BT is an 85-year-old married, Caucasian female with no previous history of psychiatric illness, brought to the outpatient psychiatry clinic by her husband on account of having auditory hallucinations and delusions

Dementia Case Study
CC:
“I hear voices.”

HPI:
BT is an 85-year-old married, Caucasian female with no previous history of psychiatric illness, brought to the outpatient psychiatry clinic by her husband on account of having auditory hallucinations and delusions. She is sitting quietly in a chair. Her husband reports that for the past two months BT has been suspicious of him. She believes that he is not loyal to her and is involved with another woman. She argues with him and follows him secretly, wherever he goes. She told him that she hears a female voice in the house and it must be the woman with whom she suspects he is involved. She has become increasingly upset and agitated over the past two months and argues with her husband frequently. He tried to explain to her that this is not true and that he is not having an affair, but she is adamant that he is hiding his affair from her.

BT started hearing voices approximately two months ago. At times she hears noises, and sometimes she hears the voice of one or more persons. She at first believed that her husband brought a woman into the house. She later started believing that the woman and other people are now living in her house. She hears voices of multiple people, using foul language. Sometimes she hears them singing. The voices do not talk to her and are not commanding, and she mostly hears them when her husband is not around. These voices wake her up early in the morning. Over all the voices have progressively gotten worse, affecting her relationship with her husband and causing significant stress in her life. She has been having frequent arguments with her husband. For the past month she has started seeing people in her house. She has seen a woman in the house multiple times, and believes that her husband has brought her into the house. She has anxiety and stress related to the current symptoms, otherwise she does not have depressed mood and has no problems with appetite and energy. She has disturbed sleep as voices wake her up early in the morning. She does not enjoy activities as much as he used to, due to the voices as well as due to the fact that she believes her husband is unfaithful. She does not have any suspicion about anyone other than her husband. She never had symptoms consistent with mania or hypomania. She does have problems with her memory and has been forgetful for few months, does not remember recent events, and has problems coming up with words. 0therwise, her overall functioning is not impaired.

BT’s husband provided a history consistent with the foregoing and reports that her current symptoms started approximately two months ago. Symptoms stay the same and do not seem to fluctuate over the course of a day. She was seen by her primary care clinician for these psychotic symptoms. Her husband brought the records from her family physician, including labs and imaging reports. Routine laboratory tests including urinalysis, CBC, CMP, B12, TSH, and
RPR were all unremarkable. A CT scan of the head showed mild cortical brain atrophy, mild cerebral ventricular enlargement, and mild periventricular white matter changes. BT’s son called the clinic to provide additional information. He states he is concerned about his mother’s current symptoms because he has noticed that she has been increasingly forgetful over the past year. Although mild problems with memory started more than a year ago, it became more noticeable and worsened in past year. She often has difficulty remembering recent information. She asks the same questions repeatedly about recent events and gets upset when someone points it out. She exhibits problems with finding words and remembering names on introduction to new people. She misplaces things and loses them often. There have been few instances when she had left the stove on. She has been unable to cook as effectively as before and has been having problems with managing her finances. She does not drive and has never driven in the past.

PMH:
Hypertension
Hyperlipidemia
GERD

PPH:
BT has no previous psychiatric history. She has never been diagnosed with any psychiatric illness and has never been on any psychotropic medication. She never had any episodes of depression or mania or psychotic symptoms in past and has never been hospitalized to any psychiatric unit.

FH:
There is no history of any psychiatric illness in BT’s family, including major depression, bipolar disorder, or schizophrenia. Her mother died in a nursing home at the age of 90 years and had problems with memory in later years of her life. BT’s father died at the age of 70 years from heart disease.

SH:
BT was born and raised in Traverse City, Michigan. She was the only child of her parents and had a very good childhood. She was a good student and finished high school. After graduation she got married to her high school boyfriend. She has been married to him for 63 years. She lives with her husband who is now 87 years old. She still remembers the beautiful days when she was dating him, and she remembers the first gift he gave to her. She has one son who lives close to her house. He is supportive and sees her often. She worked in the past as cook in a restaurant before her son was born. She has not worked in over 50 years and has been a homemaker. Her husband reports that she has managed the finances and has helped him keeping books all her life, until a few months ago when she had started having difficulties with it. She loves reading books and follows current affairs and news. She has always been well informed about current affairs, but for the past several months she did not seem to remember daily events and forgets them often. She used to cook gourmet dishes and is known for making delicious food but has not been able to do so for some time. There is no history of tobacco smoking, alcohol, or recreational drug abuse.

Allergies/Intolerances/Adverse Drug Events:
None

Meds (Current):
Atorvastatin 20 mg po at bedtime
Amlodipine 10 mg po daily
Omeprazole 20 mg po daily

Review of Systems:
Neurological exam: Glabellar and palmo-mental reflexes are positive. No focal neurological deficits present. No other positive finding on neurological examination.

Mental Status Examination:
BT is an elderly white female with average build, well dressed and well groomed. She walked-into the room with slow gait. No psychomotor or abnormalities are noticed. Impulse control is intact. She is cooperative and has fair eye contact. Her speech is spontaneous, soft, and fluent with average rate and rhythm. She is alert and oriented to time, place, person, and situation. Registration is mildly impaired. Immediate and recent memory are impaired. Remote memory is intact. Overall she is able to provide information during the interview, but does exhibit some deficits in memory of personal history. Concentration is impaired. Her affect is mood congruent, mildly anxious, and restricted. She describes her mood as “fair.” There are no suicidal or homicidal ideations, intent, or plan. Language overall is average except difficulty finding the right word at times. Thought process is linear and goal directed, with normal association. Thought content is positive for delusions. She is able to abstract proverbs. She has some difficulty doing simple calculation. Intelligence is average. She is able to name the current president of United States, but is unable to name three presidents prior to the current one. Insight is limited. Judgement is intact She has had auditory hallucinations on and off, but are not present at the time of interview. There are no current visual hallucinations. No illusions, depersonalization, or derealization present.

Mini-Mental State Exam (MMSH): 23/30.

Labs:
All WNL. Urinalysis, CBC, CMP, B12, TSH, and RPR were all unremarkable.

Case Study Overview

The Case Study: Analyses and Critiques constitute a significant learning portion of this course, and you are expected to put forth a thoughtful and scholarly effort.

The instructor will place you into 1 of 2 groups (Group 1 or Group 2). Each group will complete 3 Case Study: Analyses and 3 Case Study: Critiques.

Analyses: Beginning in Module/Week 2, each student in Group 1 will complete the Case Study: Analysis in current APA format and will post it on the designated Discussion Board Forum for review by his/her classmates. Each analysis must use at least 2 sources (including national guidelines) to support information.

Critiques: After the members of Group 1 post their analyses, each student in Group 2 will select an analysis from Group 1. They will then prepare a Case Study: Critique in current format, and post it on the designated Discussion Board Forum.

Groups 1 and 2 will alternate weekly between completing the Case Study: Analyses and the Case Study: Critiques.

The Case Study: Analyses and Critiques must be completed in Microsoft Word and conform to proper current APA format. You are required to write a minimum of 1 page for each analysis and critique. To ensure consistency and quality of effort, reference and follow the examples provided.

The Case Study: Critiques are expected to be academic in nature and insightful. Hence, it is inappropriate and of little academic value to state, “I agree with the pharmacotherapy plan.” You must provide a rationale and properly referenced evidence to support your critique. In order to receive maximum credit, multiple sources must be cited. Likewise, if you disagree with the plan, be sure to include an alternative recommendation with supporting evidence. Each critique will use a minimum of 3 literature references to support comments.