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Mr. RC, age 78

Mr. RC is a 78-year old male retired construction worker who recently moved into an apartment in a large continuing care retirement community so he and his wife could live near their only child, a son. He is seen in the clinic to initiate primary care follow-up.

By his wife's report, Mr. RC has a history of five years of progressive memory loss, and has had a decline in his ability to perform daily tasks. He is unable to perform complex household tasks, shopping, or walking in familiar neighborhoods without getting lost. He still performs his basic activities of daily living, such as personal hygiene, dressing, and preparing simple meals.

Mr. RC has a ten-year history of hypertension, congestive heart failure, and cataracts. His medications include lisinopril 10 mg/d; and atenolol 50 mg bid. He has no history of psychiatric illness or alcohol/ substance abuse. His family history is positive for several cardiovascular diseases in his father. Physical exam reveals a pleasant, cooperative, and well-groomed male. His blood pressure is 130/80 and pulse 80 without orthostasis. His respiratory rate is 16 and he is afebrile. His head and neck, chest, cardiovascular, abdominal, and neuromuscular exams are unremarkable. His mental status exam reveals deficits in orientation, memory, insight, judgment, and language skills. He has no focal neurologic deficits.

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Questions

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1. What is the likely diagnosis?

2. What investigations would help confirm the diagnosis?

3. If this appears to be Dementia of the Alzheimer's type, is he a suitable candidate for specific pharmacologic treatment?

4. What type of specific screening and follow-up should be undertaken?

Over the next several months, Mr. RC begins to have periods of excessive anger, wherein he is verbally abusive and uncooperative. He is started on alprazolam 0.25 mg every 4 hours as needed for anxiety with moderate beneficial effects. However, Mr. RC becomes progressively more withdrawn at home, his cognitive functioning deteriorates, and his mood becomes more labile, with frequent crying spells. His sleep is poor with middle and late night insomnia. On the day prior to returning to clinic, Mr. RC has an episode of acute agitation and paranoia, in which he attempted to strike his wife on a number of occasions. His wife had to enlist the help of their son to get Mr. RC to clinic for his visit.

5. What are possible etiologies for this change in personality and behavior?

Pearl:

Depression is a very common problem in patients with neurodegenerative disorders like Alzheimer's disease.

Over the next week, Mr. RC is tapered off his alprazolan and atenolol with remarkable improvement in his level of agitation and mild improvement in his apparent depression. However, he continues to have moderate restlessness and paranoia with occasional verbal outbursts when reassessed in clinic two weeks later. Mr. RC is prescribed citalopram (antidepressant) 10 mg at bedtime for the next two weeks with a significant improvement.

Additionally, he has a brighter affect and is more socially interactive.

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