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Difficulty: MediumNeurocognitive Disorders

A 68-year-old man is brought to the clinic by his son for evaluation of cognitive decline. The son reports that his father's memory has worsened significantly over the past 4 months, which coincided with the unexpected death of his wife. The patient frequently misplaces his glasses and forgets the names of acquaintances. During the interview, the patient appears visibly distressed about his memory, stating, "My brain is completely useless now. I can't remember a single thing." When asked orientation questions and to perform a three-word delayed recall, he frequently answers "I don't know" with little initial effort. However, with gentle encouragement and extra time, he is able to correctly recall two of the three words. The patient also reports early morning awakenings, poor appetite, and a 5-kg (11-lb) weight loss over the past 3 months. His medical history includes hypertension well-controlled on lisinopril. Vital signs are within normal limits. Physical and neurological examinations reveal no abnormalities. Which of the following is the most appropriate next step in management?

  1. Initiate trial of a selective serotonin reuptake inhibitorAnswer
  2. B
    Prescribe donepezil
  3. C
    Order non-contrast computed tomography of the head
  4. D
    Provide reassurance and schedule a follow-up in 6 months
  5. E
    Initiate haloperidol

Answer

Initiate trial of a selective serotonin reuptake inhibitor
The patient's clinical picture is classic for major depressive disorder with prominent cognitive impairment, a condition historically termed 'pseudodementia'. Key distinguishing features from a primary neurocognitive disorder (such as Alzheimer disease) include the relatively acute onset following a significant life stressor, the patient's severe distress and retained insight regarding his memory loss, and the characteristic 'I don't know' responses on cognitive testing that improve with encouragement. In true dementia, patients typically have an insidious onset, lack insight (anosognosia), try to conceal their deficits, and genuinely cannot recall information despite encouragement. The presence of vegetative symptoms (weight loss, early morning awakenings) further supports the diagnosis of major depression. The most appropriate next step is to initiate a trial of an antidepressant medication, such as an SSRI.

Step-by-Step Solution

1
Analyze the onset and nature of the cognitive symptoms.
The cognitive decline had an abrupt onset 4 months ago following a major stressor (spouse's death), and the patient shows significant distress and insight regarding his memory loss.
Differentiating between neurocognitive disorders and psychiatric conditions requires evaluating the timeline, precipitating factors, and the patient's awareness of their deficits.
2
Evaluate the patient's performance on cognitive testing.
The patient gives 'I don't know' answers and displays poor initial effort, but performs adequately with encouragement.
Patients with true dementia typically make genuine attempts to answer but confabulate or fail, whereas patients with depression often show poor effort but intact underlying cognition.
3
Identify the primary underlying pathology.
The combination of depressed mood, weight loss, early morning awakenings, and cognitive complaints points to major depressive disorder (pseudodementia).
Recognizing the somatic and psychological criteria for major depression is necessary to guide treatment.
4
Determine the most appropriate management.
Treating the underlying depression with a selective serotonin reuptake inhibitor (SSRI) is the correct next step.
Reversing the depressive episode will likely resolve the secondary cognitive impairment.

Key Concept

Major depressive disorder in the elderly can present with prominent cognitive deficits (pseudodementia), which are distinguished from true dementia by the patient's prominent distress over memory loss, poor effort on testing that improves with encouragement, and an acute onset associated with a stressor. The primary treatment is targeted at the underlying depression.
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Topics

Neurocognitive Disorders

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