The patient is a widower, living with a caretaker 24 hours a day.

In 2003, prostate cancer treated with a radical prostatectomy surgery and subsequent radiotherapy.

No other internal pathologies and/or relevant surgeries.

Case History:

The patient was evaluated at the Alzheimer’s Center in August 2006, and at that time he was diagnosed with a “possible mild Alzheimer’s disease”.

Re-evaluated in December 2007.

 

Cognitive and behavioral history

From the medical history information collected from the son, the cognitive-behavioral condition seems to have slightly but globally worsened compared with last year:

he is very repetitive, doesn´t remember recent events, has difficulty finding objects, does not remember to take medications, doesn’t show up at appointments because he forgets them; he shows signs of confabulation (compensatory false recollections);

has maintained memories of his youth and remembers distant past more clearly;

his spontaneous language is fluent but characterized by frequent difficulties to find quickly the right words; uses a reduced vocabulary compared with the past and resorts to circumlocutions in an attempt to be more informative; has no difficulty reading and writing but has problems with calculations;

adequate use of common objects;

confuses at times the use of the telephone with that of the remote control; knows how to use electric shaver but doesn’t cook anymore;

recognizes familiar faces and doesn’t make mistakes in layering his clothes;

has difficulty in managing cash money and doesn’t handle any longer bank transactions;

he doesn’t go out by himself because he would get lost; he moves around comfortably in his own apartment;

he is disoriented in time;

hallucinations and delirious thoughts, present at the last visit, have disappeared.

From a behavioral perspective, the patient is slightly inert and apathetic. No sleep or eating abnormalities. Does not report sphincter incontinence.

 

Autonomy in daily functions

The patient is capable of taking care of himself but requires supervision in some basic daily activities (ex. going out, managing money, housework, etc.)

 

Brain CAT scan (December 6, 2007)

No focal abnormalities with pathological characteristics in sub- and supratentorial structures.

Normal ventricular system.

Median structures in axis.

 

Neuropsychological evaluation (December 6, 2007)

At an informal visit, the patient appears disoriented in time, space and autobiographical parameters. Spontaneous speech is characterized by fluent language, with normal prosody, sufficiently adequate and communicative; an occasional anomic aphasia is noted, no paraphasia or dysgrammatism; moderate deficit in the oral comprehension of the speech;

Informally: slight dysgraphia, some acalculia in simple written calculations with preservation of arithmetic rules.

On the Overall Dementia Assessment test the patient has obtained a score of 63.8/100, corrected for age and education level to 64.5/100; this score is in the medium range of cognitive pathology and indicates an actual decrease of 0.81 points per month.

The score, obtained at the evaluation session, converted through a formula developed by the Center, corresponds to a M.M.S.E. (Mini-Mental State Exam) score of 17/30 (estimated within a wide confidence band).

Conclusions:

On the basis of medical history and psychometric information, the patient is confirmed to be suffering with a moderate degree, chronic cognitive progressive impairment of a degenerative nature, which by exclusion, is nosographically ascribable to probable Alzheimer’s disease.

Provided that the requirements set forth in the ministerial protocol are met, we believe that the patient may profit from an anti-cholinesterasic central therapy received at the out-patient ____________ facility. The aim is to begin the administration of anti-cholinesterase drugs.

Questions:

• Do you confirm the diagnosis?
• Would you recommend any further diagnostic tests?
• Do you agree with the efficacy of the anti-cholinesterasic therapy suggested? Are there any better therapeutic alternatives?
• Any experimental therapies available in Europe?

Thank you for the referral and the copy of the medical records for Mr. _________.

I am providing the following opinion based on the review of the material provided. I have not evaluated the patient in person; therefore this opinion represents suggestions for future treatment that the patient may choose to explore with the treating physician.

He is a 78 year-old with a slow and progressive cognitive decline of at least 2 years duration. His current symptoms include an impairment of short-term memory with intact remote memory, anomia with circumlocution, difficulty with calculation, and disorientation to time and unfamiliar locations. Note is made of hallucinations and delerium at a prior visit (August 2006?) but not currently. He does not have incontinence or a disturbance of sleep. The reported history does not indicate the presence or absence of disturbances of mood, gait, or coordination. A past medical history of treated prostate cancer is noted. His current medications are not reported. The cognitive examination describes a moderate dementia (MMSE equivalent of 17/30). No physical examination is given. Report is made of a head CT from December 2007 that was unremarkable.

The nature and progression of his symptoms strongly suggest an organic dementing illness. The differential diagnosis would include Alzheimer’s disease; fronto-temporal dementia; and the Parkinson’s related dementias, with Diffuse Lewy Body Dementia (DLB) the most relevant. Fronto-temporal dementia is rendered less likely given the older age of onset and the absence of early and specific alterations in language and personality. DLB is associated with an antecedent history of REM behavior disorder (yelling and kicking during dream sleep), hallucinations, and eventually extrapyramidal motor dysfunction (particularly gait disturbance). Mr. ________’s history of hallucinations in 2006 may have been simple, transient delirium in the setting of a generalized illness (which is commonly seen in any of the organic dementias). If hallucinations are a persistent phenomenon, or if a history of REM behavior disorder or motor impairments is present, then DLB should be considered. If additional history to suggest DLB is not present, then Alzheimer’s disease is most likely.

Reversible causes of dementia should also be excluded. The normal CT scan (as well as the absence of a history of gait disturbance and incontinence) excludes normal pressure hydrocephalus. Testing for a vitamin B12 deficiency (serum B12 and methylmalonic acid level), and hypothyroidism should be conducted. The patient should be screened for depression and treated if it is present, optimally with an SSRI (e.g, Zoloft).

Treatment of Alzheimer’s disease begins with an acetylcholinesterase inhibitor. The three medications used in the US (Aricept, Exelon, Reminyl) have equal efficacy. I typically titrate the medication at a half-dose for 1 month to reduce side effects (typically diarrhea and insomnia). Treatment should also include memantine (Namenda in the US, Ebixa in the EU). This medication is initiated using a titration pack for 1 month, then continued at 10mg BID thereafter. There are minimal side effects. The combination of memantine and an acetylcholinesterase inhibitor has been shown to be more effective than either alone. The patient and family should be warned that the treatment at best only slows disease progression, and should not be expected to reverse cognitive impairment.

There are clinical trials for investigational treatments underway at multiple centers throughout Europe. It is difficult to provide a general recommendation for a clinical trial. I would suggest that you contact the nearest tertiary care, University-level hospital and inquire about available clinical trials for Alzheimer’s disease. I could provide further information regarding a particular clinical trial if one is being considered.

If I can be of any further help to the patient, please have the patient contact me through Medical Opinion.

Sincerely,

_______________________

Assistant Professor of Neurology