Table 1 The dementia case vignette

Medical background

Mrs. G.C. is a 76 year old married woman with Grade 12 education. She had a mother who developed Alzheimer’s Disease onset age 84. Her medical history including hypertension, hyperlipidemia and osteoporosis. Her medications are Hydrochlorothiazide, Adalat XL, Lipitor, Calcium, Vitamin D, and Fosamax.

0 months (T1)

Warning signs

In the last six months her husband noted that she seemed to be a little bit forgetful, having some problems with names, “not quite as sharp” as one year previously, having a little more difficulty planning the bigger family social events and being a little less interested in leisure activities. She was still driving, shopping, cooking, independent in all her IADL’s although she occasionally needed a reminder to take her medication.

6 months (T2)

Screening results and early recognition

While at the local Pharmacy her husband noticed that the Pharmacist was offering a 2 min Dementia Screening Test so he and Mrs. G.C. did the test. He was fine but his wife had difficulties in animal naming (9 in one minute) and clock drawing. He realized that this was a significant issue which needed medical attention.

7 months (T3)

Mild cognitive impairment

Her husband was now worried that this was more than normal ageing and did in fact arrange an appointment with the family physician.

The family physician tested first with the MMSE on which her score was 25/30. Laboratory testing was negative. The conceptualization was that Mrs. G.C. was not as “sharp with her memory” as she was six months previously but no other areas of cognitive function or functional abilities were affected.

The Family Physician explained the concepts of mild cognitive impairment and gave advice about being physically, mentally and socially active. He explained that it could progress to more problems with memory and said that he would see her in one year or earlier if there was greater concern about memory or function. The patient’s hypertension and hyperlipidemia were well controlled and enteric coated aspirin was started at 81 mg daily.

1 year and 7 months (T4)

Annual follow-up

One year later there didn’t seem to be any progression of symptoms or functional loss. Her MMSE was now 24/30.

2 years and 7 months (T5)

Diagnosis

One year later the husband was more concerned because she got lost once while out driving the car back from her sister’s home 30 miles away, and because he noticed that she was having more trouble with cooking more complicated meals, being more forgetful about medications and occasionally having angry outbursts. He was a little bit worried about leaving her alone for a weekend to go to his big curling bonspiels in the winter. Her MMSE was now 20/30. Her family physician did further evaluation which showed poor visual spatial function (clock drawing) and poor performance of Trails A and Trails B.

A CT scan was done which showed periventricular white matter changes and two old lacunar infarcts. The family physician made the diagnosis of mild mixed Alzheimer’s and vascular dementia and she was started on cholinesterase inhibitor treatment. Based on her overall assessment he advised her that she needed to stop driving.

2 years and 10 months (T6)

3 month follow-up

Three months later she was seen and she had improved. She was more active, more attune to social situations and conversation and more like her old self. Her MMSE had improved to 22. At this stage she only needed a little bit of cueing for finances and shopping.

She was referred to a Day Centre at a Senior’s Centre for increased stimulation and socialization and to provide her husband with some respite.

3 years and 7 months (T7)

Increased support for IADL

Nine months later she was about the same, though a little more forgetful. Her husband had hired a maid to do some of the simple cleaning services through the local community for-profit support agency and he also needed to become more involved in cooking simple meals, shopping and finances. Her MMSE was now 20/30.

4 years and 7 months (T8)

IADL, ADL, and behavioral and psychological symptoms

One year later she was more forgetful, was unable to cook on the stove but still could use the microwave and do simple cold meals. She needed help with laundry and help with shopping. She was independent in her personal ADL’s and only occasionally needed some cueing with respect to clothes selection. She did need help with respect to bathing and homecare became involved. Her MMSE was 16/30. She was more emotionally labile, apathetic and became very anxious if left alone. She was also having episodic bouts of agitation and occasionally aggressive behavior.

Memantine (Ebixa) was started and there was some improvement in terms of cognition, (MMSE 18/30), ADL, agitation and anxiety.

5 years and 7 months (T9)

Increased support in ADL and caregiver stress

One year later her MMSE had declined to 15/30. Her husband was doing all the instrumental activities of daily living. She needed help with bathing, hygiene and toileting and there was considerable caregiver stress in that she could only be left alone for approximately an hour. Homecare was providing more services in terms of bathing and personal care. She was occasionally incontinent. Her gait was unsteady and her fall risk was increased, and thus she needed to use a walker.

A day program helped with respect to daytime respite and there was an increase in paid services by the husband to lessen caregiver stress.

6 years and 7 months (T10)

Stroke and hospitalization

One year later she had a small stroke leaving her with some weakness on the right side. Her incontinence was worse. She was admitted to the hospital where she became much more confused.

6 years and 8 months (T11)

Transition from home to long-term care

Following a conference attended by phone by their daughter in Florida who felt that her parents should be together, she was discharged home. She developed a tendency towards wandering about the house and once wandered outside. Her husband was no longer able to look after her. It was decided that she would re-locate to residential care. This move was very positive for the husband.

7 years and 8 months (T12)

Increase in behavioral and psychological symptoms

One year later her communication skills were markedly affected. Her mobility was decreased. The nursing staff noted that she began having increasing hallucinations and angry outbursts.

8 years and 8 months (T13)

Death

One year later after receiving appropriate end of life care she was found deceased on morning nursing rounds.