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CAS E STU DY

38 ALZHEIMER DISEASE

For the Disease Summary for this case study,

see the CD-ROM.

PAT I E N T C A S E

Patient’s Chief Complaints

“I got lost in the grocery store and my children think that I need those diapers that old peo-
ple have to wear.”

HPI
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 moti-
vation 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 fea-
tures of Alzheimer disease. She started having difficulty with numbers, could no longer bal-
ance 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 for-
got 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

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178 PART 5 ■ N E U R O L O G I C A L D I S O R D E R S

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 becom-
ing unmanageable and the children are currently considering admitting their mother into a
long-term nursing care facility.

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

Patient Case Question 1. What is plantar fasciitis?

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

SH
• 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
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CASE STUDY 38 ■ ALZHEIMER DISEASE 179

• Ibuprofen 200 mg q4h PRN

• Docusate sodium 100 mg po BID

All
Co-trimoxazole → rash

Patient Case Question 2. Identify this patient’s two major risk factors for Alzheimer
disease.
Patient Case Question 3. Why is the patient taking allopurinol, and why is this medica-
tion effective in individuals with this condition?
Patient Case Question 4. Why is the patient taking lisinopril, and why is this medica-
tion effective in individuals with this condition?
Patient Case Question 5. Why is the patient taking docusate sodium, and why is this
medication effective in individuals with this condition?

PE and Lab Tests

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

Patient Case Table 38.1 Vital Signs

BP 140/80 left arm, sitting RR 15, unlabored HT 5⬘6⬙
P 85, regular T 98.8°F WT 114 lbs

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

Patient Case Question 6. What are senile lentigines?

Patient Case Question 7. What are ecchymoses?

HEENT
• Fundi WNL
• TMs intact
• Dentures present
• Buccal and pharyngeal membranes moist and without lesions or exudate
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180 PART 5 ■ N E U R O L O G I C A L D I S O R D E R S

Neck/LN
• 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

Heart
• 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

Genitalia
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

Neurological
• 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
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CASE STUDY 38 ■ ALZHEIMER DISEASE 181

Patient Case Question 8. Have the results of the patient’s mini-mental state exam
improved, worsened, or remained the same since her last mental state test?

Laboratory Blood Test Results (Fasting)

See Patient Case Table 38.2

Patient Case Table 38.2 Laboratory Blood Test Results (Fasting)

Na 144 meq/L ALT 22 IU/L HDL 39 mg/dL
K 4.3 meq/L Alk Phos 124 IU/L LDL 117 mg/dL
Cl 105 meq/L T Bilirubin 1.2 mg/dL Uric acid 5.7 mg/dL
HCO3 29 meq/L D Bilirubin 0.4 mg/dL Vitamin B12 288 pg/mL
Hb 14.9 g/dL BUN 14 mg/dL Ca 9.2 mg/dL
Hct 44% Cr 1.2 mg/dL PO4 4.5 mg/dL
RBC 4.85 ⫻ 106/mm3 Glu 87 mg/dL Mg 2.4 mg/dL
Plt 161 ⫻ 103/mm3 Cholesterol 185 mg/dL TSH 3.6 µU/mL
WBC 7.34 ⫻ 103/mm3 Trig 147 mg/dL T4 5.9 µg/dL
AST 28 IU/L T Protein 6.5 g/dL Alb 4.1 g/dL

Patient Case Question 9. Identify all of the abnormalities associated with this patient’s
CBC.
Patient Case Question 10. Is this patient’s renal function normal or abnormal?
Patient Case Question 11. Is this patient’s hepatic function normal or abnormal?
Patient Case Question 12. Is this patient’s serum lipid profile normal or abnormal?
Patient Case Question 13. Is this patient’s thyroid function normal or abnormal?
Patient Case Question 14. Identify any laboratory blood test results in Table 38.2 that
might explain the patient’s deteriorating neurologic function.
Patient Case Question 15. Are there any indications for treating this patient with
memantine?
Patient Case Question 16. Multi-infarct dementia has to be ruled out as a possible cause
of this patient’s changes in cognitive function, because this condition presents in a similar
manner. Identify two risk factors that predispose this patient to multi-infarct dementia.
Patient Case Question 17. Does multi-infarct dementia present in the same manner
with a CT scan study as does Alzheimer disease?
Patient Case Question 18. Clinical depression in an elderly patient is often mistaken for
Alzheimer disease. Is there any way to distinguish depression from Alzheimer disease in
the geriatric population?
Patient Case Question 19. Why might a trial of risperidone be appropriate for this
patient?