Mr JB lives with his wife and their teenage daughter. He recently retired from a governmental agency and is a keen handyman. He has a history of gout and age-related macular degeneration, with Lucentis, aspirin and allopurinol his only medications. He was referred by his general practitioner for geriatrician assessment of cognition and general health.
His wife had noticed a two year decline in memory although he was less convinced. He had begun repeating information and questions, sometimes up to 5 times over a few hours, and was placing items in incorrect locations- eg the icecream back into the refrigerator rather than the freezer. He was frequently losing his personal belongings. He was forgetting to lock doors, close windows and had left the stove on- his wife had begun to check these each night before retiring. He was also frequently forgetting the names of friends, and on several car trips to very familiar destinations became lost or needed a great deal of direction from his wife.
He had become very frustrated and even verbally aggressive when these problems were pointed out to him or when he saw that he was affected by these amnestic problems. He had become “negative”, less motivated and was more socially withdrawn. His handyman skills had deteriorated, with his wife attributing this to impaired problem-solving. He had ceased water colour painting, a previous passion.
He was drinking 3 light stubbies on 5 nights a week and was a non-smoker.
His father and two of his father’s sisters had developed dementia- his father died in his 80s, in a nursing home.
The general practitioner had arranged blood tests and a CT scan- the latter showed a right internal capsular infarct. He commenced Mr JB on aspirin.
Physical examination revealed no focal neurological signs. Visual acuity was reduced (6/12 bilaterally, uncorrected) and there were no abnormalities in the cardiovascular or respiratory systems, or in the abdomen.
The MMSE was 26/30 including 1/3 for short term memory. On the Montreal Cognitive Assessment he scored 19/30, including 0/5 for short term memory although all 5 words were recalled with cuing. He was unable to complete the modified Trails B or to place the clock hands as requested, indicating some executive dysfunction. Orientation was normal.
Whilst there may have been a cerebrovascular contribution, Alzheimer’s dementia was strongly suspected.
The MRI did support a vascular contribution, with multiple old subcortical, internal capsular and bilateral lentiform nucleus lacunar infarcts as well as considerable periventricular chronic small vessel ischaemia (Fazekas stage 2). The hippocampi were only mildly atrophic. The SPECT scan showed severe left parietotemporal, mild right parietotemporal and bilateral prefrontal hypoperfusion with sparing of the primary sensorimotor cortices. The Neurostat 3D- SSP statistical analysis also showed posterior cingulate and precunei hypoperfusion, worse on the left. He proceeded to the more accurate FDG-PET scan which confirmed the SPECT findings, with a pattern of hypometabolism typical of that seen in (somewhat asymmetrical) Alzheimer’s disease, including involvement of the posterior cingulate and the parietal and temporal cortices, moreso on the left, with sparing of the primary sensorimotor cortices.
Alzheimer’s dementia with coexisting cerebrovascular cognitive impairment was diagnosed. The diagnosis was relayed to him and his wife, some 6 months after initial assessment, the delay largely due to delays in obtaining the neuroimaging. The MMSE was repeated and found to be 23. Donepezil was commenced and at followup 3 months later there was some improvement in cognition, with a repeat MMSE 25, but the short term memory was still poor, at now 0/3.
Souvenaid became available and was commenced for his mild Alzheimer’s dementia. On review 4 months later his wife and family had noted that short term memory had improved and this was confirmed on the MMSE, where it was now 2/3. He was also noted to be less frustrated as a result of forgetting less. He was more interactive socially and had lost his negativity. He was more motivated and was now keen to not only do his own chores but to help neighbours- eg with their gardens and even building a new decking. His wife felt that whilst the donepezil had helped, the addition of Souvenaid had “given (him) a new lease on life”. Her own quality of life had improved and her perception of burden had declined.
He is now engaged in a trial of a new anti-tau therapy in our research centre, and remains motivated and very engaged with life.
A/Professor Michael Woodward,