Reference no: EM133907597

Question

A 75-year-old man presented to your office accompanied by his spouse. He was alert, cooperative, and dressed neatly. He maintained minimal eye contact and his affect was flat. His gait was normal. No tremors or unusual movements were noted. He denied feeling depressed. His speech was normal in volume, rate, and rhythm. He denied having any problems with his memory. He denied suicidal or homicidal thoughts, plan, or intention.

His cognitive exam revealed the following: He was oriented except for the date. He made multiple errors when performing serial 3s backward from 20 and was unable to spell "WORLD" backwards. His score on the St. Louis University Mental Status Examination (SLUMS) was a 10. His score on the clock drawing task was a 1 out of 4 possible points. He was able to recall several childhood events but was not able to remember what he had eaten for breakfast or what he had done the previous evening.

His spouse reported that she had noticed changes following his retirement several years ago. The man had been employed as a civil engineer for many years. He had been the first and only college graduate in his family. He had gradually stopped socializing with his friends, no longer wanted to play golf, sing in the church choir, or go out to eat with friends. He preferred to stay at home because being around others "stresses" him out. His spouse has taken over the driving, shopping, finances, meal preparation, and planning for the household. "He used to be a planner, wanting everything to be in order but not anymore." He no longer drives because he "lost the car in the parking lot" and was "unable to find his way home." He no longer manages the couple's finances, having made major errors which fortunately were detected by his spouse. His spouse reported a recent incident in which he appeared to be confused about how to use a can opener. His spouse attempted to have him keep in contact with friends via Facebook but the man became frustrated because he was not able to remember how to use a laptop or log into the site. He sometimes forgets the names of common items and recently, had to be reminded of the names of his children and grandchildren. His spouse denied that he was verbally or physically aggressive or that he wandered from the home. She did report that he has sleeping problems, sometimes staying up during the night and then sleeping the next day.

He and his spouse have been happily married for 40 years. They have two children and four grandchildren. His family history was notable in that his mother developed dementia in her seventies. His medical history was notable for hypertension which was well-controlled with the use of lisinopril. His current blood pressure was 130/80.

1. What are the differential diagnoses? Rationales.

2. What are the patient's diagnoses? List DSM-5 diagnostic criteria and the patient's symptoms that reflect the diagnostic criteria to support the diagnosis(es).

3. What level of care is appropriate for the patient? Provide rationale.

4. What screening tools are appropriate to use to assist with diagnosis?

5. What diagnostic labs would you order? Provide rationales.

6. What are the red flags in this patient's presentation?

7. What treatments would be appropriate to include psychopharmacology and psychotherapy for the patient? Provide rationales.