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Difficulty: HardNeurocognitive Disorders

Evaluate the following clinical scenarios detailing distinct neurocognitive or acute neuropsychiatric presentations. Pair each patient vignette with the single most appropriate next step in management or definitive therapeutic intervention.

  • A hospitalized patient experiences severe rigidity, autonomic instability, and worsening confusion shortly after receiving haloperidol for well-formed visual hallucinations. The family reports a pre-existing history of acting out dreams.Immediate discontinuation of the offending agent and substitution with a low-potency atypical antipsychotic if absolutely necessary
  • An ambulatory patient presents with a newly developed 'glued-to-the-floor' ambulation pattern, concurrent with uninhibited detrusor contractions and mild executive dysfunction. Brain imaging demonstrates enlarged ventricles without proportional cortical atrophy.Therapeutic trial of cerebrospinal fluid removal via high-volume lumbar tap
  • A previously tactful executive begins making highly inappropriate comments to colleagues, exhibits profound emotional blunting, and develops a compulsive eating pattern focused exclusively on carbohydrates. Memory testing remains surprisingly intact.Symptom-targeted pharmacotherapy utilizing a selective serotonin reuptake inhibitor for behavioral dysregulation
  • A patient rapidly deteriorates into akinetic mutism and exhibits exaggerated myoclonic jerks upon exposure to loud noises. This catastrophic decline occurred over a period of mere weeks. EEG demonstrates characteristic periodic biphasic sharp waves.Strictly supportive and palliative care with specialized handling protocols for bodily fluids
  • An individual with known major neurocognitive disorder due to Alzheimer disease abruptly exhibits a fluctuating level of consciousness, disorganized thinking, and inattention on the second day following an orthopedic surgery.Urgent systematic evaluation to identify and reverse acute systemic stressors or iatrogenic triggers

Answer

Match the DLB vignette with antipsychotic discontinuation; NPH with CSF removal; bvFTD with SSRI therapy; CJD with palliative care; and delirium with evaluation for systemic triggers.
Each correct pairing links the pathognomonic clinical presentation of a neurocognitive or acute neuropsychiatric syndrome with its evidence-based standard of care or immediate next management step.

Step-by-Step Solution

1
Analyze the first vignette focusing on haloperidol sensitivity in the context of visual hallucinations and dream enactment.
Diagnosis is Dementia with Lewy Bodies presenting with severe neuroleptic sensitivity.
Patients with DLB lack dopamine and are exquisitely sensitive to dopamine antagonists, requiring immediate cessation of haloperidol.
2
Identify the etiology behind the 'glued-to-the-floor' gait, incontinence, and enlarged ventricles.
Diagnosis is Normal Pressure Hydrocephalus.
The standard diagnostic and initial therapeutic step for NPH is high-volume CSF drainage to document gait improvement before considering permanent shunting.
3
Evaluate the isolated behavioral changes, loss of tact, and hyperorality without initial memory deficits.
Diagnosis is behavioral variant Frontotemporal Dementia.
Management for bvFTD relies heavily on symptom control using SSRIs to blunt impulsivity and compulsive behaviors.
4
Assess the rapidly progressive presentation featuring akinetic mutism, myoclonus, and specific EEG findings.
Diagnosis is Creutzfeldt-Jakob disease.
CJD is uniformly fatal and non-treatable; the focus shifts entirely to palliative care and appropriate prion precautions.
5
Differentiate acute post-surgical cognitive fluctuation from chronic progressive dementia.
Diagnosis is post-operative delirium superimposed on Alzheimer disease.
Delirium is a medical emergency necessitating rapid investigation of underlying causes (e.g., sepsis, medication effects) rather than primary psychiatric interventions.

Key Concept

Targeted management and definitive interventions for major neurocognitive disorders based on underlying pathophysiology.
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Topics

Neurocognitive Disorders

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