Discussion: mild neurocognitive Disorder

Discussion: mild neurocognitive Disorder

Discussion: mild neurocognitive Disorder

Blog #6
Patient: LE
Age: 73
Gender: Female
HPI: Patient and daughter are present for clinic visit. Daughter reports mother is experiencing greater confusion after news the patient’s sister passed away this week. She reports mothers’ dementia symptoms exacerbate with stress, often improving with greater support. Currently she reports her thoughts are more delayed and she is more forgetful. This change occurred after she was told about her sister’s death. The patient has a history of dementia that was diagnosed in 2019 and depression diagnosed 15 years ago after the death of her husband. Daughter is requesting referral to counseling services.

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Assessment:
Patient is quiet, cooperative, but requires prompting to participate in assessment. Appearance is neat. Eye contact is good, speech is soft, slow rate and rhythm. She has no involuntary movements in extremities, no fasciculations of tongue or face. Gait is steady and coordinated. Thought process is slow but she is able to answer questions appropriately. She is oriented to person, place, time, situation. She occasionally looks to daughter to answer questions that require specific or detailed responses. She has minor difficulty with word recall. Her affect is constricted. She reports feeling sad about the loss of her sister but denies feeling depressed. She has intermittent anxiety due to increased forgetfulness and confusion that started 4 days ago. She denies difficulty sleeping or changes in appetite. She denies SI or HI. She denies hallucinations or delusions. She denies side effects of medications.
Social History:
Patient lives alone. She is widowed and has three living adult children. She has one deceased child who died during infancy. She currently is able to care for ADL’s such as cooking, cleaning, bathing, and managing homecare activities. Daughter is her support system and calls every morning and evening to make sure she is taking medications. She assists patient weekly pill containers. She is socially active with friends and family. Highest level of education is 9th grade. She denies legal history or trauma history.
Family History:
Mother and grandmother were both diagnosed with dementia in their 80’s.
Past Psychiatric History:
Patient has been treated for depressive symptoms and anxiety for 15 years. This treatment was initiated by primary care provider. She has been on Zoloft 100mg for 15 years without complications or side effects. In 2019 her neurologist diagnosed with dementia after her daughter recognized she was more forgetful, had difficulty focusing, wondering (such as getting lost in town), and difficulty answering questions. In 2019 the patient was admitted for inpatient psychiatric treatment after experiencing delusions and hallucinations. She was found knocking on neighbor’s doors during night. Daughter reports event occurred after she was started on steroids, Neurontin, and pain medication due to hurting her back. During admission she was tapered off her klonopin that she had been receiving for 5 years. Steroid, Neurontin, and pain medication were also discontinued at that time.
Past Medical History:
Hypothyroidism
Hyperlipidemia
Medications:
Olanzapine 2.5mg po BID (started 2019)
Namenda 5mg po BID (started 2019)
Donepezil 10mg po HS (started 2019)
Zoloft 100mg po daily (15 years)
Levothyroxine 112mcg po daily (approximately 20 years)
Lipitor 10mg po (take ½ tablet) po HS (approximately 20 years)
Allergies:
NKDA
Diagnosis:
Mild Neurocognitive Disorder, Unspecified (R41.9)
Unspecified Depressive Disorder (F32.9)
Unspecified Anxiety Disorder (F41.9)
Hypothyroidism
Hyperlipidemia
Differential Diagnosis:
Medication induced depressive/anxiety disorder
Adjustment disorder
Mild Neurocognitive disorder, another medical condition
Treatment Plan:
• Continue medication as prescribed.
• Psychotherapy, individual or group
• Evaluate caregiver support and utilizing community resources.
Education:
• Educate family and patient on structured activities such as mental stimulating activities, hobbies, exercising, and CAMs.
Referral
• Refer patient and family to Alzheimer support group (Alz.org)
• Refer family support group for dementia (Calvary Baptist Church)
• Refer patient to individualized counseling services for psychotherapy for management of grief/bereavement.
Follow-up:
• Patient will follow up in four weeks
o Monitor for change in condition or exacerbation of symptoms
o Evaluate progress with establishing counseling

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Patient: Ms BW

Age: 67 years

Gender: Female

HPI: Patient visits the clinic alongside her caregiver with complains over her difficulty recalling where she placed objects, her increased dependence on written and digital reminders and her forgetfulness about recent events and conversations. Her symptoms are unchanged in both intensity and frequency and exacerbated when under stressful and angry episodes. The patient has a history of depressed mood and anxiety symptoms diagnosed 10 years ago following an almost fatal accident. According to the caregiver, the patient requires further neurocognitive assessment and treatment.

Assessment: Patient is good health, attentive, relaxed, calm and cooperative. Appearance is neat. Gait is coordinated and steady. Eye contact is appropriate, speech is normal in volume, rate and articulation. General demeanor and facial expression as well as body posture and attitude demonstrate depressed and anxious mood. Verbal fluency is below expectation, with phonemic dysfunction considered to be higher when compared to semantic dysfunction. No apparent signs of delusions, hallucinations and/or bizarre behaviors. Thinking is slow and illogical, and thought content appears marked with forgetfulness and confusion. Short term and long-term memory disrupted. Whilst judgment appears fair, the patient reported feelings of self-doubt and upset about herself. Suicidal thoughts are strongly denied. No signs of intoxication or withdrawal are in sight.

Social History:  The patient lives with a caregiver. She is divorced and has four living adult children. She’s currently unable to undertake daily activities such as cleaning, cooking, cleaning and management of home care chores. The caregiver is very supportive and ensures the patient is taking medications as prescribed.

Family History: Father diagnosed with Alzheimer’s dementia with depression at the age of 78.

Past Psychiatric History: Patient treated for anxiety and depressive symptoms for at least 10 years. The patient appears distracted, unhappy and has difficulty naming and remembering objects. Whilst no signs of severe anxiety and depression are reported, the thinking and speech is slowed by depressive symptoms.

Past Medical History:

Depressed Mood

Memory Impairment

Medications:

Paroxetine 30 mg/d (started 2012)

Donepezil 10 mg/d (started 2020)

Allergies:

NKDA

Diagnosis:

Anxiety disorder, unspecified, F41.9 (ICD-10) (Active)

Generalized anxiety disorder, F41.1 (ICD-10) (Active)

Mild Neurocognitive Disorder, Unspecified (R41.9) (Active)

Differential Diagnosis:

Mood Disorder

Alzheimer’s Dementia with Depression

Mild Neurocognitive Disorder, Unspecified (R41.9)

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Treatment Plan:

• Continuation of medication as prescribed.
• Psychosocial interventions (cognitive training, problem-solving therapy)
• Behavioral therapy

Education:

• Educate patient on lifestyle modifications in favor of the Mediterranean diet and folate supplementation for at least 3 years for positive benefits in memory, sensorimotor speed and proceeding speed (Petersen 2016).

Referral

• Refer patient to cognitive training sessions
• Refer behavioral therapy support group for MCI
• Refer patient to individualized counseling and guidance sessions for psychosocial programs

Follow-up:

• Patient will follow up in five weeks
  • Several visits and period neuropsychological assessment
  • Consult with an elder-law attorney to tackle planning for the future including residential supports, financial planning, driving, health care proxy, and others.

References

Petersen R. C. (2016). Mild Cognitive Impairment. Continuum (Minneapolis, Minn.), 22(2 Dementia),

404–418. https://doi.org/10.1212/CON.0000000000000313