Case 3neurocognitive Disordersbackgroundmr Charles Wingate Is A 76 ✓ Solved

Case #3 Neurocognitive Disorders BACKGROUND Mr. Charles Wingate is a 76-year-old Caucasian male who presents to your office for an initial psychiatric evaluation. He is accompanied by his eldest son, Mark, who lives with Mr. Wingate. Mr.

Wingate was referred to you by his primary care provider who has performed an extensive diagnostic workup to rule out an organic basis for his changes in cognition. Mr. Wingate’s son Mark has verbalized a concern that Mr. Wingate may have Alzheimer’s disease. When questioned, Mr.

Wingate states that he is unaware of anyone in his family ever having been diagnosed with Alzheimer’s disease. SUBJECTIVE Mr. Wingate states that he has always been “a little bit forgetful,†but he noticed that in his 60s and 70s, it got worse. Mark states that “for the past 2 years, it has been getting worse. He doesn’t even notice how bad his memory has become.†On at least two occasions, Mr.

Wingate has gotten lost when he was driving to the grocery store. Mr. Wingate protested his disagreement with this accusation stating, “but they were doing road construction, anyone could have gotten mixed up!†While his son conceded to this, he pointed out that Mr. Wingate’s memory has caused some other problems, such as errors with paying his monthly utility bills (at one point, the electric company threatened to shut off his electricity due to his nonpayment of the bill). His son Mark also pointed out that the family is concerned for Mr.

Wingate’s safety as he twice left his keys hanging in the door and just two evenings ago, put food in oven and forgot about it until the smoke detector in the kitchen began to alarm. Mr. Wingate also has had a few issues with managing his medications. Specifically, he took too many Norvasc tablets a few months ago, which resulted in hypotension and a fall. Since that time, Mark’s wife has been setting up Mr.

Wingate’s pills in pill boxes, but recently, multiple “missed doses†have been noted. Mr. Wingate states: “but those are my night pills that I miss—I’m always better at remembering things in the morning.†Mark agrees, stating that Mr. Wingate’s cognition does vary throughout the course of the day and appears to worsen in the evening. He also reports that his father seems much less alert in the evenings, and more alert in the mornings.

Mr. Wingate reports that he has had poor sleep for “a long time now.†He does report that over the past few months, he has been having what he describes as “very vivid nightmares.†His son states that sometimes he is awakened by his father’s yelling during nightmares, and enters his father’s room, and sees his father swinging or kicking in his sleep. He reports that his appetite is “alright†and that his energy levels do fluctuate throughout the course of the day. He states: “sometimes, I can concentrate really well; other times I can’t … it is very frustrating!†Specific to substance use, Mr. Wingate notes that he used to enjoy a glass of wine or two with dinner, but states that it just doesn’t interest him, anymore.

Plus, he stated that he notices that when he does drink, he develops slow muscle contractions. Mr. Wingate’s son also shares a concern about his father’s abnormal movements. He states that for about the last 6 months, his father has had problems with coordination. He states that he raised these concerns with the family doctor who suggested it may be “late onset Parkinson’s disease.†However, he was not treated because the symptoms were “not that bad.†OBJECTIVE Mr.

Wingate was overall calm and pleasant during the clinical interview. Throughout the clinical interview, you notice that Mr. Wingate is not really involved in the discussion. He seems somewhat indifferent to the assessment and does not seem very concerned with what is being discussed. He only protested when discussing how he got lost on his way to the supermarket and his evening medication dose.

Review of systems and screening physical assessment were unremarkable, with the exception of fine resting tremors noted in both of Mr. Wingate’s hands. The psychiatric/mental health nurse practitioner (PMHNP) also reviewed laboratory studies that were sent from Mr. Wingate’s primary care provider; they were within normal limits with the exception of a serum sodium level of 130 mEq/L. MENTAL STATUS EXAM Mr.

Wingate is alert. He is oriented to person, place, and partially oriented to time (he knows that it is morning, but cannot tell the hour). His speech is clear, coherent, goal directed, and spontaneous. Mr. Wingate’s self-reported mood is “ok.†Affect is somewhat constricted.

His eye contact is fleeting throughout the clinical interview. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes appreciated. Judgment seems well preserved, but insight appears impaired as he is having trouble understanding why his son brought him to this appointment. Concentration and attention also appear impaired, which prompts the PMHNP to perform a mini-mental status exam (MMSE) on Mr. Wingate.

RESULTS OF MMSE Score of 17, with primary deficits in orientation; calculation; recall (he was unable to recall any of the three items presented after 5 minutes); and he was unable to perform serial 7’s or spell the word “WORD†in reverse, despite the fact that he is a high school graduate and attended 1 year of college. He also needed prompting with the three-step command. His score suggests severe cognitive impairment. At this point, please discuss any additional diagnostic tests you would perform on Mr. Wingate.

Decision Point One BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO MR. WINGATE? In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis. Major fro Decision Point One BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO MR. WINGATE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis. Major frontotemporal neurocognitive disorder (FTNCD) Major neurocognitive disorder due to Alzheimer’s disease Major neurocognitive disorder with Lewy bodies ntotemporal neurocognitive disorder (FTNCD) Decision Point One Major frontotemporal neurocognitive disorder (FTNCD) Decision Point Two BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS: Begin Citalopram 20 mg orally daily Begin Selegiline 6 mg orally daily Begin Memantine 5 mg orally daily Major neurocognitive disorder due to Alzheimer’s disease Decision Point Two BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS: Begin Donepezil 5 mg orally daily Begin Memantine 5 mg orally daily Begin Seroquel 50 mg orally at bedtime Decision Point One Major neurocognitive disorder with Lewy bodies Decision Point Two BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS: Begin Rivastigmine 1.5 mg orally twice a day Begin Olanzapine 5 mg orally at bedtime Begin Ramelteon 8 mg at bedtime

Paper for above instructions

Introduction

Mr. Charles Wingate is a 76-year-old male exhibiting several concerning symptoms suggestive of neurocognitive disorders. Given the details presented, the purpose of this write-up is to adequately assess Mr. Wingate's condition, propose a diagnosis based on the DSM-5 criteria, and recommend the appropriate treatment options. We shall focus on identifying key symptoms related to Major Neurocognitive Disorder (NCD), particularly Alzheimer's disease and Lewy Bodies, before making treatment recommendations based on the diagnosis.

Diagnostic Evaluation

Clinical Symptoms

Mr. Wingate’s clinical symptoms include:
1. Memory Impairment: Mr. Wingate has shown progressive memory difficulties marked by forgetfulness and getting lost while driving (American Psychiatric Association, 2013).
2. Cognitive Decline: His Mini-Mental State Examination (MMSE) score of 17 indicates severe cognitive impairment. Specific areas of deficits include orientation, recall, and the capacity for attention and concentration (Folstein, Folstein, & McHugh, 1975).
3. Medication Management Issues: Mr. Wingate has experienced challenges managing his medications, which escalated to a dangerous situation involving taking excess doses and resulting hypotension (American Psychiatric Association, 2013).
4. Altered Sleep Patterns & Nightmares: Poor sleep and vivid nightmares may indicate an underlying sleep disorder or impact from cognitive decline (Hirshkowitz et al., 2015).
5. Motor Symptoms: Mr. Wingate’s fine resting tremors suggest possible Parkinsonian symptoms, adding complexity to the diamond diagnosis (Litvan et al., 2015).
6. Affective Changes: His constricted affect and lack of insight into his cognitive problems indicate the possibility of underlying mood or affective-related concerns (American Psychiatric Association, 2013).
7. Safety Concerns: Compromised safety related to forgetfulness and cognitive impairment when leaving keys in the door and forgetting food in the oven indicates a significant level of impairment in daily living activities (American Psychiatric Association, 2013).

Differential Diagnosis

Based on the symptoms, several potential diagnoses can be considered including:
1. Major Neurocognitive Disorder due to Alzheimer’s Disease: The gradual progression of cognitive decline, memory issues, and inability to manage activities of daily living are strongly indicative of this condition (Dubois et al., 2016).
2. Major Neurocognitive Disorder with Lewy Bodies: This diagnosis could be valid considering the combination of cognitive impairment, motor signs (tremors), and vivid dreams or nightmares (McKeith et al., 2005).
3. Major Frontotemporal Neurocognitive Disorder: This is less likely due to the lack of significant behavioral changes that typically characterize FTNCD (Petersen et al., 2019).

Diagnostic Conclusion

Based on comprehensive evaluation against the DSM-5 criteria, Major Neurocognitive Disorder with Lewy Bodies (NCD) is the most likely diagnosis for Mr. Wingate. The confluence of cognitive decline, the presence of motor symptoms, and the sleep disturbances strongly aligns with the symptoms associated with this disorder (McKeith et al., 2017).

Treatment Options

Given the diagnosed Major NCD with Lewy Bodies, treatment options must be thoughtfully considered.
1. Cognitive Enhancers: Rivastigmine, a cholinesterase inhibitor, is a first-line treatment for dementia associated with Lewy Bodies. It can help in managing cognitive symptoms and assist with daily functioning (Levin et al., 2019).
2. Antipsychotic Medications: Given Mr. Wingate’s vivid nightmares and potential behavioral disturbances, careful monitoring and potential use of medications such as Olanzapine can be warranted but need to be handled cautiously because of the risk of severe side effects in Lewy Body dementia patients (McKeith et al., 2017).
3. Sleep Disorder Management: If sleep disturbances persist, medications like Ramelteon (a melatonergic agent) may be beneficial for regulating sleep (Kraft et al., 2016).

Conclusion

Mr. Wingate’s clinical presentation is intricately linked to Major Neurocognitive Disorder with Lewy Bodies. His cognitive impairment, sleep disturbances, and motor symptoms speak volume against the backdrop of neurodegenerative conditions. The recommended treatment, focused on enhancing cognition and managing behavioral symptoms, hinges on the balance between benefits and risks associated with pharmacotherapy, especially given his age and overall health.

References

1. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
2. Dubois, B., et al. (2016). Advancing research diagnostic criteria for Alzheimer's disease: the IWG-2 criteria. The Lancet Neurology, 15(6), 632-652.
3. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). "Mini-Mental State": A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189-198.
4. Hirshkowitz, M., et al. (2015). National Sleep Foundation's sleep time duration recommendations: methodology and results summary. Sleep Health, 1(1), 40-43.
5. Kraft, M. et al. (2016). Ramelteon for the management of sleep disturbances in dementia: A systematic review. Alzheimer's Research & Therapy, 8(1), 6.
6. Levin, A. V., et al. (2019). Efficacy of Rivastigmine in dementia with Lewy bodies and Alzheimer's disease: A systematic review. Neuropsychiatric Disease and Treatment, 15, 1621-1631.
7. Litvan, I., et al. (2015). Diagnosis and management of Parkinson's disease: A systematic review. JAMA, 313(4), 381-391.
8. McKeith, I., et al. (2005). Guidelines for the clinical and pathological diagnosis of dementia with Lewy bodies (DLB): The Sixth Consensus Report of the DLB Consortium. Neurology, 65(12), 1863-1872.
9. McKeith, I. G., et al. (2017). Diagnosis and management of dementia with Lewy bodies: A consensus report. Practical Neurology, 17(5), 490-498.
10. Petersen, R. C., et al. (2019). Dementia with Lewy bodies: A clinical perspective. Alzheimer's & Dementia, 15(10), 1352-1363.