Case 4 – Elderly Man Repeating Questions about Upcoming Appointments

Abstract

A 75-year-old, right-handed man accompanied by his wife presented at initial consultation, with a history of mild difficulties with short-term recall for the past 2 years. Although he wrote down the time and place of upcoming appointments accurately, he repeatedly sought reassurance from his wife about them. He kept rechecking where things had been deposited. There was some hesitation for words during conversations.

Case 4 Elderly Man Repeating Questions about Upcoming Appointments

Serge Gauthier , Mira Chamoun , Tharick A. Pascoal , Jean-Paul Soucy , and Pedro Rosa-Neto

4.1 Case History

He had no difficulties playing bridge, paying his bills, driving his car, helping with grocery shopping, and putting dishes away at the proper location. He was independent for self-care.

He was sad because one of his sons was going through a recent divorce and he had been put on citalopram 2 months prior to the initial visit.

4.2 Past Medical History

He was in good general health, taking low doses of a statin and of an antihypertensive drug. He had uneventful cataract surgery.

4.3 Family History

Although his mother did not have dementia, some of his maternal aunts and uncles were reported to have had Alzheimer’s disease (AD) in their 80s.

4.4 Social History

The patient was born in Montreal and completed a university degree in accounting. He worked in business management until he retired at age 65. He lives in his condo with his wife, and they have two sons and three grandchildren.

4.5 Initial Clinical Examination

The patient was fully cooperative during the examination. His blood pressure was 120/80, pulse 60 and regular. His general neurologic examination was normal for his age.

Cognitive assessment was performed in his mother tongue, English. His Mini-Mental State Examination (MMSE) score was 23/30, with errors in orientation to time (2) and place (1), impaired recall (3), and impaired drawing (1). His (MoCA) version 7.1 score was 18/30, with errors in visuospatial/executive tasks (3), animal naming (1), delayed recall (5), and orientation (3).

4.6 Clinical Diagnosis

The patient was initially diagnosed with mild dementia probably due to AD. Donepezil was prescribed at 5 mg a day.

4.7 Additional Clinical Investigations

A head computed tomography (CT) scan without infusion done 3 days after the initial consultation showed mild frontoparietal and cerebellar atrophy with mildly prominent ventricles. No significant cerebrovascular disease identified.

A positron emission tomography (PET)-glucose scan performed 1 month after the initial consultation showed hypometabolism of the posterior cingulum as well as both mesiotemporal regions (Figure 4.1).

Figure 4.1 PET-glucose.

4.8 Clinical Course

The patient was seen after 6 months of treatment with donepezil 5 mg a day, which was well tolerated despite slight nose dribbling (rhinorrhea) and a pulse of 48/min. The MMSE score improved to 25, although the family did not see an improvement, finding him repeating the same thing, and at times being unsure of himself, whereas at other times being very sharp. The donepezil dose was not increased because of concern about the asymptomatic bradycardia.

After 18 months of treatment with donepezil 5 mg a day, there had been no clinical change in the patient’s daily routine, the pulse was 60, and the MMSE score was back to 23.

After 22 months of treatment with donepezil 5 mg the patient needed to be accompanied and helped with directions when driving his car, the pulse was 48, and the MMSE score was 22. Because of the inability to increase the donepezil to 10 mg, the patient and family chose a switch to the transdermal rivastigmine patch. Unfortunately, a skin reaction to the patch despite topical steroids caused a switch back to donepezil 5 mg a day.

After 3 years of treatment with donepezil and 5 years into his illness, the patient was stable in his daily routine, the MMSE score was 25. He expressed interest in participating in a research study.

4.9 Additional Research Investigations

A research 3T brain MRI was performed, showing diffuse brain atrophy with predominant atrophy in the inferior parietal, posterior cingulate, and precuneus cortices bilaterally and symmetrically. Hippocampus had bilateral atrophy, particularly on the left side (Figure 4.2a).