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Rounds From Banner Alzheimer's Inst.

Alone in the Home

See related blog by Hall and Yaari.

CASE CONFERENCE

The Banner Alzheimer’s Institute Case Conference is a weekly event in which physicians and staff discuss challenging and/or teaching cases of patients seen at the Institute’s Memory Disorders Clinic. These conferences are attended by a multidisciplinary group that includes Banner Alzheimer’s Institute dementia specialists, community physicians (internal medicine, family medicine, and radiology), physician assistants, social workers, nurses, medical students, residents, and fellows.

BANNER ALZHEIMER’ S INSTITUTE

The Banner Alzheimer’s Institute located in Phoenix, Arizona, has an unusually ambitious mission: to end Alzheimer’s disease without losing a generation, set a new standard of care for patients and families, and forge a model of collaboration in biomedical research. The Institute provides high-level care and treatment for patients affected by Alzheimer’s disease, dementia, and related disorders. In addition, the Institute offers extensive support services for families and many unique and rewarding research opportunities.

Prim Care Companion CNS Disord2012;14(1):doi:10.4088/PCC.11alz01337

© Copyright 2012 Physicians Postgraduate Press, Inc.

Submitted: December 20, 2011; accepted December 20, 2011.

Published online: February 23, 2012.

AUTHORS

Roy Yaari, MD, MAS, a neurologist, is associate director of the Memory Disorders Clinic of Banner Alzheimer’s Institute and a clinical professor of neurology at the College of Medicine, University of Arizona, Tucson.

Geri R. Hall, PhD, ARNP, GCNS, FAAN, is a gerontology clinical nurse specialist at Banner Alzheimer’s Institute and an adjunct clinical professor at the College of Nursing, University of Arizona, Tucson.

Helle Brand, PA, is a physician assistant at the Memory Disorders Clinic of Banner Alzheimer’s Institute.

James D. Seward, PhD, ABPP, is a clinical neuropsychologist at Banner Alzheimer’s Institute.

Anna D. Burke, MD, is a geriatric psychiatrist and dementia specialist at the Memory Disorders Clinic of Banner Alzheimer’s Institute.

Adam S. Fleisher, MD, MAS, is associate director of Brain Imaging at the Banner Alzheimer’s Institute, a neurologist at the Institute’s Memory Disorders Clinic, and an associate professor in the Department of Neurosciences at the University of California, San Diego.

Jan Dougherty, RN, MS, is director of Family and Community Services at Banner Alzheimer’s Institute.

Pierre N. Tariot, MD, a geriatric psychiatrist, is director of Banner Alzheimer’s Institute and a research professor of psychiatry at the College of Medicine, University of Arizona, Tucson.

Corresponding author: Roy Yaari, MD, MAS, 901 E. Willetta St, Phoenix, AZ 85006 (Roy.Yaari@bannerhealth.com).


CME Background

Original material is selected for credit designation based on an assessment of the educational needs of CME participants, with the purpose of providing readers with a curriculum of CME activities on a variety of topics from volume to volume. This special series of case reports about dementia was deemed valuable for educational purposes by the Publisher, Editor in Chief, and CME Institute Staff. Activities are planned using a process that links identified needs with desired results.

To obtain credit, read the material and go to PrimaryCareCompanion.com to complete the Posttest and Evaluation online.

CME Objective

After studying this case, you should be able to:

  • Evaluate and treat an elderly outpatient with gradual short-term memory loss, anomia, weight loss, and symptoms of psychosis

Accreditation Statement

The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation

The CME Institute of Physicians Postgraduate Press, Inc., designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note: The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 1.0 hour of Category I credit for completing this program.

Date of Original Release/Review

This educational activity is eligible for AMA PRA Category 1 Credit™ through February 28, 2015. The latest review of this material was February 2012.

Financial Disclosure

All individuals in a position to influence the content of this activity were asked to complete a statement regarding all relevant personal financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute has resolved any conflicts of interest that were identified. In the past year, Larry Culpepper, MD, MPH, Editor in Chief, has been a consultant for AstraZeneca, Pfizer, Takeda, and Trovis; and has been a member of the speakers/advisory boards for Forest and Merck. No member of the CME Institute staff reported any relevant personal financial relationships. Faculty financial disclosure appears at the end of the article.


HISTORY OF PRESENT ILLNESS

Ms A, an 85-year-old woman with a history of hypothyroidism, presented for a new patient evaluation at the Banner Alzheimer’s Institute with her daughter, who provided the clinical history. Two years ago, Ms A was observed to have an insidious onset and gradual progression of short-term memory difficulties with mild anomia that gradually worsened over time. She was having difficulty with orientation to date, tracking appointments, and recalling details of recent events and conversations. Additionally, Ms A developed delusions and visual hallucinations. For example, she had accused her daughter of not inviting her to a party that never existed. Ms A also started to complain of seeing a young man in her room, who would disappear under her bed. Ms A was living alone and began to lose weight about 1 year ago.

Several months ago, Ms A suffered from significant fatigue and refused to get out of bed for many days. Her daughter called the paramedics, and Ms A was hospitalized. It was discovered that Ms A had stopped taking her medications including levothyroxine. Once levothyroxine was restarted, she returned to baseline within days. Ms A was discharged to her home, and her daughter started to help manage her medications. Ms A’s daughter set up Meals on Wheels for her, and there was some improvement in Ms A’s weight. Ms A refused a home caregiver. She stopped paying her bills 6 months ago, and her daughter took over the finances.

Soon thereafter, Ms A began believing that somebody had replaced her gun with an exact replica. She called the police and gave the gun to them. She began to believe that her grandson, the grandson’s girlfriend, and their daughter were living on the roof of her house. Her psychosis, although mildly irritating, did not result in significant agitation or anxiety.

Currently, Ms A is significantly forgetful, misplaces items, has word-finding difficulty, and is disoriented. She cannot use appliances. She confuses her daughter with her sister and her mother. She is described as depressed and apathetic and is agitated and irritable. Her time is spent watching TV and caring for her dog. She sleeps much of the day and has diminished interests. Ms A has no feelings of guilt or hopelessness and has no suicidal ideation.

PAST MEDICAL HISTORY

Ms A is treated for hypertension and hypothyroidism. She had a hysterectomy in the past.

MEDICATIONS

Ms A is prescribed levothyroxine and lisinopril but takes them irregularly despite current assistance from her daughter.

ALLERGIES

Ms A has no known drug allergies.

SOCIAL HISTORY

Ms A has 8 years of education and worked in sales management. She has been married and divorced 2 times and has 1 child. She currently lives alone, but her daughter is planning on moving Ms A to a mobile home nearby in the community where she resides. Ms A has no significant history of alcohol consumption, and she quit smoking cigarettes about 20 years ago after smoking an average of 1 pack per day for approximately 50 years.

FAMILY HISTORY

Ms A has 2 brothers and a sister. All 3 siblings have Alzheimer’s disease.

PHYSICAL EXAMINATION

Ms A’s vital signs include blood pressure: 110/60 mm Hg, pulse: 88 bpm, height: 63 in, and weight: 85.7 lb. Of note, Ms A’s daughter states that the current weight is a 6-lb increase from the last time it was checked.

NEUROLOGIC EXAMINATION

The neurologic examination was unremarkable except for broken smooth pursuits and mild impairment in hearing bilaterally to finger rub. Deep tendon reflexes were attenuated but symmetric throughout. Ms A has diffuse muscle atrophy.

Smooth pursuit can be tested by asking the patient to track a small moving target at a distance of about 1 meter, while keeping the head stationary (Kennard, 2007). Both horizontal and vertical smooth pursuit should be assessed. The target should be moved at a slow uniform speed, and the pursuit eye movements are observed to determine whether they are smooth or broken up by catch-up saccades or a fast movement of the eye. Because smooth pursuit requires the coordination of many brain regions, it is a nonspecific finding but could be indicative of cerebral degeneration. Sudo et al (2010) reported that impaired smooth pursuit can be indicative of impaired intellectual and frontal lobe function and can be regarded as a primitive reflex (frontal release sign).

Based on the clinical history alone, do you think a dementia is present?

Your colleagues who attended the Banner Alzheimer’s Institute Case Conference answered as follows:

A.  Yes 60%
B.  No 0%
C.  Not enough information 40%

Those who answered C (not enough information) stated that, in the context of medication noncompliance, the patient could have cognitive decline due to untreated hypothyroidism. Hypothyroidism in nondemented older adults is associated with impairments in learning, word fluency, visuospatial abilities, and some aspect of attention, visual scanning, and motor speed (Osterweil et al, 1992). Before presuming that a diagnosis of dementia is present, as the clinical history suggests, it was suggested to obtain a thyroid-stimulating hormone (TSH) level. Additionally, due to Ms A’s weight loss and undernourishment, it was suggested to check her vitamin B12 level. Ms A was also in the hospital recently, and one could presume that her electrolyte levels were checked, so dehydration, hyponatremia, or other metabolic disturbances are most likely not contributing to a delirium, but without knowledge of her metabolic panel, electrolyte imbalance could be a consideration.

Those who answered A (yes) believed that the insidious onset and gradual progression of cognitive decline is consistent with a progressive neurodegenerative dementia. Although hypothyroidism could have exacerbated symptoms, when Ms A was hospitalized and resumed treatment for hypothyroidism, her cognitive status returned to her baseline level, which is impaired.

A MMSE (Folstein et al, 1975) score generally correlates with disease severity. Scores ≤ 9 can indicate severe dementia, scores between 10-20 can indicate moderate dementia, and a score > 20 can indicate mild dementia (Mungas, 1991). MMSE scores vary by age and education. MMSE scores and age have an inverse relationship, with scores ranging from a median of 29 for people aged 18 to 24 years, to a median of 25 for individuals over the age of 80. MMSE scores and years of education have a direct relationship. Those with 0 to 4 years of education have a median MMSE score of 22, whereas those with at least 9 years of education have a median MMSE score of 29 (Crum et al, 1993).

Based on the information thus far, what would you expect the MMSE score to be?

Your colleagues who attended the Banner Alzheimer’s Institute Case Conference answered as follows:

A.  26-30 10%
B.  21-25 40%
C.  16-20 40%
D.  11-15 10%
E.  10 or below 0%

Ms A scored 14 points on the MMSE. She missed 4 points on orientation, 5 points on attention, 1 point on comprehension, 3 points on recall, 2 points on language, and 1 point on visuospatial. Her intersecting pentagons are shown in Figure 1. On the basis of the response of those present at the conference, Ms A appears to be somewhat more impaired than expected given the clinical history. Often, when the informant does not live with the patient and does not see the patient on a regular basis, the clinical history may not reflect the true severity of the symptoms.

On the Category Retrieval test, Ms A listed 7 different animals with 1 repetition. The clock drawing was also impaired as shown in Figure 2. Other cognitive screening tests such as the Montreal Cognitive Assessment were not performed.

Figure 1

 

Figure 2

LABORATORIES/RADIOLOGY

Ms A has recent complete blood cell count (CBC), comprehensive metabolic panel (CMP), and TSH results that are unremarkable.

Based on the information thus far, what tests, if any, should be ordered to complete the dementia workup?

Your colleagues who attended the Banner Alzheimer’s Institute Case Conference answered as follows:

A.  No further tests 10%
B.  Vitamin B12 level 0%
C.  Structural brain scan (CT or MRI) 0%
D.  B and C 90%

A community internist who was present at the case conference felt that further workup was neither necessary nor cost effective. He felt that further tests such as brain imaging would not change the management of Ms A and could lead to incidental findings, resulting in further unnecessary tests. It was counterargued that vitamin B12 deficiency is common in the elderly (Pennypacker et al, 1992), and findings have shown patients with vitamin B12 deficiency to have slightly lower cognitive performance than nondeficient subjects (Bernard et al, 1998). Thus, due to the ease (and relatively low cost) of measuring vitamin B12 and replenishing low levels, measurement of vitamin B12 is recommended as part of a dementia assessment. It was also counterargued that the head CT could assist in the differential diagnosis (help rule out neoplasm, hydrocephalus, subdural hematoma, or strokes), which could affect management of Ms A. One study found that 5% of patients had a clinically significant structural lesion but no features in the history or examination that would have predicted the lesions (Chui and Zhang, 1997).

Guidelines for a routine dementia workup include CBC, CMP, vitamin B12, and TSH measures and structural brain imaging with either an MRI or CT (Knopman et al, 2001). In this case, the treating physician ordered a vitamin B12 level and a noncontrast head CT.

Based on the information thus far, what is the most likely diagnosis?

Your colleagues who attended the Banner Alzheimer’s Institute Case Conference answered as follows:

A.  Depressive psychosis 0%
B.  Frontotemporal dementia 0%
C.  Alzheimer’s disease 80%
D.  Lewy body dementia 0%
E.  Vascular dementia 20%

The Treating Physician’s Impression

Ms A is an 85-year-old woman who presents for a cognitive evaluation. The clinical history and cognitive findings are consistent with a dementia. The most likely etiology of Ms A’s dementia is Alzheimer’s disease. However, further testing will be initiated to rule out other potential etiologies such as intracranial pathology or vitamin B12 deficiency. Ms A’s dementia has been complicated with delusions, visual hallucinations, and agitation. Furthermore, she has been living alone with failure to thrive and weight loss. The daughter is planning on moving Ms A to live close by with better supervision.

On Living Alone

An advanced practice nurse (G.R.H.), who is a member of the Banner Alzheimer’s Institute Family and Community Services, stated that at this time Ms A would require environmental modification prior to initiation of psychoactive medications and that the Live Alone Assessment (Figure 3) could have been used to assess this patient. Given that Ms A has had significant weight loss and psychosis, her case would be regarded as “A = Emergent,” and immediate help or placement is required. The advanced practice nurse also felt that the daughter’s plan of moving Ms A into a separate home in the same mobile home community was not optimal, as Ms A requires 24/7 care. Furthermore, the daughter’s plan could worsen confusion because Ms A would still be alone, but now in an unfamiliar environment.

Figure 3

Approximately 25%-33% of people with early dementia live alone (Lehmann et al, 2010). Evidence suggests that people with dementia who live alone are at high risk for malnutrition (Gillette-Guyonnet et al, 2003), premature loss of instrumental activities of daily life function, psychotic symptoms, social isolation, and risks to safety, especially from misused medications and financial mismanagement (Neufeld et al, 2004). These individuals are less physically active and have fewer day-to-day activities (Suzuki and Murase, 2010).

People with dementia who live alone have significantly more unmet home maintenance, psychological, social, medical, and personal care needs, resulting in accidental injury, self-neglect, and emotional distress and causing excessive disability. Due to diminished awareness of their condition and limitations, they are highly likely to refuse supportive social, activity, and nutritional services (Durand et al, 2009; Miranda-Castillo et al, 2010). Moreover, their cognitive decline is more likely to be overlooked by their primary care provider (Finkel, 2003; Wilkins et al, 2007). Moving cognitively impaired people who live alone in with family or into an institution with more structure will often result in a decline in psychosis, increased function, more activities, and better nutrition.

If this patient had supervision regarding medication management, what medication, if any, should be started first?

Your colleagues who attended the Banner Alzheimer’s Institute Case Conference answered as follows:

A.  Atypical antipsychotic 10%
B.  Cholinesterase inhibitor 50%
C.  NMDA receptor antagonist (memantine) 20%
D.  SSRI 0%
E.  Tetracyclic antidepressant (specifically, mirtazapine) 10%
F.  Short-acting benzodiazepine 0%
G.  None at this time 10%
H.  Aspirin 0%

Many conference attendees opted for a cholinesterase inhibitor at this time, as Ms A quite likely has Alzheimer’s disease and a cholinesterase inhibitor is indicated; however, some opted for memantine. In our collective experience at Banner Alzheimer’s Institute, we have observed that memantine may have a greater likelihood than cholinesterase inhibitors in reducing psychosis and agitation, noting that no medication is approved by the US Food and Drug Administration (FDA) for the treatment of behavioral symptoms in dementia, and there are no clinical trial data guiding best practices in this situation. Data suggest that memantine may be beneficial in treating behavioral and psychological symptoms of dementia in some patients (Clerici et al, 2011; Wilcock et al, 2008; Winblad et al, 2007).

It was suggested to start memantine and a cholinesterase inhibitor at the same time, but most conference attendees opted for a more conservative approach of 1 medication change. Those who opted for memantine first felt that Ms A’s weight should be improved and stabilized prior to starting a cholinesterase inhibitor, as possible side effects of cholinesterase inhibitors include anorexia, nausea, and weight loss among others (Farlow et al, 2008).

Most in attendance felt that an atypical antipsychotic for treatment of psychosis was not indicated, as the psychosis was nonagitating or threatening, again noting the lack of FDA approval for use of such medications, as well as warnings regarding use in the elderly (FDA Web site, 2008).

The Treating Physician’s Plan

  1. Order a noncontrast CT of the brain and vitamin B12 level to complete the dementia workup.
  2. Discuss the concerns related to patient safety and optimization of function with regard to living alone; 24/7 care is recommended as optimal at this time. Ms A’s daughter is strongly encouraged to meet with a member of the Family and Community Services team.
  3. Encourage increased caloric intake given Ms A’s weight loss. Ms A’s daughter notes that her mother has been regaining weight since food has been provided for her.
  4. Initiate memantine once Ms A’s medications are monitored daily. A starter pack will be provided as well as a prescription for 10 mg twice a day.
  5. Consider initiation of a cholinesterase inhibitor in the future.
  6. Monitor Ms A’s visual hallucinations, delusions, and agitated behaviors. Use of an atypical antipsychotic may be necessary in the future. At this time, see if memantine improves any of these issues.
  7. Refer Ms A’s daughter to a Banner Alzheimer’s Institute caregiver class as well as a support group. Again, Ms A’s daughter is encouraged to meet 1-on-1 with a member of our Family and Community Services team.
  8. The possibility of being involved in clinical research was briefly discussed with Ms A and her daughter, but they were not interested.
  9. Ms A will follow up in approximately 2 months.

 

Figure 4

 

LABORATORY RESULTS

Ms A’s B12 level was normal. The head CT (Figure 4) was unremarkable except for a 7.5-mm hyperdense focal lesion at the level of the foramen magnum. The radiologist requested further evaluation with MRI and magnetic resonance angiography (MRA). The radiologist’s differential diagnosis of this lesion was brainstem lesion versus partially calcified or thrombosed vertebral artery aneurysm.

Given the location of this lesion, it does not account for Ms A’s cognitive symptoms. A brainstem lesion would most likely cause a significant focal neurologic deficit, and, thus, a lesion within the brainstem is less likely.

Given the results of the head CT, what action should be taken?

Your colleagues who attended the Banner Alzheimer’s Institute Case Conference answered as follows:

A.  Discuss the results with the daughter (medical power of attorney) to assess whether further workup is desired 100%
B.  Refer the patient to neurosurgery for further evaluatio 0%
C.  Order an MRI and MRA as recommended by the radiologist 0%
D.  It is not in the best interest of the patient to go through further testing; no further steps should be taken in this regard 0%

After a telephone discussion with Ms A’s daughter, the decision was made to forego further evaluation.

2-Month Follow-Up

Ms A presented with her daughter for follow-up. Since the first visit, Ms A moved into the same mobile home retirement community as her daughter, who is now a 2-minute walk away.

Ms A’s daughter brings meals to her and monitors medications daily. Ms A has gained 11 lb. Memantine was initiated with a remarkable reduction in Ms A’s visual hallucinations, which the daughter now describes as minimal. However, cognition continues to worsen, and the short-term memory with repetition of questions is reported to be worsening. Ms A was recently seen by her primary care physician, who has adjusted the doses of levothyroxine and lisinopril.

What medication should be added at this time, if any?

Your colleagues who attended the Banner Alzheimer’s Institute Case Conference answered as follows:

A.  Atypical antipsychotic 0%
B.  Cholinesterase inhibitor 20%
C.  No new medication 80%
D.  SSRI 0%
E.  Tetracyclic antidepressant (specifically, mirtazapine) 0%
F.  Short-acting benzodiazepine 0%

PLAN

  1. Continue memantine 10 mg twice a day.
  2. Discuss the possibility of initiation of donepezil. Given that Ms A continues to gain weight at this time, and the fact that she has just been adjusting her hypertensive medication and thyroid medication, hold off on a cholinesterase inhibitor. Consider initiation of this medication at the next visit.
  3. Monitor Ms A’s visual hallucinations, auditory hallucinations, and agitation. There could be consideration of starting an atypical antipsychotic in the future if indicated, noting the lack of FDA approval for use of such medications as well as warnings regarding use in the elderly (FDA Web site, 2008).
  4. Continue to stress the importance of providing food and increased caloric intake.
  5. Discuss functional and safety issues with regard to living alone. Recommend that Ms A’s daughter meet with our Family and Community Services team to discuss optimization of the living situation (note: Ms A’s daughter later declined when this issue was discussed).
  6. Follow up in approximately 4 months.

Update

Two months later, Ms A’s daughter called stating that her mother is having mood swings, is angry at everyone, and wants to return to her home in Michigan. Ms A has not lived in Michigan for over 20 years. Ms A is calling 911 repeatedly for no reason. The daughter now realizes that Ms A needs 24/7 care. A follow-up appointment was made for Ms A sooner than the scheduled visit.

At this follow-up visit, Ms A was found to have a 17-lb weight loss since her last appointment 2 months prior. Due to the frequent 911 calls, Ms A has received an eviction notice from her mobile home community. Even though her daughter lives in close proximity, Ms A is failing to thrive living alone. A social worker was available at this visit to help facilitate the move to an assisted living facility.

Disclosure of off-label usage

The authors have determined that, to the best of their knowledge, memantine is not approved by the US Food and Drug Administration for the treatment of psychosis and agitation in Alzheimer’s disease.

FINANCIAL DISCLOSURE

Dr Yaari is a consultant for Amedisys Home Health. Dr Tariot has served as a consultant for Acadia, AC Immune, Allergan, Eisai, Epix, Forest, Genentech, MedAvante, Memory Pharmaceuticals, Myriad, Novartis, Sanofi-Aventis, Schering-Plough, and Worldwide Clinical Trials; has received consulting fees and grant/research support from Abbott, AstraZeneca, Avid, Baxter, Bristol-Myers Squibb, GlaxoSmithKline, Elan, Eli Lilly, Medivation, Merck, Pfizer, Toyama, and Wyeth; has received educational fees from Alzheimer’s Foundation of America; has received other research support from Alzheimer’s Association, Arizona Department of Health Services, GE, Institute for Mental Health Research, Janssen, National Institute of Mental Health, and National Institute on Aging; has received honoraria from AstraZeneca, Eli Lilly, Eisai, and Pfizer; is a stock shareholder in Adamas and MedAvante; and holds a patent for “Biomarkers of Alzheimer’s Disease.” Drs Hall, Seward, Burke, Fleisher and Mss Brand and Dougherty have no personal affiliations or financial relationships with any commercial interest to disclose relative to the activity.

Funding/Support

None reported.

DISCLAIMER

The opinions expressed are those of the authors, not of Banner Health or Physicians Postgraduate Press.

Clinical Points

  • People with dementia who live alone are at high risk for malnutrition, premature loss of instrumental activities of daily life function, misuse of medications, social isolation, and financial mismanagement.
  • The Live Alone Assessment can be used to help identify whether it is safe for a patient with dementia to continue to live alone.
  • Moving cognitively impaired people who live alone in with family or into an institution can result in decreased psychosis, increased function, more activities, and better nutrition.

This CME activity is expired. For more CME activities, visit cme.psychiatrist.com.
Find more articles on this and other psychiatry and CNS topics:
The Journal of Clinical Psychiatry
The Primary Care Companion for CNS Disorders

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