Psychiatric Annals

Case Challenges 

A 70-year-old Man With Long-Term Alcohol Dependence, Cognitive Impairment

Abstract

Mr. N. is a 70-year-old married Caucasian man with a 50-year history of continuous alcohol dependence who was assessed for treatment at an outpatient addiction treatment service. His other psychiatric diagnoses at the time of initial evaluation were cognitive disorder – not otherwise specified and major depressive disorder. His pertinent medical issues include a 13-year history of well-controlled hypertension and a questionable history of head trauma 2 years before this assessment.

Mr. N was unable to provide any history due to the severity of his deficits. Hence, the following information was obtained from his family and friends. Mr. N began drinking at age 13 and met criteria for dependence at age 18 with tolerance, withdrawal, and more than intended use. He had no significant periods of sobriety and had been drinking two bottles of wine daily for the past 20 years.

Mr. N was diagnosed with depression 4 years ago. At that time he endorsed anhedonia, weight loss, and low mood. He had a has normal developmental history and did well in school and college. He has a bachelor's degree in engineering, was last employed 20 years ago, and has been supporting himself with Supplemental Security Income since 1995. He does not have any significant family history for any mental illness or substance use disorder.

Mr. N. was unable to participate in outpatient support groups. He was unable to contribute to the groups in a meaningful way or complete assigned tasks. He did not endorse any major depressive symptoms while in the program; however, he continued to drink and had positive breath alcohol tests.

Mr. N showed extensive cognitive deficits during his initial assessment. He did not remember his Social Security number, home telephone number, or address. He scored 8 out of 30 on a short mental status exam and exhibited global deficits.

Mr. N was referred for neuropsychological testing. The results were as follows:

Mr. N underwent a complete basic dementia workup. All of the laboratory tests were normal, including B12, folate, and thyroid-stimulating hormone. A rapid plasma reagin test for syphilis was nonreactive. A computerized tomography scan showed mild hypodensity in the periventricular white matter regions, which is a nonspecific finding that may be consistent with chronic small vessel ischemic change.

These options could be considered as appropriate management strategies for the clinician.

Prescribe an antidepressant.

Prescribe a cholinesterase inhibitor.

Refer Mr. N to a social services office for evaluation of safe living situation and home help.

Contact the state department of motor vehicles to revoke Mr. N's driver's license.

Conduct a family meeting to discuss his illness and prognosis.

In this case, all the treatment choices were chosen. Mr. N was discharged from the outpatient program, given his inability to participate. He was started on donepezil and mirtazapine to treat his cognitive impairment and his depression, respectively. No further neuropsychological testing was performed, given the conclusive evidence of the first tests.

Mr. N was referred to social services and now receives home help and home aid services. He resides with his best friend and has maintained sobriety for 2 months.

The family meeting involved educating the family about the patient's illness and the available resources in the community for the patient. The family was provided with a list of support meetings for family members and friends of patients with severe cognitive impairments.

Editor's Note: This monthly presentation describes a case of a psychiatric disorder, discusses past treatment attempts, offers options for continuing treatment, and explains the reasons the solution was selected. Submissions of interesting psychiatric case reports are being accepted for this department. Please e-mail soconnor@slackinc.com for…

Patient History

Mr. N. is a 70-year-old married Caucasian man with a 50-year history of continuous alcohol dependence who was assessed for treatment at an outpatient addiction treatment service. His other psychiatric diagnoses at the time of initial evaluation were cognitive disorder – not otherwise specified and major depressive disorder. His pertinent medical issues include a 13-year history of well-controlled hypertension and a questionable history of head trauma 2 years before this assessment.

Mr. N was unable to provide any history due to the severity of his deficits. Hence, the following information was obtained from his family and friends. Mr. N began drinking at age 13 and met criteria for dependence at age 18 with tolerance, withdrawal, and more than intended use. He had no significant periods of sobriety and had been drinking two bottles of wine daily for the past 20 years.

Mr. N was diagnosed with depression 4 years ago. At that time he endorsed anhedonia, weight loss, and low mood. He had a has normal developmental history and did well in school and college. He has a bachelor's degree in engineering, was last employed 20 years ago, and has been supporting himself with Supplemental Security Income since 1995. He does not have any significant family history for any mental illness or substance use disorder.

Treatment History

Mr. N. was unable to participate in outpatient support groups. He was unable to contribute to the groups in a meaningful way or complete assigned tasks. He did not endorse any major depressive symptoms while in the program; however, he continued to drink and had positive breath alcohol tests.

Mr. N showed extensive cognitive deficits during his initial assessment. He did not remember his Social Security number, home telephone number, or address. He scored 8 out of 30 on a short mental status exam and exhibited global deficits.

Patient Status

Mr. N was referred for neuropsychological testing. The results were as follows:

  • Performance on a comprehensive screening battery of cognitive functioning was extremely poor. He was able to perform above the 5th percentile (relative to age-matched peers) in only one area of five cognitive domains tested. His ability to learn and subsequently recall previously learned information was extremely impaired, falling below the 0.1 percentile.
  • Language skills were similarly impaired, with a marked verbal fluency deficit; he was only able to produce two words in 60 seconds when given a semantic cue. His ability to pay attention to tasks also was significantly impaired, falling at the 2nd percentile. The only area of functioning tested that remains in the normal range was his visuospatial abilities (37th percentile).
  • The pattern of results is not consistent with an alcohol-related dementia.

Mr. N underwent a complete basic dementia workup. All of the laboratory tests were normal, including B12, folate, and thyroid-stimulating hormone. A rapid plasma reagin test for syphilis was nonreactive. A computerized tomography scan showed mild hypodensity in the periventricular white matter regions, which is a nonspecific finding that may be consistent with chronic small vessel ischemic change.

Treatment Options

These options could be considered as appropriate management strategies for the clinician.

  1. Prescribe an antidepressant.

  2. Prescribe a cholinesterase inhibitor.

  3. Refer Mr. N to a social services office for evaluation of safe living situation and home help.

  4. Contact the state department of motor vehicles to revoke Mr. N's driver's license.

  5. Conduct a family meeting to discuss his illness and prognosis.

Treatment Choices

In this case, all the treatment choices were chosen. Mr. N was discharged from the outpatient program, given his inability to participate. He was started on donepezil and mirtazapine to treat his cognitive impairment and his depression, respectively. No further neuropsychological testing was performed, given the conclusive evidence of the first tests.

Mr. N was referred to social services and now receives home help and home aid services. He resides with his best friend and has maintained sobriety for 2 months.

The family meeting involved educating the family about the patient's illness and the available resources in the community for the patient. The family was provided with a list of support meetings for family members and friends of patients with severe cognitive impairments.

Editor's Note: This monthly presentation describes a case of a psychiatric disorder, discusses past treatment attempts, offers options for continuing treatment, and explains the reasons the solution was selected. Submissions of interesting psychiatric case reports are being accepted for this department. Please e-mail soconnor@slackinc.com for further information.

This case is presented by Elizabeth Caliboso, RN, nursing assessment and coordinator for outpatient addiction treatment services at the Veterans Administration Palo Alto Health Care System, Palo Alto, CA; and Nirmaljit Kaur Dhami, MD, program director of the outpatient addiction services, Veterans Administration Palo Alto Health Care System.

Authors

10.3928/00485713-20050901-03

Sign up to receive

Journal E-contents