Case Scenario

A 76-year -old man is brought to the primary care office by his wife with concerns about his worsening memory. He is a retired lawyer who has recently been getting lost in the neighborhood where he has lived for 35 years. He was recently found wandering and has often been brought home by neighbors. When asked about this, he becomes angry and defensive and states that he was just trying to go to the store and get some bread.

His wife expressed concerns about his ability to make decisions as she came home two days ago to find that he allowed an unknown individual into the home to convince him to buy a home security system which they already have. He has also had trouble dressing himself and balancing his checkbook. At this point, she is considering hiring a day-time caregiver help him with dressing, meals and general supervision why she is at work.

Past Medical History: Gastroesophageal reflux (treated with diet); is negative for hypertension, hyperlipidemia, stroke or head injury or depression

Allergies: No known allergies

Medications: None

Family History

· Father deceased at age 78 of decline related to Alzheimer's disease

· Mother deceased at age 80 of natural causes 

· No siblings

Social History

· Denies smoking

· Denies alcohol or recreational drug use 

· Retired lawyer

· Hobby: Golf at least twice a week

Review of Systems

· Constitutional: Denies fatigue or insomnia

· HEENT: Denies nasal congestion, rhinorrhea or sore throat.  

· Chest: Denies dyspnea or coughing

· Heart: Denies chest pain, chest pressure or palpitations.

· Lymph: Denies lymph node swelling.

· Musculoskeletal: denies falls or loss of balance; denies joint point or swelling

General Physical Exam  

· Constitutional: Alert, angry but cooperative

· Vital Signs: BP-128/72, T-98.6 F, P-76, RR-20

· Wt. 178 lbs., Ht. 6'0", BMI 24.1

HEENT

· Head normocephalic; Pupils equal and reactive to light bilaterally; EOM's intact

Neck/Lymph Nodes

· No abnormalities noted  

Lungs 

· Bilateral breath sounds clear throughout lung fields.

Heart 

· S1 and S2 regular rate and rhythm, no rubs or murmurs. 

Integumentary System 

· Warm, dry and intact. Nail beds pink without clubbing.  

Neurological

· Deep tendon reflexes (DTRs): 2/2; muscle tone and strength 5/5; no gait abnormalities; sensation intact bilaterally; no aphasia

Diagnostics

· Mini-Mental State Examination (MMSE): Baseline score 12 out of 30 (moderate dementia)

· MRI: hippocampal atrophy

· Based on the clinical presentation and diagnostic findings, the patient is diagnosed with Alzheimer's type dementia.

Discussion Questions

1. Compare and contrast the pathophysiology between Alzheimer's disease and frontotemporal dementia.

2. Identify the clinical findings from the case that supports a diagnosis of Alzheimer's disease.  

3. Explain one hypothesis that explains the development of Alzheimer's disease

4. Discuss the patient's likely stage of Alzheimer's disease.