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AdmiralProton10767
Mr. E is a 68-year-old married man with two children who has…
Mr. E is a 68-year-old married man with two children who has been followed by a multidisciplinary team at a Department of Veterans Affairs (VA) geriatrics research and clinical center for the past 6 years. The occasion for this evaluation is Mrs. Es request for residential placement for her hus
Mr. E was first evaluated 9 years ago when his wife observed changes in his memory and behavior and suggested that they seek medical advice. At that time, Mr. E was still employed as a security guard. During the couples initial visit to a physician, Mr. E acknowledged that he had been aware of increasing memory problems for at least the past 2 years. He said that he frequently forgot his keys or would go into the house to get something and then forget what he wanted. Mrs. E noted that he had changed from an outgoing, pleasant person to one who avoided conversation. She said that he also seemed hostile at times for no apparent reason. Mr. E was in good general health and was not taking any medications. His alcohol consumption was limited to two to three beers a week. He had no significant medical or psychiatric history and no significant family history for either cognitive or psychiatric disorders.
Three years later, Mrs E contacted the VA center for treatment of her husband’s cognitive and behavioral symptoms. The general physical examination conducted during the visit was unremarkable. The neurological examination demonstrated an absence of focal abnormalities, but glabellar, snout, and palmomental responses were present. Mr. E was hesitant and had difficulty with sustained attention, which made determination of visual fields difficult. There was no evidence of any disturbance of mood. On examination of his sensorium, Mr. E was disoriented about place and date: He missed the actual date by 2 years and 1 month. However, he seemed to comprehend most of the questions and was aware that he was experiencing cognitive difficulties.
On neuropsychological testing, Mr. E showed moderate to severe impairment in memory, attention, visual spatial reasoning, set shifting, and judgment and planning abilities. Results of laboratory screening tests were unremarkable. An electroencephalogram (EEG) was mildly abnormal, showing nonspecific theta waves and sharp discharges bilaterally. A CT head scan showed slight enlargement of lateral ventricles and the third ventricle, which was consistent with mild atrophy.
Mrs. E reported that her husband had begun exposing himself to neighbors, especially children who walked by their windows. She said that he had become sexually aggressive toward her and at times would chase her around the house and try to remove her clothing. When told of these activities, he claimed to have no recollection of them.
Mr. E was started on 1mg of haloperidol at bedtime. Shortly after this, his wife became concerned that the medication was actually increasing his agitated behavior because he had begun to lock himself in the bedroom and would not allow her to clean him up after he was incontinent of stool in his clothing. The haloperidol was then reduced to .5 mg/day. Mr. Es behavior did not improve after 4 months of medication, so the drug was discontinued at Mrs. E’s request. A year and a half after Mr. E’s initial visit to the geriatric center (and 6 years after he began experiencing cognitive and behavioral symptoms), Mrs. E first began discussing long-term placement for Mr. E with the treatment team. By this time, the symptoms were severe: Mr. E paced most of the night, experienced frequent crying spells, and had become physically threatening to his wife. On one occasion, Mrs. E had gotten up during the night to find that her husband had turned up the thermostat to the maximum temperature, turned on all the burners on the stove, and turned the oven on at 500 degrees.
However, after exploring family support options with the team, Mrs. E decided to continue to care for her husband in their home. A selective serotonin reuptake inhibitor was prescribed for him, after which Mrs. E noted an initial decrease in Mr. E’s crying, an improvement in his sleep, and an increased willingness to help with some of the household chores. However, Mrs. E soon felt the medication was making Mr. E more confused and unmanageable and after 4 months it was discontinued.
About 7 months later, Mrs. E brings her husband in for his evaluation to seriously investigate residential placement for him. She says she is at the end of her rope because Mr. E constantly wanders off when she isn’t watching him and has nearly been run over on several occasions.
Although she describes feeling terribly guilty about abandoning him, she does not think she can cope any longer with the responsibility of ensuring his safety. She doesn’t see any alternative but to arrange for his placement in a residential facility. Mr. E is therefore transferred from the geriatric center to a VA long-term-care center 120 miles away.
What would be the diagnosis you would give this? DSM 5 reference please
