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Alzheimer Disease Case
Case 2 Mr. Jones is a 75-year-old man with the diagnosis of Alzheimer disease (AD).
Background Information: There is no psychiatric or dementia history in Mr. Jones's family. Mr. Jones was a healthy child and a good student. He achieved an MBA from Harvard and went on to work for a Fortune 500 company, rising steadily through the ranks. He had never been fired from a position and was considered an even-tempered, reliable worker. He retired at age 65 and has traveled for the last number of years with his wife and friends, remaining active in social and community organizations. He has been married for 48 years, and has 3 children and 6 grandchildren. He lives with his wife in their own house. His family describes him as a devoted husband, father and grandfather, who relished time with the little ones, remembering their birthdays and always sending cards and gifts on time. There is no history of substance abuse. He has always managed their finances conservatively.
Medical history is significant for:
1.Elevated cholesterol
2.Type II diabetes mellitus
3.Hypertension
4.Osteoarthritis
5.Cataracts
6.Remote appendectomy
Current medications include: Baby aspirin, atorvastatin (cholesterol), metformin (diabetes), metoprolol (hypertension), multivitamin, and Tylenol as needed for pain.Prior to the onset of his illness, Mr. Jones had no history of psychiatric symptoms or treatment.
Present Illness: For the very first time at age 71, Mr. Jones began having difficulties with his memory. His wife noticed that he would occasionally repeat a question just 5-10 minutes after having asked it before, and would have no memory of even having asked it before. Although his driving remained safe, on a few occasions he made a wrong turn when returning home. These problems were initially attributed just "to old age", as Mr. Jones really did not appear much different than their friends of the same age. Mr. Jones continued to be active socially, working efficiently around the house and garden and exercising regularly.
Over the ensuing year however, further changes were noted. Mr. Jones began to forget to send cards to the family for birthdays, and although Mrs. Jones helped him make up a calendar with the relevant information, he would forget to check the calendar on a regular basis. Mrs. Jones noticed that he started to make subtle language errors, substituting "pencil" for "pen", and"table" for "desk". He would begin home improvement projects such as replacing light fixtures and then leave them uncompleted, a significant change from his baseline. Despite this deterioration Mr. Jones remained cheerful and optimistic, enjoying his time with family and friends, and participating in community events. His friends, while noticing his deficits, continued to seek out his company and he never lacked for activity.
Eventually, Mrs. Jones brought Mr. Jones to see a neurologist, the daughter of a close friend. They spent the first 10 minutes "talking about the old days" and Mr. Jones remembered details from 40 years ago flawlessly. Mr. Jones knew he was there for an evaluation of his memory, though he did not feel that it was very impaired. When told that his family did believe his memory was impaired he pleasantly responded, "well they usually know better than I do." A general physical and neurological examination was completely normal. On cognitive testing, Mr. Jones was quite impaired. He did not know the date, thought it was Wednesday instead of Friday and did not know the floor of the building that they were on. He made errors in calculation. Object naming was fairly well preserved but he made a few errors that were abnormal for his education level. Tests of new learning showed that he was very impaired. A brain MRI showed mild atrophy (shrinkage) throughout the brain without evidence of strokes. A diagnosis of probable AD was made, about 2 years after the onset of the initial symptoms.
Although the Jones family was saddened by this diagnosis, daily life continued much as before, although the gradual decline in memory and functional ability continued. Memory enhancing medications prescribed by the neurologist were only minimally helpful and were ultimately discontinued. At one point Mr. Jones developed the belief that someone was hiding his wallet and keys from him but this symptom improved when they developed a system of putting these objects in the same place every evening. A bout of mild depression was successfully treated with an antidepressant medication. Overall, Mr. Jones enjoyed his daily routine, and although he socialized somewhat less, he was content overall.
Mr. Jones was admitted to the hospital for hyperglycemia (elevated blood sugar). It became clear that he had not been taking his medications regularly. When this was discussed with him he said that he thought he had been taking them properly but did not become angry or defensive about it. Later, he did not remember why he was in the hospital or what the problem was that led to the hospitalization. Mrs. Jones was educated about medication supervision and a system to address this was devised.
While in the hospital it was noted that Mr. Jones had a large inguinal hernia that needed urgent repair to prevent intestinal damage. Mr. Jones agreed to the surgery, stating, "the doctors know best." Mr. Jones was able to state that if the surgery was not done, "something bad would happen" and he never resisted the preparations for the surgery. However, it was noted that 10 minutes after discussion of the surgery, he did not remember its purpose (other than "to help me") or its risks and benefits. A competency evaluation found him incompetent to consent to the surgery and his wife took over this role. Mr. Jones interacted cheerfully and pleasantly with all of the hospital staff during his stay, complementing and thanking them all, and had no inappropriate behavior.
Alzheimer’s Disease Fact Sheet
Alzheimer’s disease (AD) is a brain disorder that affects as many as 4.5 million Americans.The disease usually begins after age 60, and risk increases exponentially with age.About 5 percent of men and women ages 65 to 74 have the disease; however, as many as half of those age 90 and older have the disease.Alzheimer’s disease involves the parts of the brain that control thought, memory, and language.The disease is progressive and, in its most advanced stages, debilitating.
Alzheimer’s disease begins slowly, with symptoms such as mild forgetfulness.In this stage, people may have trouble remembering recent events, activities, or the names of familiar people or things. As the disease progresses, patients develop impairments in language (communication), perception (such as the ability to recognize familiar people and places) and the ability to perform everyday learned activities such as brushing their teeth or dressing. Persons with end stage AD almost always need totalcare.The average patient with Alzheimer’s lives 8-10 years after diagnosis, although some patients have lived as long as 20 years.The most common cause of death among patients with Alzheimer’s is infection. At present, treatment is symptomatic. Both medication and environmental therapies can improve quality of life, but whether disease progression can be modified is unknown.
The cause or causes of AD are not known.The most important risk factor is age, but scientists do believe that genetics may play a role in some AD cases.
