solved

1. Carl E., a 74-year-old right-handed man, was brought for a neuropsychiatric evaluation after
a multi-year decline marked by stiffness, forgetfulness, and apathy. His wife had been trying to
get him in for an evaluation for years and had finally become desperate enough to enlist his
brothers to bring him for the evaluation. He has become uncharacteristically forgetful,
misplacing items, and neglecting to pay bills. He had trouble with appointments, medications,
and calculations. He had declined to see a physician at her urging until he was involved in a
traffic accident a few years prior to this evaluation, claiming that he was “surprised” by a small
animal that seemed to run in front of his car.
Over the past year, things had gotten worse. Mr. E. often could not recall the outcome of
sporting events that he had just watched on television, although his memory improved with
cues. He resisted activities such as travel and socializing that he had previously enjoyed. A
former athlete, he quit taking walks around the neighborhood after several falls. He ceased
playing cards with neighbors because the rules had become confusing. He looked depressed
and acted apathetic but generally said he was “fine”. His judgment and problem-solving skills
were rated as poor. A retired plumbing contractor who had completed 4 years of college, Mr. E.
sometimes seemed unable to operate household appliances. All these cognitive problems
seemed to fluctuate, so that his wife reported he was “almost like his old self,” whereas at
other times it was “like living with a zombie, a depressed zombie.” She described his excessive
daytime drowsiness and frequent staring spells.
When asked specifically about sleep, Mrs. E. reported that neither of them slept well. Mainly,
she said, it was because of her husband “acting out his dreams”: punching, screaming, and
occasionally falling out of bed. A few years earlier, a friend had offered a “sleeping pill”; Mr. E.
had responded to it with extreme rigidity and confusion.
When asked about psychotic symptoms, his wife said he often seemed to swat at invisible
things in the air.
Mr. E. medical history was pertinent for hypercholesterolemia, cardiovascular disease with a
stent, and possible transient ischemic attacks. His family history was positive for his mother
having developed dementia in her mid-70s.
On examination, Mr. E. was a stooped, stiff man who shuffled into the office. While listening to
his wife present the history he often stared into space, seeming to pay no attention to the
content of the conversation. His right hand was tremulous. He appeared depressed but when
asked, he said he felt fine. His voice was so quiet that words were often unintelligible even
when the interviewer leaned close. He drooled at times and did not notice until his wife wiped
his chin.
1a. What would be the most likely diagnosis for Mr.E. given his history and presentation?
1b. What criteria supports your “diagnosis”?
1c. What would be appropriate psychopharmacologic treatment for his diagnosis?
1d. What would be helpful for his episodic visual hallucinations?
1e. What other issues in his history would need to be addressed in his treatment plan?

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