Examkin

Question

Difficulty: EasyNeurocognitive Disorders

A 68-year-old retired female executive presents to an outpatient memory clinic, expressing profound distress that she is developing early-onset Alzheimer disease. She reports a 3-month history of significant cognitive decline, stating, "My brain is just broken; I can't remember anything anymore." During the Montreal Cognitive Assessment (MoCA), she makes poor eye contact and frequently answers "I don't know" to orientation and recall questions; however, when gently encouraged by the physician to guess, she answers the majority of the questions correctly. She also reports early morning awakenings, a 4.5-kg (10-lb) weight loss, and a feeling that her life lacks purpose since her retirement 4 months ago. She currently takes no medications. A recent laboratory workup shows a normal thyroid-stimulating hormone (TSH) level and a normal free T4 level. Which of the following is the most appropriate initial management step for this patient?

  1. Initiate a trial of a selective serotonin reuptake inhibitor and recommend psychotherapyAnswer
  2. B
    Diagnose schizophreniform disorder due to the 3-month duration of symptoms and prescribe an antipsychotic
  3. C
    Conclude that the patient has secondary hypothyroidism despite the normal laboratory results and initiate levothyroxine
  4. D
    Immediately prescribe a combination of fluoxetine and phenelzine to aggressively target her severe anhedonia and weight loss
  5. E
    Determine that her cognitive deficits render her legally incompetent and require a surrogate to make all healthcare decisions

Answer

Initiate a trial of a selective serotonin reuptake inhibitor and recommend psychotherapy
The correct answer addresses the underlying major depressive disorder. This patient demonstrates the classic features of 'pseudodementia'—a reversible cognitive impairment secondary to severe depression. Key distinguishing features include a relatively abrupt onset following a life stressor (retirement), acute distress and insight regarding the memory loss, and a characteristic lack of effort on cognitive testing ('I don't know' answers) that improves with encouragement. The first-line management is a combination of an SSRI and psychotherapy.

Step-by-Step Solution

1
Analyze the patient's presentation and cognitive testing performance.
The patient complains bitterly of memory loss, exhibits vegetative symptoms of depression (weight loss, insomnia), and gives 'I don't know' answers on cognitive testing but performs well when encouraged.
Identifying the pattern of cognitive deficits helps distinguish between true neurocognitive disorders and mood disorders affecting cognition.
2
Differentiate between true major neurocognitive disorder (dementia) and pseudodementia.
Patients with true dementia typically lack insight, try to hide their deficits, and confabulate answers. Patients with pseudodementia (depression) are highly distressed by their perceived deficits and exhibit poor effort ('I don't know').
Accurate differentiation prevents the misapplication of dementia medications and guides appropriate psychiatric care.
3
Determine the most appropriate management.
Because the underlying etiology is major depressive disorder, the standard of care is to treat the depression using antidepressants (e.g., SSRIs) and psychotherapy.
Treating the underlying mood disorder in pseudodementia typically reverses the cognitive deficits.

Key Concept

Major depressive disorder in the elderly can present with prominent cognitive impairment (pseudodementia). It is distinguished from true dementia by the patient's acute awareness of deficits, distress regarding memory loss, and a tendency to give 'I don't know' answers rather than confabulating.
Estimated Time:1m 0s
Rate this question

Topics

Neurocognitive Disorders

More questions from this topic