CASE STUDY

A Case Study in
Alzheimer’s Disease
A 69-year-old woman presents with symptoms of forgetfulness that worsen over time.
Now the doctor must decide when a diagnosis of Alzheimer’s disease should be made,
how the family should be told and what support can be offered to the caregiver.

by Serge Gauthier, MD, FRCPC

History Twenty months later, Mrs. J. is reassessed and she

Mrs. J. is a 69-year-old Caucasian woman who pre- reports that her memory impairment has worsened and is
sents with symptoms of forgetfulness. She has trouble now “embarrassing” her. She has stopped working in an
remembering names and the location of certain keys on office and her husband has observed her to be more irri-
her typewriter. Her past medical history includes table as well as nervous. The neurologic exam shows that
uncomplicated shingles and treatment with prednisone the patient now has buccolingual and limb apraxia. Her
for temporal arteritis between the ages of 65 to 67, with clock drawing is now impaired in that she has put in at
residual osteoporosis. Consequently, she has been tak- least 15 numerals and has no idea how to place the hands
ing calcium supplements as well as low doses of thyroid of the clock. A diagnosis of early Alzheimer’s disease
replacement therapy. (AD) is made.
One year later, Mrs. J. is assessed by an AD specialist.
Her symptoms now encompass some word-finding diffi-
Twenty months later, Mrs. J. is culties and the need for supervision to look after her
financial affairs and for cooking. Her affect is described
reassessed and she reports that her as sad, with a tendency to sleep more in the daytime. A
memory impairment has worsened and psychogeriatric consultation rules out depression. Her
MMSE is 24/30 and her clock drawing is impaired. The
is now “embarrassing” her. She has
diagnosis of AD is confirmed and felt to be of stage 4 on
stopped working in an office and her the seven stages Global Deterioration Scale (GDS)
husband has observed her to be more (Table 1).
A year after that, Mrs. J. is forgetting to give phone
irritable as well as nervous. messages, can still dial familiar phone numbers, and has
shown temporary spatial disorientation in her condo in
Florida and when visiting her brother’s house. She has
Her family history includes a maternal uncle with stopped cooking altogether, is afraid of the oven and
dementia who is in his 90s. A standard laboratory blood needs some supervision for the selection of her clothes.
work-up is negative except for mild normocytic anemia. She is still able to stay alone for several hours at a time,
The neurologic exam reveals mild limb apraxia. Her allowing her husband some time at his golf club.
Mini-Mental Status Exam (MMSE) score is 27/30 (con- Nevertheless, she shows anxiety for upcoming events.
sidered normal) and her clock drawing is perfect The MMSE is now 20/30. Her GDS stage is 5. Her hus-
(Figure 1). The initial diagnostic impression is that of band and children have heard about new AD drugs and
uncertainty as to the benignity of the cognitive (predom- hope that some drug intervention might stabilize
inantly recent memory) loss. Mrs. J.’s symptoms. A follow-up visit is scheduled.

18 • The Canadian Alzheimer Disease Review • March 1998

AD Case Questions Table 1

and Related Commentary Global Deterioration Scale

Stage Clinical characteristics
Questions 1 —
• Are there early markers of AD? 2 Subjective forgetfulness, but normal examination
3 Difficulty at work, in speech, when traveling in
• In this case, how would you follow up on your unfamiliar areas, detectable by family; subtle
suspicion of AD? memory deficit on examination
• When should a diagnosis of AD be attempted? 4 Decreased ability to travel, count, remember
current events
Comment 5 Needs assistance in choosing clothes;
disorientation to time or place, decreased recall
In screening for dementia, the primary care physician of names of grandchildren
has a number of practical tests available to assist in 6 Needs supervision for eating and toileting, may
differentiating between cognitive changes associated be incontinent; disoriented to time, place and
with normal aging, and cognitive loss indicative of possibly to person
7 Severe speech loss; incontinence and motor
early-stage dementia. The MMSE is a well-known
stiffness
cognitive screening tool, but is subject to some degree
of educational bias. Serial administration of the MMSE Reisberg B, Ferris SH, DeLeon MJ, et al: The global deterio-
is useful in plotting cognitive loss over time. In addition, ration scale for assessment of primary degenerative demen-
tia. Am J Psychiatry 1982; 139:1136-9.
the clock drawing test is sensitive to early dementia and,
like the MMSE, offers an opportunity for documenting
cognitive changes over the course of dementia.
Figure 1
Serial administration of the MMSE is Illustrations of Clock Drawings From Four
useful in plotting cognitive loss over Alzheimer Patients at Different Disease Stages
time. In addition, the clock drawing
test is sensitive to early dementia and,
like the MMSE, offers an opportunity
for documenting cognitive changes
over the course of dementia. MMSE 28 MMSE 27

These serial cognitive assessments, in addition to

functional assessments, are integral to the physician’s
ongoing clinical record-keeping that is necessary for
treatment, patient management at home and institution-
alization at the more advanced stages of dementia. The
physician should be careful in mentioning suspicion of
MMSE 24 MMSE 13
AD at this stage or at the first visit, given the uncertainty
of the diagnosis of dementia and the risk of reactive Gauthier S, Burns A, Pettit W: Alzheimer’s Disease in
depression. Other concomitant medical disorders that Primary Care. Martin Dunitz, London, 1997, p.15.

could cause or contribute to cognitive decline should be

ruled out. for serial brain imaging using MRI, PET and SPECT, as
Despite advances in our knowledge of the etiology of well as neuropsychological batteries studying delayed
AD, even now there are no diagnostic tests of sufficient recall and word fluency. Equally promising is a recent
sensitivity and specificity to make a firm diagnosis of report of EEG changes during sleep, which may lead to
AD at this very early stage. There are evolving protocols an early diagnostic marker.

The Canadian Alzheimer Disease Review • March 1998 • 19

 CASE STUDY

Questions The staging of AD requires a good understanding of

• How is the diagnosis of AD made? the multiple symptomatic domains in dementia.
• How do you tell the family that the Depression and anxiety-related symptoms in early AD
patient has AD? tend to decrease in severity as insight becomes progres-
• How do you follow the progression? sively more limited. There is a progressive loss of high-
er cognitive functions and functional independence
Comment (usually beginning with the instrumental activities of
The DSM-IV criteria for dementia are: daily living), followed by the emergence of neuropsy-
• Memory impairment; one of aphasia, apraxia, chiatric symptoms, which eventually abate as
agnosia and/or disturbance of executive functioning Parkinson-like motor changes suppress all behavior.
• Impairment in occupational or social functioning
• Decline from previous level of functioning
In order for a diagnosis of dementia to be made, the In order for a diagnosis of dementia
cognitive impairment of the patient must have a func-
tional impact that is clearly evident. In the natural histo-
to be made, the cognitive impairment
ry of dementia the loss of functional independence sig- of the patient must have a functional
nals a disease milestone. impact that is clearly evident.
Two instruments for gauging functional status, the
Functional Activities Questionnaire (FAQ) and the
Physical Self-Maintenance Scale (PSMS), facilitate While variations in the progression of AD and in the rate
assessment and signal disease milestones which require of its progression are not uncommon, the staging of the
more intensive formal care. At this early stage, the higher disease through instruments such as the GDS offers a
executive functions are more likely to be affected. Family clinical timeline for the progression of dementia. It is at
caregivers should be referred to the local chapter of the stages 3, 4 and 5 that most of the drugs for AD have
Alzheimer Society for ongoing family education, infor- been tested in clinical trials.
mation on local resources and primary caregiver support.
Medico-legal issues are now of concern to the physician Question
and include the safety of the patient in the home envi- • What kind of support can be offered to the
ronment, driving ability and advanced directives for the caregiver?
late stages of AD.
Comment
Question The load on the caregiver increases progressively with
• When do you suspect a mood disorder? the loss of functional autonomy. The anxiety of being
left alone could have limited the husband’s availability
Comment of free time and impaired his psychological health. As
Depression must be carefully ruled out in early AD and a preventive measure, respite or day care can be
may require a specialist referral if there is uncertainty as arranged by the physician. Sensitivity to the health
to the diagnosis. Depression may mask early dementia so needs and well-being of the primary caregiver is a key
that depressed patients with cognitive impairment should component of the primary care management of AD, and
be followed over time and further cognitive impairment knowledge of community-based formal supports is nec-
should be documented once depressive symptoms are essary for appropriate referral. Planning for institution-
resolved. When antidepressants are indicated, they alization is critical in the later stages of the disease and
should be selected on the basis of safety, tolerability and is facilitated by physician and family contacts with
their drug interaction profile. local social services.

This case study is part of an Alzheimer’s Case Study Continuing Medical Education (CME) series sponsored by
Pfizer Canada. For more information regarding the program in your area, please call your local Pfizer representative.

20 • The Canadian Alzheimer Disease Review • March 1998