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. Wingate’s son Mark has verbalized a concern that Mr. Wingate may have Alzheimer’s disease. When questioned, Mr. Wingate states that he is unaware of anyone in his family ever having been diagnosed with Alzheimer’s disease. Neurocognitive Disorders
Mr. Wingate states that he has always been “a little bit forgetful,” but he noticed that in his 60s and 70s, it got worse. Mark states that “for the past 2 years, it has been getting worse. He doesn’t even notice how bad his memory has become.” 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, “but they were doing road construction, anyone could have gotten mixed up!” While his son conceded to this, he pointed out that Mr. Wingate’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. Wingate’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. Neurocognitive Disorders
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, Mark’s wife has been setting up Mr. Wingate’s pills in pill boxes, but recently, multiple “missed doses” have been noted.
Mr. Wingate states: “but those are my night pills that I miss—I’m always better at remembering things in the morning.” Mark agrees, stating that Mr. Wingate’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. Neurocognitive Disorders
Mr. Wingate reports that he has had poor sleep for “a long time now.” He does report that over the past few months, he has been having what he describes as “very vivid nightmares.” His son states that sometimes he is awakened by his father’s yelling during nightmares, and enters his father’s room, and sees his father swinging or kicking in his sleep.
He reports that his appetite is “alright” and that his energy levels do fluctuate throughout the course of the day. He states: “sometimes, I can concentrate really well; other times I can’t … it is very frustrating!” 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 doesn’t interest him, anymore. Plus, he stated that he notices that when he does drink, he develops slow muscle contractions.
Mr. Wingate’s son also shares a concern about his father’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 “late onset Parkinson’s disease.” However, he was not treated because the symptoms were “not that bad.” Neurocognitive Disorders
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. Wingate’s hands. The psychiatric/mental health nurse practitioner (PMHNP) also reviewed laboratory studies that were sent from Mr. Wingate’s primary care provider; they were within normal limits with the exception of a serum sodium level of 130 mEq/L. Neurocognitive Disorders
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. Wingate’s self-reported mood is “ok.” 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 7’s or spell the word “WORD” 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. Neurocognitive Disorders
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 domain—in this case, complex attention and executive function. The decline is based on a knowledgeable informant, as well as a clinician (the patient’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. Neurocognitive Disorders
While one may be initially inclined to consider major neurocognitive disorder due to Alzheimer’s disease, probable Alzheimer’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