Case Study III Psychiatric Perspectives

Mrs. Walker is a 76-year-old married woman who was referred by her internist for evaluation of depression and withdrawal.

Mrs. Walker was in her usual state of health, an active retiree (retired schoolteacher), until about three years before this evaluation when she developed some short-term memory difficulties. Over the ensuing year, this memory difficulty slowly progressed, and she found she was burning food on the stove and getting lost driving when she ventured beyond her neighborhood. She remained active, however (volunteering at her local church four days a week), and in good spirits. She was initially seen by her internist, who, after performing a physical examination and obtaining routine laboratory studies, found no immediate cause for this memory loss and referred her for neurologic evaluation. The consulting neurologist diagnosed early-stage AD and prescribed donepezil, 10 mg/day. Her Folstein MMSE score at that time was 26. An MRI scan was essentially normal, with only a question of minimal cortical atrophy.

Over the next year, Mrs. Walker did well, although her deficits did slowly progress. She remained active but gave up driving except for very short trips to her local grocery store. Her husband drove her to her volunteer job, which she had reduced to twice weekly. He also took over cooking for them. She depended more and more on lists to remember activities, names, and places. She and her husband joined a support group sponsored by the local chapter of the Alzheimer's Association. At her one-year neurologic follow-up, her MMSE was 24.

Over the following eight months, Mrs. Walker suffered several stressors. Her best friend of many years died, her husband was diagnosed with prostate cancer, and her eldest daughter was divorced. She became more forgetful and was unable to continue with her volunteer work. She confused the names of her grandchildren and even her children. At times, she appeared to be lost in her own house. She became tearful and withdrawn and ate only sporadically, losing 10 pounds over three months. Her personal hygiene deteriorated, and she often refused to bathe. Her husband took her to her internist, who found no abnormalities on physical exam other than the weight loss and, after obtaining normal laboratory studies, referred her for geropsychiatric evaluation.

Mrs. Walker's medical history was significant for hypertension, hypothyroidism, osteoarthritis, and osteoporosis. Her recent thyroid function tests performed by her internist were normal. Her medications included donepezil, Vitamin E, levothyroxine, lisinopril, and alendronate. She had a period of " the blues" for three weeks after the birth of her second child, which resolved without treatment. There is no other significant psychiatric history. She has never smoked; she drank socially when younger, but not at all in recent years. Mrs. Walker's mother died of "senility" at age 71. Mrs. Walker was the third of five siblings and grew up in a small town. She completed a master's degree in education and taught elementary school until her retirement at age 62. She has been married for 52 years to her husband, a retired businessman; they have three children and seven grandchildren.

On examination, Mrs. Walker appeared somewhat disheveled, had poor eye contact, little spontaneous speech, and appeared depressed, although she brightened when mention was made of her grandchildren. She could provide little detail as to the events of the prior several months, turning to her husband for help. She knew she had "memory problems" and said she wasn't " worth a damn" any more. She acknowledged "maybe it's time for me to go," but denied any suicidal intent. There was no evidence of delusions or hallucinations. Her MMSE score was 13.

After reviewing her internist's medical workup, a diagnosis of major depressive disorder complicating AD was made. It was felt that in addition to her psychiatric symptoms and worsened functional status, her mood syndrome was likely contributing, at least in part, to the recent dramatic decline in her cognitive function.

A trial of antidepressant therapy was begun with sertaline, beginning at 25 mg/day. With a dose increase to 50 mg/day, the patient developed diarrhea in the first 10 days of therapy and had no improvement in her depressive symptoms. Sertraline was discontinued, and a trial of venlafaxine was initiated, beginning with a dose of 37.5 mg/day, increasing to 75 mg b.i.d. She tolerated the medication and maintained good blood pressure control but showed little clinical response in the first three weeks of treatment. The dose was incrementally increased to 150 mg b.i.d., and within two weeks of achieving that dosage, her mood and appetite began to improve, and she began to attend to her personal hygiene. In addition, she was less confused and more accurate in remembering names of relatives. Over the next month, she continued to improve, regained the weight she had lost, and although she did not return to volunteer work, she did begin attending her neighborhood senior center several days a week. At a subsequent follow-up visit about six weeks after her initial improvement, she appeared in good spirits, denied any suicidal ideation, although she remained vague on any details of her life. Her MMSE score at that time was 20.

Over the next year, Mrs. Walker's course was fairly stable; she continued to show slowly progressive but minimal decline in her cognitive function. She then had a fairly abrupt decline, with development over the course of a week of confusion, agitation, and some physical aggressiveness toward her husband, who was now more frail physically and less able to care for her. She expressed a belief that her husband was having an affair and called the police several times complaining that he was plotting to kill her. Her daughter took her to her internist, who found, on urinalysis, a urinary tract infection. She was treated with antibiotic therapy, started on risperidone, 0.5 mg qhs, and re-referred urgently to the geropsychiatrist. When seen the same week, she appeared distracted, agitated, and initially refused to have her husband present during the visit. She eventually agreed but said he "couldn't be trusted." She was poorly cooperative with cognitive testing but scored 18 on a MMSE. Over the next two weeks, her behavior improved, she no longer suspected her husband, and she returned to her baseline. After one month, risperidone was discontinued. A visiting nurse was hired to assist with her care, and her children visited daily.

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