Mixed Dementia in a Patient with Alzheimer: A Case Report

Gonzalo Anguiano
Clinical psychology student, Cetys University, Mexicali 21259, Mexico Correspondence should be addressed to Gonzalo Anguiano, gonzalito.03@hotmail.com We present a case of a patient with Alzheimers disease which according to her clinical history, and her symptoms could be suffering from Mixed Dementia. This is a medical condition in which vascular dementia and Alzheimers diseases coexist at the same time. A good diagnosis in these cases its very important because the combination of these diseases may have a greater impact on the brain than each of these diseases by itself. This was a 75 years old widow female who came to a geriatric center after an aggressive incident with her direct family. The patient arrives with a diagnosis of Alzheimers disease and a NMRI with a left lateral ventricle cyst (11mm) and moderate cortical and subcortical vascular injury. The symptoms were severe cognitive impairment and memory and reality, time and space disorientation. The family did not mention any history of this kind of illness. The speed of the cognitive decline and the result in the test gave enough information to suspect that the diagnosis of the patient could be Mixed Dementia, and with this explain the accelerated cognitive decline of the patient and in some way change the course of the treatment.

1. Introduction The Mixed dementia its a medical condition in which Alzheimers disease and Vascular Dementia coexist at the same time. This coincidence always raises the question if one is consequence of the other one or vice versa and which way they affect each other [6]. Experts discovered that Mixed Dementia occurs more often than they though, and that it becomes more common in advanced age. This discovered was made through the brain autopsies; they have shown that up to 45% of the people with dementia have signs of vascular disease and Alzheimers disease [1]. Is well established that Alzheimers disease is accompanied in many cases of vascular pathologies like amyloid angiopathy, myocardial ischemia or white matter vascular disease. These allow us to elaborate the hypothesis that in many cases both medical conditions contribute to the onset and progression of cognitive

changes and dementia. The diagnosis of Mixed Dementia is important because the combination of these diseases may have a greater impact on the brain than each of these diseases by itself. This means these pathologies combined could accelerate the cognitive decline [1, 2]. The treatment with most common drugs used for Alzheimers disease have shown similar benefits with the Mixed Dementia, with the difference that attention is more given to the vascular risk factors. This could play a key role delaying, preventing progression of the symptoms [1]. 2. Case Presentation Mrs. G is a 75-year-old Latina retired businesswoman that this year became a member of Nuevo Atardecer geriatric center. 6 years ago after the dead of Mrs. G husband, the patient started to develop some symptoms of mild cognitive

decline. In 2008-2009, the patient was submitted to a neuropsychological evaluation, that showed depression and anxiety indicators, and that Mrs. G was suffering Alzheimers disease, but still was independent and functional. At this point the patient was already taken medication for dementia and presented the injury in the left brain hemisphere. Approximately 18 months ago her children noticed more serious symptoms of cognitive and memory decline, and they started to take care of her. The accelerated cognitive decline made very difficult to handle the patient the whole day, so they think in a geriatric center. At the beginning of becoming a member of the geriatric center, Mrs. G was just a day care user, she was going back home at nights. On our first psychological encounter, she was disorientated in time and place and her speech was incoherent, but physically she was in a very good shape, even looking younger for her age. Her minimental status exam (MMSE) was 8/30 and she was kind of frustrated during the tests, like she was trying very hard but she could not do it. I tried to apply the Mini-Cog, but it was impossible (figure 1) the patient got frustrated and started to hit herself.

After I noticed the cognitive deficit of the patient and her lack of tolerance to frustration, I decide to apply scales that involve observation and caregivers. In the Global Deterioration Scale (GDS) the patient is in a stage 5 because Mrs. G does not require assistance with toileting, eating, but cognitively the patient is more described by the stage 6. It was in this point when I started to ask myself why the cognitive decline was so accelerated. After the incident of hitting herself I applied the Cohen-Mansfield Agitation Inventory (CMAI) and I found some agitation symptoms in Mrs. G. I was interested in knowing the level of dependence of the patient so I applied the KATZ scale and because the patient no motor deficit she scored 2, according to this we can think that, the patient could be almost independent, but I knew that the cognitive impairment would not allow her be independent. Therefore, when I talked with the youngest son to get the clinical history, I applied him the Lawton and Brody (AIVD), unlike to the other related scale the patient score 0. During the clinical history, the relative (the family caregiver) of the patient told me that since 2 weeks ago, they decided to keep Mrs. G in the geriatric center full time, because they had an incident with his wife and family, the patient was aggressive with her and the other members of the family and pull his wife hair. To complete the evaluation process I gave another look to the patient files and I found a NMRI which conclusions were that the patient had a left lateral ventricle cyst (11mm) and moderate cortical and subcortical vascular injury.

Figure 1

3. Discussion Mrs. G presented a diagnosis of Alzheimers diseases and the NMRI that I mentioned, that said that the cyst and the ventricular injury, were not affecting the patient, but in the neuropsychological evaluation the psychologies said that that the brain injury should be controlled. Also according to the file of the patient the cognitive decline has been abrupt, despite the fact she has been taking medication for Alzheimer since years ago. Another interesting point that I already mentioned is the fact that the cognitive impairment taking place very fast and the motors skills are almost intact as the GDS showed. With all these facts we can conclude that Mrs. is suffering Mixed Dementia instead of Alzheimers disease. Alzheimer disease is a gradual and progressive disease this means the changes reflect the slow accumulation of abnormal proteins in the brain, in other word the process slow and gradual. In contrast, the symptoms of a vascular dementia can worsen noticeably from one day to another. This reflects the dead of large number of cells that have been deprived of their blood supply. This is why when these conditions coexist (Mixed Dementia) the cognitive decline occurs faster, because these different kinds of dementia attack the brain cells from different ways. It is important that this kind disease it well diagnostic, for research purpose but the most important for treatment course. Even though the medication for both dementias is almost the same, there some medication that have show more benefit in mixed dementia like the galantamine and rivastigmine. So if the diagnosis is not right you could be treating someone

just for the Alzheimers disease and not for the vascular dementia. Also the risk factors are different and focus on the right risk factor could delay or prevent the progression of the symptoms and with this improve the quality of life of the patient and their families. Besides is important for the family have a good diagnostic so they can be prepare for the implication of this disease. 4. Prognosis The patient has already a severe cognitive impairment, but she has on his favor the good physical health. One of the things that the relative mentioned is good general health of Mrs. G. 5. Recommendations Because of cognitive impairment I recommend behavioral therapy with the patient that is the one that have shown more result with severe demented patient to treat the anxiety and depression symptoms. Also with behavioral therapy treat the self aggression according to the observed and the information given by the relative, she used as blackmail to get what she wants. I recommend that the patient has another NRMI to evaluate how the vascular injury has going. Have in mind the risk factors of mixed dementia like blood pressure, glucose levels, etc. Be prepared for any abrupt decline in the brain functions. Acknowledgments I thank the family members for they cooperation, the nurses of Nuevo Atardecer Geriatric Center for they attentions and in the general to the

geriatric center for the opportunity to practice there.

References
[1] Alzheimer's Association. (2010, November 17). Mixed Dementia. Retrieved November 28, 2011, from Alzheimer's Association: http://www.alz.org/alzheimers_disease_mixed _dementia.asp [2] Alzheimer's Association. (2011, June 7). Mixed Dementia. Retrieved November 2011, 2011, from Alzheimer's Association: http://www.alz.org/professionals_and_researc hers_13516.asp [3] HBO. (2011). Connecting Alzheimer's Disease to Vascular Disease. Retrieved November 28, 2011, from HBO The Alzheimer's Proyect: http://www.hbo.com/alzheimers/scienceconnecting-alzheimers-disease-to-vasculardisease.html [4] HBO. (2011). Vascular Dementia and Alzheimer's Disease. Retrieved November 28, 2011, from HBO The Alzheimer's Proyect: http://www.hbo.com/alzheimers/sciencevascular-dementia-and-alzheimersdisease.html [5] Langa, K. M., Foster, N. L., & Larson, E. B. (2004). Mixed Dementia. Retrieved November 28, 2011, from The Journal of the American Medical Association: http://jama.amaassn.org/content/292/23/2901.abstract [6] Martnez-Lage, P., & Manubens, J. (2011). Cognitive deterioration and dementia of vascular origin. Retrieved November 28, 2011, from Anales: http://www.cfnavarra.es/salud/anales/textos/v ol23/suple3/suple18.html