mr. Wingate protested his disagreement with this accusation stating, â€œbut they were doing road construction, anyone could have gotten mixed up!â€ While his son conceded to this, he pointed out that Mr. Wingateâ€s memory has caused some other problems, such as errors with paying his monthly utility bills (at one point, the electric company threatened to shut off his electricity due to his nonpayment of the bill).
His son Mark also pointed out that the family is concerned for Mr. Wingateâ€s safety as he twice left his keys hanging in the door and just two evenings ago, put food in oven and forgot about it until the smoke detector in the kitchen began to alarm.
Mr. Wingate also has had a few issues with managing his medications. Specifically, he took too many Norvasc tablets a few months ago, which resulted in hypotension and a fall. Since that time, Markâ€s wife has been setting up Mr. Wingateâ€s pills in pill boxes, but recently, multiple â€œmissed dosesâ€ have been noted.
Mr. Wingate states: â€œbut those are my night pills that I missâ€”Iâ€m always better at remembering things in the morning.â€ Mark agrees, stating that Mr. Wingateâ€s cognition does vary throughout the course of the day and appears to worsen in the evening. He also reports that his father seems much less alert in the evenings, and more alert in the mornings.
Mr. Wingate reports that he has had poor sleep for â€œa long time now.â€ He does report that over the past few months, he has been having what he describes as â€œvery vivid nightmares.â€ His son states that sometimes he is awakened by his fatherâ€s yelling during nightmares, and enters his fatherâ€s room, and sees his father swinging or kicking in his sleep.
He reports that his appetite is â€œalrightâ€ and that his energy levels do fluctuate throughout the course of the day. He states: â€œsometimes, I can concentrate really well; other times I canâ€t â€¦ it is very frustrating!â€ Specific to substance use, Mr. Wingate notes that he used to enjoy a glass of wine or two with dinner, but states that it just doesnâ€t interest him, anymore. Plus, he stated that he notices that when he does drink, he develops slow muscle contractions.
Mr. Wingateâ€s son also shares a concern about his fatherâ€s abnormal movements. He states that for about the last 6 months, his father has had problems with coordination. He states that he raised these concerns with the family doctor who suggested it may be â€œlate onset Parkinsonâ€s disease.â€ However, he was not treated because the symptoms were â€œnot that bad.â€
Mr. Wingate was overall calm and pleasant during the clinical interview. Throughout the clinical interview, you notice that Mr. Wingate is not really involved in the discussion. He seems somewhat indifferent to the assessment and does not seem very concerned with what is being discussed. He only protested when discussing how he got lost on his way to the supermarket and his evening medication dose.
Review of systems and screening physical assessment were unremarkable, with the exception of fine resting tremors noted in both of Mr. Wingateâ€s hands. The psychiatric/mental health nurse practitioner (PMHNP) also reviewed laboratory studies that were sent from Mr. Wingateâ€s primary care provider; they were within normal limits with the exception of a serum sodium level of 130 mEq/L.
MENTAL STATUS EXAM
Mr. Wingate is alert. He is oriented to person, place, and partially oriented to time (he knows that it is morning, but cannot tell the hour). His speech is clear, coherent, goal directed, and spontaneous. Mr. Wingateâ€s self-reported mood is â€œok.â€ Affect is somewhat constricted. His eye contact is fleeting throughout the clinical interview. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes appreciated. Judgment seems well preserved, but insight appears impaired as he is having trouble understanding why his son brought him to this appointment. Concentration and attention also appear impaired, which prompts the PMHNP to perform a mini-mental status exam (MMSE) on Mr. Wingate.
RESULTS OF MMSE
Score of 17, with primary deficits in orientation; calculation; recall (he was unable to recall any of the three items presented after 5 minutes); and he was unable to perform serial 7â€s or spell the word â€œWORDâ€ in reverse, despite the fact that he is a high school graduate and attended 1 year of college. He also needed prompting with the three-step command. His score suggests severe cognitive impairment.
At this point, please discuss any additional diagnostic tests you would perform on Mr. Wingate.
Decision Point One
BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO MR. WINGATE?
In your write-up of this case, be certain to link specific symptoms presented in the case to DSMâ€“5 criteria to support your diagnosis.
Major frontotemporal neurocognitive disorder (FTNCD)Â
Major neurocognitive disorder due to Alzheimerâ€s diseaseÂ
Major neurocognitive disorder with Lewy bodies(I selected this option)
Decision Point One
Major neurocognitive disorder with Lewy bodies
Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:
Begin Rivastigmine 1.5 mg orally twice a day (selected)
Begin Olanzapine 5 mg orally at bedtimeÂ
Begin Ramelteon 8 mg at bedtime
Decision Point Two
Begin Rivastigmine 1.5 mg orally twice a dayÂ
RESULTS OF DECISION POINT TWO
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Begin Clonazepam 0.5 mg orally at bedtime(selected)
Begin Seroquel 25 mg orally at bedtime
Educate Mr. Wingate and his son regarding the fact that it will take time for the Rivastigmine to stop the nightmares
Decision Point Three
Begin Clonazepam 0.5 mg orally at bedtime
Guidance to Student
In the case of Mr. Wingate, he meets the diagnostic criteria for major neurocognitive disorder as evidenced by a decline from a previous level of performance in more than one cognitive domainâ€”in this case, complex attention and executive function. The decline is based on a knowledgeable informant, as well as a clinician (the patientâ€s primary care provider) who referred him to you, as well as substantial impairment in another quantified clinical assessment (the MMSE). Cognitive deficits that Mr. Wingate demonstrates interfere with independence in everyday activities and he requires help with complex IADLs such as medication management and paying bills.
Nothing in the scenario suggests that delirium could be responsible for the cognitive decline, nor is anything in the scenario suggestive of another mental disorder.
While one may be initially inclined to consider major neurocognitive disorder due to Alzheimerâ€s disease, probable Alzheimerâ€s would require evidence of a causative genetic mutation either from family history or genetic testing, and/or decline in memory and learning and at least one other cognitive domain; steadily progressive, gradual decline in cognition without extended plateaus; and no evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease, or another neurological, mental, or systemic disease or condition likely contributing to the cognitive decline). Similarly, while there is some evidence of mild apathy, and decline in executive abilities, there is insufficient evidence of three or more behavioral symptoms that would be needed to make a diagnosis of major frontotemporal neurocognitive disorder (e.g., behavioral disinhibition, loss of sympathy or empathy, perseverative, stereotyped or compulsive/ritualistic behavior, hyperorality and dietary changes, or prominent decline in social cognition and/or executive abilities) nor is there evidence of prominent decline in language ability, in the form of speech production, word finding, object naming, grammar, or word comprehension that would suggest major frontotemporal neurocognitive disorder.
In Mr. Wingateâ€s case, there is clear evidence of fluctuating cognition, and spontaneous features of Parkinsonism, which had their onset subsequent to the development of cognitive decline. These symptoms, coupled with the presence of a rapid eye movement sleep behavior disorder, are suggestive of MNDLB. Diagnostic testing should focus on determining the presence of a synucleinopathy.
Since Mr. Wingateâ€s symptoms are more consistent with MNDLB, the addition of Seroquel may result in severe side effects that could be life threatening and include severe sedation, muscle rigidity, delirium, neuroleptic malignant syndrome, and depending on the source of the study reviewed, neuroleptics may be associated with a 2- to 3-fold increase in mortality, including cerebral vascular accident. Although Seroquel can be used off-label to induce sleep in some patients, there is an FDA warning against the use of antipsychotics in older adults with dementia as they have been associated with an increase in mortality. Therefore, in consideration of the probably diagnosis and presenting symptoms, antipsychotics would not be appropriate.
Acetylcholinesterase inhibitors may be useful in the treatment of NDAD, but there is limited data of their efficacy with MNDLB. If the PMHNP decides to try an acetylcholinesterase inhibitor, the PMHNP should always begin with the lowest starting dose, and then slowly titrate upward, being mindful of the development of side effects. Mr. Wingate and his son should be educated on the fact that acetylcholinesterase inhibitors may slow disease progression, but will not have a significant impact on existing cognitive deficits.
The addition of low-dose Clonazepam (0.25 or even 0.125 mg) may be considered as a treatment for REM sleep disorders in individuals with MNDLB. Since clonazepam has a long half-life, the PMHNP should begin at a low dose, and slowly titrate upward, being mindful to educate the client and family about potential side effects and therapeutic end-goals. Remember that safety is always the first priority with prescribing.
There is no evidence that Rivastigmine has any effect on REM sleep disorders; therefore, the PMHNP should not tell Mr. Wingate or his son that this is an expected outcome of the drug.