MODEL ANSWERS

Behaviour and Appearance:

Mrs Wilkins was a young looking 60 year old woman who was dressed neatly. Rapport was poor as she was guarded and suspicious. There was some fidgeting noted. There were no obvious abnormal motor or physical findings on inspection.

Orientation and Cognition:

She was orientated to place and person. However she was not aware of the date. She showed poor registration of 3 objects. The rest of the Mini Mental Status Examination was not done. There was no fluctuation of consciousness during the interview.

Affect and Mood:

Affect was restricted in range and was appropriate to the content. Mood was subjectively reported as “not good”. Objectively, mood was dysphoric, anxious and distraught. Neurovegetative symptoms of sleep, concentration and appetite are disrupted.

Thought Form:

She was goal directed in her responses. There was no evidence of though disorder.

Speech:

A few times during the interview, she was hesitant in her responses and was slightly stuttering. There was some mild latency in some of her answers. Otherwise her speech volume and rate were normal.

Thought Content:

She had persecutory delusions. Examples of this include 1) her neighbour who enters her home and moves things around, 2) mechanic who altered her car engine, 3) supermarket staff shifting her car. There were no obsessions, phobias or compulsions.

Perceptual Disturbances:

She denied experiencing perceptual disturbances. She did not appear to be responding to internal stimuli.

Insight and Judgment:

She has no insight at all about her current deficits and disabilities. Judgment has been poor as evidenced by recent actions like crashing her car, hitting the woman at the supermarket with the load of bread and leaving the stove on resulting in a fire.

Safety Concerns:

She does not have thoughts of self-harm or harm to others. However, her self-care is severely compromised by her cognitive difficulties. She is a danger to herself in several areas like driving and cooking. Because of her paranoia, she might lash out again at someone else.

MODEL ANSWERS

Preferred Diagnosis in Axis 1 is Dementia, most probably Alzheimer’s type.

Differential Diagnosis includes 1) Delirium, 2) general medical condition causing the dementia, 3) Major Depressive Disorder with psychosis and pseudodementia, 3) late onset Chronic Schizophrenia

MODEL ANSWERS

Safety issues:

It must be ensured that she does not drive until she has been formally tested. Family must ensure that she does not use potentially dangerous appliances (i.e. stove heater) without supervision. Ideally, a family member should be with her for support and to keep her sae. One should consider a good rest home facility where she can be observed and further assessed. An admission to a psychogeriatric unit can facilitate observation as well as rapid investigation.

Gathering more information and establishing the diagnosis:

1. Further history from the daughter/family should be obtained.

2. Details of levels of functioning, difficulties, onset of symptoms and decline will be helpful.

3. Previous medical records should be obtained. There should be special focus on history of hypertension, diabetes and heart disease.

4. Family history of dementia should be obtained.

5. Mini Mental Status and other executive function tests should be completed.

6. Full physical and Neurological examination should be performed.

7. Routine blood examinations including full blood count, ESR, renal and liver function, calcium and phosphates, glucose, B12 and folate, thyroid function, VDRL and urinalysis.

8. Electrocardiogram for ischaemic changes should be arranged.

9. Brain imaging (MRI) can be helpful.

10. Neuropsychological testing is important.

Biopsychosocial Management:

1. The clinician should engage not only with the patient but also with her family.

2. Educational sessions about the disorder, treatment options and management planning should be arranged with the patient and the family.

3. Support services for the patient and the family should be made available. (i.e. Meals on Wheels, Alzheimer’s Society)

4. Treatable causes (i.e. thyroid disease) for the dementia should be addressed.

5. Use of cognitive enhancers like acetylcholinesterase inhibitors should be discussed with the patient and the family.

6. For behavioural disruptions or psychotic symptoms from the dementia, low dose antipsychotics should be considered (i.e. 0.25mg of Risperidone, gradually titrated upwards).

7. Issues like Wills and Power of Attorney should be discussed.