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Patient Management Exercise
Published Online: 17 January 2017

Neurocognitive Disorders in Geriatric Psychiatry

This exercise is designed to test your comprehension of material relevant to this issue of Focus as well as your ability to evaluate, diagnose, and manage clinical problems. Answer the questions below to the best of your ability with the information provided, making your decisions as if the individual were one of your patients.
Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.

Case Vignette

James Garcia is a 62-year-old male who was referred to you by his primary psychiatrist for a second opinion consultation regarding the management of a single episode of depression that has been refractory to treatments. The patient voiced his chief complaint as “something’s wrong with me—it seems I can’t be happy, and I can’t think straight anymore.” He was accompanied to the appointment by his wife of 35 years, who provided collateral history.
The patient reported that this episode began insidiously about four years previously, when he was 58 years old. He had been promoted at work, where he was an engineering supervisor at a defense contractor. The promotion increased his scope of responsibility and the number of decisions he needed to make, which led to an increase in the level of stress he experienced. After six months of feeling “stressed out,” he sought care with his primary care physician and eventually was prescribed zolpidem for his sleep difficulties. After three months, he was seen again and was given a prescription for sertraline; he also refilled his zolpidem. He took one dose of the antidepressant, had gastrointestinal side effects, and stopped taking it. A few days later, he took an overdose of zolpidem (29 of 30 pills) during the day and was found that evening when his wife returned from work. His wife described his condition when she found him as “semi-comatose.” She called the paramedics, who took him to a local general hospital.
Mr. Garcia was kept overnight and released the next day, with a diagnosis of accidental ingestion. That evening, he admitted to his family that the overdose had not been accidental but was actually a suicide attempt; his wife said he was sobbing and crying out, “Why am I still alive?” The next day, he was admitted for inpatient psychiatric care for 10 days and then transitioned to a partial hospital program, but he could manage to attend only two or three days a week because of functional impairments (“I just could not get out of bed to make it to the program every day”). He has been under the care of the referring psychiatrist since that time.

Consideration Point A

Had you evaluated the patient at that time, your differential diagnosis would have been led by
A.1
Unipolar, major depressive disorder
A.2
Depression as a part of bipolar disorder
A.3
Substance-induced mood disorder
A.4
Generalized anxiety disorder

Case Vignette Continues

As you asked more questions about Mr. Garcia’s history, you learned that he had been seen by a neurologist at the time of his psychiatric hospitalization to evaluate any neurological reason for the depression and to assess whether he had experienced any neurological insult from the overdose. She had recommended electroencephalography and computed tomography imaging of his head, but the patient reported to you that the process of getting insurance company approval and setting up the appointments had proven to be “just too overwhelming to deal with” and so these tests were not obtained.
As you probed more, the patient characterized his experience as having virtually no interest in activities and a profound inability to concentrate well enough to read or make even minor decisions. He noted that his mood did not brighten at all, even with positive life events. Other target symptoms included anxiety, sleep disturbance (difficulty falling and staying asleep), decrease in appetite without noticeable weight loss in the past few weeks, very low energy, and feeling slow yet also fidgety. His wife added that his behavior at social gatherings had become unpredictably odd, in that he might laugh inappropriately at things others said or make inappropriate comments on other people’s attire. The patient did not dispute what his wife reported but did not react to this piece of collateral observation.
Mr. Garcia denied having current thoughts of death or any current plan or intent to commit suicide. He denied any past history consistent with hypomanic or manic episodes, psychosis, posttraumatic stress disorder, or social phobia. He denied any history of alcoholism or use of other substances, hallucinations, or delusions. The medical records from his inpatient stay included the observation that his intense worries at that time approached delusional proportions, for example, that being “sinfully lazy” had been at the root of his distress and that he was in jeopardy of being found out as “lazy and incompetent.” His family had confirmed at the time that these concerns did not accurately reflect his real-life work ethic, effort, or experience.
Mr. Garcia reported that no one else in his family had ever attempted suicide. His brother may have had bipolar disorder and substance use issues, but he and his brother had been estranged for many years after the brother drove while intoxicated with the patient’s then-teenage son in the backseat. Mr. Garcia’s father had died of liver cancer, and his mother had died from a pulmonary embolus. A maternal uncle had died of dementia doctors had diagnosed as Alzheimer’s disease.
While working with his primary psychiatrist, Mr. Garcia had tried treatment with several regimens, each for two to six months: citalopram (up to 20 mg per day); citalopram augmented with risperidone (4 mg per day); citalopram plus risperidone plus trazodone (100 mg every night at bedtime); citalopram, risperidone, trazodone, and bupropion (up to 300 mg per day); citalopram, risperidone, trazodone, bupropion, plus methylphenidate (20 mg every day before noon, 10 mg every day at noon); and then cross-tapering citalopram and replacing it with venlafaxine (venlafaxine 225 mg per day, while continuing risperidone, trazodone, bupropion, and methylphenidate). His symptoms had not had sustained improvement with any of these regimens.
On examination, Mr. Garcia was pleasant and cooperative, casually attired in drab clothing. Profound psychomotor slowing was noted, with a paucity of spontaneous movement. Eye contact was adequate but he stared into space at times, with long periods between blinks. Speech was of a slow rate and hypophonic volume, with some monotonous prosody. Affect was fatigued, sad, and drained. He characterized his mood as “anxious and irritable.” His thought process was slowed but logical and coherent. His thought content was free of hallucinations, delusions, or current suicidal or homicidal intent; he denied any intention or plan of suicide or other self-injurious behaviors. Cognitively, he was awake; alert; and oriented to person, place, date, and circumstances. Memory registration was intact with three out of three stimuli, and recall after delay was three out of three items. He was able to spell world forward and backward accurately. His similarities were a mix of abstract interpretations (apple/orange were both “fruit”; watch/ruler were both “used for measurement”) and more concrete (chair/table were both “wood”). He had some difficulty repeating the phrase “no ifs, ands, or buts.” His insight was intact, in that he recognized that he was depressed, needed treatment, and was still markedly ill despite prior treatments with medication. His judgment was intact, in that he was seeking care for depression, wished to return to wellness and to be able to work, and was able to contemplate potential risks and side effects and anticipate benefits of additional treatments. No tremors or involuntary movements were noted; his movements were characterized by profound slowing with reduced arm swing. He had difficulty maintaining his balance when his eyes were closed. Although his gait was slow, it was not festinating, nor did he exhibit en bloc turning, marche à petit pas, or difficulty starting or stopping.
His score on the 30-item Inventory of Depressive Symptomology, clinician-rated version, was 31 and on the Patient Health Questionnaire was 14, consistent with moderate symptom severity.

Consideration Point B

Given these details, your recommendation(s) to the referring psychiatrist are
B.1
Replace risperidone with another second-generation antipsychotic agent such as quetiapine
B.2
Replace venlafaxine with another antidepressant agent such as vortioxetine
B.3
Neuroimaging with magnetic resonance imaging (MRI)
B.4
Electroconvulsive therapy

Case Vignette Concludes

The patient underwent MRI neuroimaging and was found to have atrophic changes bilaterally in his frontal and temporal lobes. He was referred for evaluation by a neurologist who specialized in neurobehavioral disorders and underwent neurocognitive testing; the full set of findings was thought to be consistent with behavioral variant frontotemporal dementia (bvFTD), previously known as Pick’s disease (14).

Consideration Point C

Given that the patient’s diagnosis of bvFTD represents a progressive degenerative neurological disorder, other biopsychosocial recommendations that can be made to the patient and family include
C.1
Family therapy focused on coping with the patient’s pattern of social behaviors
C.2
Legal consultation to address issues of long-term care, durable power of attorney, and advance directives for health care
C.3
Referral to peer support groups for the family and the patient
C.4
Referral to governmental websites (e.g., eldercare.gov) to help access services for the patient and family

Answers: Scoring, Relative Weights, and Comments

Consideration Point A

A.1
(+3) Unipolar, major depressive disorder. The patient endorsed several of the DSM-5 criteria for major depressive disorder (5).
A.2
(+2) Depression as part of bipolar disorder. His depressive episode could be part of unipolar or bipolar mood disorder and more diagnostic information is needed (5).
A.3
(+2) Substance-induced disorder. You have not yet elicited data to support or refute this possibility and so should continue to consider it (5).
A.4
(+2) Generalized anxiety disorder. Although generalized anxiety disorder can co-occur with mood disorders and lead to impulsive behaviors, more information is needed before any conclusions can be reached about an independent diagnosis of generalized anxiety disorder (5).

Consideration Point B

B.1
(+1) Replace risperidone with another second-generation antipsychotic such as quetiapine. Augmentation with a second-generation antipsychotic medication is supported by the American Psychiatric Association evidence-based guidelines as a possibility (6), yet little clinical trial evidence compares these agents or provides information about switching from one agent to a different one.
B.2
(+1) Replace venlafaxine with another antidepressant agent such as vortioxetine. In general, switching from one antidepressant medication to another is an option supported by the American Psychiatric Association evidence-based guidelines as a possibility (6), but substitution within a multiagent regimen (as used here) has not been the focus of randomized clinical trial research, so actionable evidence is lacking.
B.3
(+3) Neuroimaging with MRI. The presence of neurological findings, such as the gait disturbance, and of cognitive disturbances, such as impaired decision making, raise concern that the patient’s depressed mood may not be part of major depressive disorder but instead could be part of a neurological disorder.
B.4
(−2) Electroconvulsive therapy. Although electroconvulsive therapy is an evidence-based practice for the treatment of depression (6), including depression in Parkinson’s disease (7), it is not the usual next step in the treatment algorithm for a patient like this who has other well-tolerated interventions available.

Consideration Point C

C.1
(+3) Family therapy focused on coping with the patient’s pattern of social behaviors. The patient’s behaviors at social events have been inappropriate at times and may become more problematic as the disorder progresses. Helping family members realize that the patient is not intentionally trying to embarrass the family is important, as well as developing strategies for redirecting the patient or otherwise coping with the behaviors (1).
C.2
(+3) Legal consultation to address issues of long-term care, durable power of attorney, and advance directives for health care. Life expectancy in bvFTD is reduced (1), so taking the legal steps to allow the patient’s family to act on his behalf can best be undertaken while the patient can still participate in making legal decisions and execute legal documents.
C.3
(+3) Referral to support groups for the family and the patient. Peer support groups may be helpful to the patient early in his illness and may be helpful to family members throughout the illness. Groups such as The Association for Frontotemporal Dementia (www.theaftd.org) maintain online directories and information about the illness (1).
C.4
(+3) Referral to governmental website (e.g., eldercare.gov) to help access services for the patient and family. Several federal agencies provide online information that may be useful to families and patients, including the National Institutes of Health (https://www.nia.nih.gov/alzheimers/publication/frontotemporal-disorders) and other parts of the U.S. Department of Health and Human Services (eldercare.gov).
Your Total

References

1.
Frontotemporal Disorders: Information for Patients, Families, and Caregivers. NIH Publication 10-6361. Bethesda, MD, National Institute on Aging, Sept 2010. www.nia.nih.gov/sites/default/files/FTDbooklet_10oct8_0.pdf. Accessed Oct 12, 2016
2.
Hodges JR, Davies RR, Xuereb JH, et al: Clinicopathological correlates in frontotemporal dementia. Ann Neurol 2004; 56:399–406.
3.
Scherder E, Eggermont L, Swaab D, et al: Gait in ageing and associated dementias; its relationship with cognition. NeurosciBiobehav Rev 2007; 31:485–497.
4.
Verghese J, Lipton RB, Hall CB, et al: Abnormality of gait as a predictor of non-Alzheimer’s dementia. N Engl J Med 2002; 347:1761–1768.
5.
Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA, American Psychiatric Publishing, 2013
6.
Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 3rd ed. Arlington, VA, American Psychiatric Publishing, 2010
7.
Borisovskaya A, Bryson WC, Buchholz J, et al: Electroconvulsive therapy for depression in Parkinson’s disease: systematic review of evidence and recommendations. Neurodegener Dis Manag 2016; 6:161–176.

Information & Authors

Information

Published In

History

Published in print: Winter 2017
Published online: 17 January 2017

Authors

Details

Ian A. Cook, M.D.
Dr. Cook is with the Department of Psychiatry and Biobehavioral Sciences of the David Geffen School of Medicine, the Semel Institute for Neuroscience and Human Behavior, and the Department of Bioengineering of the Henry Samueli School of Engineering and Applied Science at the University of California, Los Angeles. He is also with the Veterans Affairs Greater Los Angeles Healthcare System (e-mail: [email protected]).

Funding Information

Dr. Cook reports that his active biomedical device patents are assigned to the University of California. He has been granted stock options in NeuroSigma, the licensee of some of his inventions, and he currently is on leave as its chief medical officer and senior vice president.

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