Mrs.

Janet Riley is a 79-year-old Caucasian female with progressive cognitive and

memory deficits, emotional lability and behavioral changes for about 3 to 4 years now, especially

the last few months those symptoms have been worst. Mrs. Riley has been noted that she is

unable to complete her activities of daily living, and lack of interest in previous activities and

friends. She also mixes up words, forget names of familiar people, and gets angry when help is

offered. For her memory loss and confusion, medication such as cholinesterase inhibitors can be

prescribed. However, safety issue is the most concern for Mrs. Riley, and prevention is the key

(National Institute of Aging, 2017). The National Instute of Aging (2017) suggested that smoke

and carbon monoxide detectors should be installed in or near the kitchen and all bedroom, also

all phone numbers, include 911, poison control, hospital, PCP, and more, should be displayed

next to phones or anywhere easy to see around the house. They also suggested that safety knobs

and an automatic shut-off switch should be installed on the stove (National Institute of Aging,

2017). Moreover, all medications, prescribed or OTC, need to be locked up. Alcohol, cleaning or

household products are other dangerous item that need to be removed from the home (National

Institute of Aging, 2017). There should be no weapons, guns, machinery or gas online cans

around the house of patient with Alzheimer’s disease (National Institute of Aging, 2017). Last

but not least, it’s important to make sure simplify the house to reduce clusters to prevent falling.

Even though it might not be ideal to hire a caregiver for Mrs. Riley, it doesn’t hurt to try since

it’s no longer safe for Mrs. Riley to live by herself anymore. Family can continue to check in

with her or even move in with her though this is not going to be easy. Nevertheless, these options

can be suggested to family. A deeper evaluation should be done with patient’s PCP or even a

Neurologist to formally give patient a diagnose of Alzheimer disease. In a worst case scenario,

patient’s daughter might need to become her DPOA (durable Power of Artorney) to assist patient

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 in any decision making.

Janet Riley

Janet Riley presents to the office with her daughter for increased concern over confusion,

agitation, and memory problems. Mrs. Riley is not cooperative in the exam and assessment and

does not feel she has any problems. Per her daughter, the problems started approximately two to

three years ago with increased progression noted over the past year. Mrs. Riley presents with

significant body odor and indifference to the situation. She has not been caring for herself,

cooking meals, nor interacting with others.

The initial assessment was performed asking Mrs. Riley’s daughter most of the questions

with answers indicative of cognitive impairment. Mrs. Riley once again stated she does not have

any problems and wishes her family would stop meddling in her business. Pertinent questions

asked where when did the memory problem start; two to three years ago with an increase in the

past year. Is her confusion better or worse at specific times; more at night. Has she lost interest

in things; she stopped playing tennis and interacting with others. During the interview it was

also noted that she has difficulty remember things or finding the right words or names. Personal

care; inability to care for herself. Mood; irritable. Mrs. Riley is only A&Ox2 when asked

year/time, what happened. When asked about weight loss, it was noted that she has stopped

cooking for herself. Her irritability has increased and has progressed over the past year. She has

paranoid delusions of people stealing from her. Examination reveals impaired memory,

personality change, increasing confusion, poor concentration, impaired judgement, paranoid

ideation, and impaired performance of ADLs. Mrs. Riley is A&Ox2 upon examination.

For Mrs. Riley, the tests that should be obtained are a CBC to check for an elevated WBC

indicative of an infection and an elevated MCV indicative of B12 deficiency or even chronic

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 alcohol consumption (Mrs. Riley’s daughter states that she does drink occasionally but is unsure

of her habits at home when by herself. A urinalysis, a common finding in increased confusion is

a UTI; this being normal for Mrs. Riley. A BMP to determine to rule out causes of an altered

mental status; normal for Mrs. Riley. A head MRI that shows hippocampal reduced volume

(R>L), which can be indicative of Alzheimer’s disease. Surprisingly an EEG was obtained and

is also indicative of early dementia. Mrs. Riley’s EEG was abnormal showing a reduction in

EEG activity, indicative of cognitive impairment. An ESR was obtained to assist in ruling out an

inflammatory response and Mrs. Riley’s ESR was negative/normal. A serum folate

homocysteine, thyroid-stimulating hormone, vitamin B-12, RPR were also obtained, as

additional tests to rule out common treatable or reversible causes of dementia; normal for Mrs.

Riley except the RPR indicative of memory loss. Another surprising test was the HIV antibody;

associated with metabolic encephalopathy thus causing altered mental status. Mrs. Riley also

had a sleep study performed to rule out OSA and this was negative. Another test that was

surprising in ruling out dementia versus Alzheimer’s disease. Based on the above results, Mrs.

Riley is at a high risk for Alzheimer’s disease.

Based on the above assessment and test results, it appears that Mrs. Riley has

Alzheimer’s disease and thus a care plan must be devised to assist Mrs. Riley and her family.

Mrs. Janet Riley is a 79-year-old Caucasian female who presents today with her daughter,

Ann, who is concerned about Mrs. Riley’s progressive cognitive and memory deficits, emotional

lability and behavioral changes for about 3 to 4 years now, especially the last few months those

symptoms have been worst. Mrs. Riley’s daughter reports that she has noticed changes in Mrs.

Riley’s personality, and behavior. Mrs. Riley has been noted that she is unable to complete her

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 activities of daily living, and lack of interest in previous activities and friends. She also mixes up

words, forget names of familiar people, and gets angry when help is offered.

It was difficult to assess Mrs. Riley since she is not cooperating and often time stated,

“it’s time to leave. I’m not going to answer you,” and so on. Mrs. Riley presents today as

unkempt and has obvious malodorous body odor. She is alert and oriented times two (person and

place). Unintentional weight loss about 8 lbs. Daughter stated patient has not been able to cook

for herself anymore, and this has been going on for about two three months now. She recently

fell at home related to trip and fall. Had head trauma history due to the fall and ended up in the

ER for observation. Mrs. Riley has history of HTN, high cholesterol, and CAD with stent

placement.

Her geriatric depression scale is 3/15, and her MMSE score is 19/35. Test ordered for

Mrs. Riley are blood work, a brain MRI, urinalysis, EEG, CSF analysis, and a brain MRI. As the

results for CBC and B12 show normal limits, patient doesn’t have sleep obstructive sleep apnea,

UA is negative, and CSF is normal. However, the MRI does show generalized cortical atrophy

and a reduced hippocampal volume, as well as the EEG shows cortical dysfunction. Atrophy of

the cortex is indicative of Alzheimer’s disease, and per Vemuri & Jack (2010), brain atrophy is

measure on MRI, and it is a helpful test to determine the intensity of neurodegenerative process

of Alzheimer’s disease. The cerebral cortex plays an important part in memory, attention,

thought, and language. Mrs. Riley’s MRI has shown an atrophy of the cortex indicated that she

has Alzheimer’s disease.

Janet Riley is a 79 year old Caucasian female that presents with her daughter, Ann, who has

concerns about Janet’s progressive cognitive and memory deficits, emotional lability and behavioral

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 changes over the past year. Ann reports that she has noticed changes in Mrs. Riley’s personality, inability

to complete her activities of daily living, and lack of interest in previous activities and friends.

Mrs. Riley is difficult to assess, does not answer many questions and denies the need to be at the

doctor. She presents as unkempt and has obvious malodorous body odor. She is alert and oriented times

two only, to person and place. Exam reveals that she has had an unintentional weight loss of

approximately eight pounds over the last few months. Her MMSE score is 19/30 and geriatric depression

scale is 4/15. She has a recent history of head trauma related to a trip and fall four weeks ago. Mrs. Riley

has a history of hypertension, high cholesterol and CAD.

Tests ordered for Mrs. Riley include bloodwork, a brain MRI, sleep study, urinalysis, an EEG, and

CSF analysis. All lab values are within normal limits, UA is negative, and the sleep study was normal. The

CSF was normal. The brain MRI shows generalized cortical atrophy and a reduced hippocampal volume.

The EEG shows cortical dysfunction.

Brain atrophy is measured on MRI and is a powerful biomarker of the stage and intensity of

neurodegenerative aspects of the pathology of Alzheimer’s disease (Vemuri & Jack, 2010). The cerebral

cortex plays a key role in memory, attention, thought, and language (Kumar-Lama, Gwak, Park & Lee,

2017). Atrophy in the cortex is indicative of AD. Imaging study of medial temporal lobe atrophy (MTA),

particularly in the hippocampus, the entorhinal cortex, and the amygdala provides the evidence of the

progression of AD (Kumar-Lama, Gwak, Park, & Lee, 2017). Mrs. Riley’s test results accompanied by her

associated symptoms indicated that she has Alzheimer’s Disease.

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