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
- Compare and contrast the pathophysiology between Alzheimer's disease and frontotemporal dementia.
- Identify the clinical findings from the case that supports a diagnosis of Alzheimer's disease.
- Explain one hypothesis that explains the development of Alzheimer's disease
- Discuss the patient's likely stage of Alzheimer's disease.
- Instructions- Compares and contrasts the pathophysiology between Alzheimer’s disease and frontotemporal dementia.
- Identifies the clinical findings from the case that supports a diagnosis of Alzheimer’s disease.
- Explains one hypothesis that explains the development of Alzheimer’s disease.
- Discusses the patient’s likely stage of Alzheimer’s disease.
Full Answer Section
Pathophysiology
AD is caused by the buildup of amyloid plaques and tau tangles in the brain. Amyloid plaques are clumps of protein that form outside of cells. Tau tangles are twisted fibers of protein that form inside of cells. These plaques and tangles damage neurons and lead to their death.
FTD is caused by the degeneration of nerve cells in the frontal and temporal lobes of the brain. The frontal lobe is responsible for executive functions, such as planning, organizing, and decision-making. The temporal lobe is responsible for language and memory. In FTD, the nerve cells in these areas die, leading to problems with these functions.
Clinical Findings
The clinical findings of AD and FTD can overlap, but there are some key differences. In AD, patients typically experience problems with memory, language, and reasoning. They may also have problems with vision, judgment, and coordination. In FTD, patients typically experience personality changes, such as apathy, disinhibition, and loss of empathy. They may also have problems with language and movement.
Diagnosis
The diagnosis of AD and FTD can be difficult, as the symptoms of the two diseases can overlap. However, there are some tests that can help to make the diagnosis. These tests include:
- Mini-Mental State Examination (MMSE): This test is used to assess cognitive function. A low score on the MMSE can be a sign of dementia.
- Brain imaging: Brain imaging tests, such as MRI and CT scans, can be used to look for signs of AD or FTD. For example, AD can be seen on MRI as a decrease in the size of the hippocampus, a part of the brain that is important for memory.
- Biomarkers: Biomarkers are substances that can be measured in the blood or spinal fluid. Some biomarkers can be used to help diagnose AD and FTD. For example, the levels of amyloid beta and tau proteins can be measured in the spinal fluid.
Treatment
There is no cure for AD or FTD. However, there are treatments that can help to slow the progression of the diseases and improve the quality of life for patients. These treatments include:
- Medications: There are a number of medications that can be used to treat AD. These medications work by targeting the amyloid plaques and tau tangles that are thought to cause the disease.
- Non-drug therapies: There are a number of non-drug therapies that can also be helpful for people with AD and FTD. These therapies include:
- Physical therapy: Physical therapy can help to improve balance and coordination.
- Occupational therapy: Occupational therapy can help to improve activities of daily living, such as dressing and bathing.
- Speech therapy: Speech therapy can help to improve communication skills.
- Social support: Social support groups can provide emotional support and practical advice to people with AD and FTD and their caregivers.
Prognosis
The prognosis for AD and FTD is variable. Some people with AD live for many years after diagnosis, while others progress more quickly. The prognosis for FTD is also variable, but the disease typically progresses more rapidly than AD.
Conclusion
AD and FTD are two serious diseases that can have a significant impact on a person's life. However, there are treatments that can help to slow the progression of the diseases and improve the quality of life for patients. Early diagnosis and treatment are important for people with AD and FTD.