Altered mental state in the elderly

Chapter 35 Altered mental state in the elderly



Case 35.1



History


Frank, a 66-year-old retired male teacher who presents complaining of low back pain, confides during the history that he is concerned about his memory. Upon further questioning, he states that he sometimes forgets what he is supposed to be doing, has trouble remembering people’s names and difficulty in finding the right words for objects. He says that he has noticed this over the past year and that it is getting gradually worse. He is worried because his mother was diagnosed with Alzheimer’s disease at the age of 70. He has not mentioned these concerns to any other healthcare practitioner. His medical history is significant for hypertension, for which he takes Ramipril (an ACE inhibitor). He smokes 10–15 cigarettes per day and has done so since the age of 30, and drinks no more than six standard drinks of alcohol per week. He denies feeling down, depressed or hopeless, and continues with his hobbies and social activities without any loss of pleasure. He also denies any history of head or neck injury. He claims to be feeling generally well apart from his presenting complaint and his concerns regarding his memory.



Questions



1. Using only this information, list the possible causes of Frank’s reported symptoms of cognitive impairment. Justify your answer.

2. Why was Frank asked:
a whether, during the past month, he had often been bothered by feeling down, depressed or hopeless and whether during the past month he had often been bothered by little interest or pleasure in doing things

b about a history of head injury

c about his medication and whether he smokes or drinks alcohol?

3. What do you need to examine in this patient with respect to the symptoms of cognitive impairment?


Physical examination

































General The patient appeared his stated age
Vitals •Pulse rate/min 70
•Respiratory rate/min 16
•Blood pressure mm Hg 140/88
•Temperature (degrees C) 37
HEENT Unremarkable
Neck No visible or palpable enlargement of the thyroid gland, and no bruit
Chest No cardiomegaly, no murmurs, chest clear
Neurological There were no gross abnormalities detected, however the patient was slightly more hesitant than expected when naming the objects used while testing stereognosis, and in identifying letters and numbers while testing graphesthesia
Mini-mental state examination (MMSE) score of 27/30 with slight delay in memory recall


Questions



4. What information can you obtain from these findings? Can you narrow your differential diagnosis?

5. Explain the significance of the slight hesitancy in naming objects used while testing stereognosis, and in identifying letters and numbers while testing graphesthesia.

6. What investigations are required? Justify your answer.


Investigations


Laboratory tests were all normal.



Questions



7. Are any further investigations required?

8. What is the significance of the family history of Alzheimer’s affecting his mother?

9. What are the implications of this patient’s complaints of cognitive impairment on treating his back pain?


Case 35.2



History


Barbara is a 79-year-old widow living in her own home. Her daughter brings her to see you as she has had a painful left knee for 3–4 days. She describes it as more like a discomfort and stiffness rather than actual pain, and is worse at the end of the day. Although it is worse on movement, there is no particular type that makes the discomfort worse. She states that it is not tender or swollen.


While taking the history, she also complains that she feels ‘a little giddy’ and ‘not quite myself’. The giddiness is worse when she arises in the morning, or when she needs to go to the bathroom during the night. She has had nocturia for many years. Her daughter also tells you that her mother has been a little confused over the past few days, which is quite unusual for her.


Barbara suffers from a number of chronic medical problems including ischaemic heart disease, type 2 diabetes mellitus, hypertension and urinary incontinence. Her diabetes and hypertension are usually well controlled.


Her present medications are:


• Gliclazide (Diamicron®) 80mg twice daily for her diabetes

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Altered mental state in the elderly

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