An 82-year-old man is brought to the office by his daughter due to behavioral changes. She reports that over the past year her father has become increasingly paranoid and frequently talks out loud as if in conversation when no one else is present. The daughter says, "During a recent argument, he accused me of being an imposter and stealing his personal items. Also, he used to be very clean, but his personal hygiene has gotten really bad. He also stopped watching baseball, which used to be his favorite hobby." The patient's medical history is significant for hypertension, hypercholesterolemia, and type 2 diabetes mellitus. Medications include lisinopril, simvastatin, and metformin. The patient has been unable to live independently for the past 2 years due to increasing forgetfulness and an inability to perform self-care. Vital signs are stable, and physical examination and laboratory evaluation are unremarkable. Which of the following is the most likely explanation for this patient's behavior?

Question

An 82-year-old man is brought to the office by his daughter due to behavioral changes.  She reports that over the past year her father has become increasingly paranoid and frequently talks out loud as if in conversation when no one else is present.  The daughter says, "During a recent argument, he accused me of being an imposter and stealing his personal items.  Also, he used to be very clean, but his personal hygiene has gotten really bad.  He also stopped watching baseball, which used to be his favorite hobby."  The patient's medical history is significant for hypertension, hypercholesterolemia, and type 2 diabetes mellitus.  Medications include lisinopril, simvastatin, and metformin.  The patient has been unable to live independently for the past 2 years due to increasing forgetfulness and an inability to perform self-care.  Vital signs are stable, and physical examination and laboratory evaluation are unremarkable.  Which of the following is the most likely explanation for this patient's behavior?

Quizplus · Accepted Answer

This patient's 2-year history of increasing forgetfulness and functional impairment, followed by the development of psychotic symptoms (eg, delusions, hallucinations), is most likely explained by Alzheimer disease (AD). AD is the most common type of dementia, characterized by insidious onset (typically age >65), early impairment of recent memory, executive dysfunction, and visuospatial deficits. As AD progresses, it is commonly complicated by the development of neuropsychiatric symptoms, such as apathy, depressive symptoms, delusions, hallucinations, disinhibition, and agitation. Delusions with paranoid themes (eg, items being stolen, family members replaced by imposters [ie, Capgras delusion]) are common. Behavioral symptoms tend to become more common and problematic as the severity of AD worsens. (Choices B and D) Delusional disorder is characterized by one or more delusions in the absence of other psychotic symptoms (eg, hallucinations). Schizophrenia typically presents in young adulthood and is characterized by psychotic symptoms (eg, delusions, hallucinations, disorganized speech and behavior, negative symptoms) with associated functional decline lasting ≥6 months. These primary psychotic disorders are not diagnosed when psychotic symptoms are better explained by a medical condition, such as progressive dementia. (Choice C) Major depression with psychotic features is a subtype of major depressive disorder characterized by very severe depressive symptoms and delusions and/or hallucinations consistent with depressive themes (eg, guilt, worthlessness). This patient has insufficient depressive symptoms to diagnose an episode of major depressive disorder; his apathy and deterioration in personal hygiene are consistent with AD. (Choice E) Some medications (eg, corticosteroids, dopamine agonists) can induce psychotic symptoms and should be considered in the differential diagnosis of new-onset psychotic symptoms. This patient's medications are not known to induce psychosis, and his symptoms are better explained by AD. Educational objective: Psychotic symptoms (eg, delusions, hallucinations) are common in Alzheimer disease and increase with the severity of illness. __________ References: Psychosis in Alzheimer's disease. (http://www.ncbi.nlm.nih.gov/pubmed/24103379)

An 82-Year-Old Man Is Brought to the Office by His