Case study 1

This case study concerns a 79-year-old gentleman, William (not his

real name) who was referred to the Memory Assessment Service
(MAS) by his GP. Williams daughter, Kate (not her real name)
arranged for the appointment, as she was concerned about his
short-term memory. The GP had ensured there was no treatable
cause for the cognitive impairment by arranging blood tests for
vitamin B12 deficiency, hypothryoidism, diabetes and disorders of
calcium metabolism (NICE 2007), which had all returned as normal.
NICE (2007) also suggest ruling out delirium by performing a mid
urine test, which also returned as normal.
William attended the MAS clinic 3 months later with Kate. William
was asked if he wanted Kate present, which he did. Although
William was willing to engage in the assessment he frequently
looked to Kate to answer many of the questions for him. Therefore,
throughout the assessment it was imperative that equal
participation was promoted within this triad of communication
(Adams and Gardiner 2005). According to Shakespeare (1998),
William could be described as an moderately active confused
speaker, where he wants to participate in the interaction, but
needs Kate to act as his interlocutor. William also had unilateral
hearing loss and wore a hearing aid. Fortunately, Kate had ensured
William was wearing the hearing aid, which would further enhance
an enabling dementia communication for him (Shakespeare 1998).
Kate described that Williams memory had gotten worse since he
had a fall nearly a year ago. Since the fall William had started to ask
the same questions repeatedly. He had another fall 6 months later
and a bout of unexplained dizziness a few weeks ago. Kate noticed
that following each incident William would display new aspects of
cognitive decline. Kate stated he was gradually starting to neglect
his Activities of Daily Living, such as wearing the same clothes for
days, needing help to button up his shirt, not washing, not able to
prepare himself a simple meal or manage his finances. She stated
that she had to visit daily to ensure he had taken his medication for
his angina and hypertension, and to take him a hot meal. William
had also lost interest in his previous hobbies, such as his beloved
garden and going to watch football.
William has a history of angina and hypertension and was an exsmoker of 10 years. William remembered that his father died of a
heart attack. He could vaguely remember an aunt having problems
with her memory, but couldnt elaborate. He continues to enjoy the
occasional pint of beer, but has never been a heavy drinker. He
remembered that he left school at age 15, and went to work as an
apprentice engineer in a local iron works factory. William stated that
he remained in engineering until he retired and worked in various

factories. William married his childhood sweetheart, Lily and they

had the one daughter, Kate. William couldnt quite remember what
year Lily died, but according to Kate it was 10 years ago. He stated
that he has always been a quiet family man, but did enjoy watching
his local football team play on a Saturday and have a couple of pints
afterwards with friends to either celebrate or commiserate. William
stated that he often feels fed up because he is often on his own,
but he denied feeling low in mood or having ideas that life was not
worth living. He stated that his sleep was reasonable and he
doesnt cook, as there is no point cooking for one. He stated, that he
does enjoy the meals prepared by his daughter. There was no
evidence that William was experiencing any psychotic phenomena
such as visual hallucinations or delusions.
William agreed to complete a formal cognitive assessment. He was
made aware that he could stop the assessment any time he wished.
The assessment tool used was the Addenbrookes Cognitive
Examination III (ACE-III) and he scored a total of 63/100,
demonstrating deficits in all domains, particularly short-term
memory, language, orientation and visuospatial functions. According
to Crawford, Whithnall, Robertson and Evans (2011) the cut off point
for dementia is 82-88/100.
From the information gained from William, Kate and the GP, it would
appear that William might have a vascular type dementia. By using
the NINDS-AIREN criteria for the clinical diagnosis of probable
vascular dementia (VaD) (NICE 2007) we can see that the onset
appears to be a fluctuating stepwise progression of cognitive
deficits. There is evidence of amnesia plus impairment in of two or
more cognitive domains such as executive functioning, (not able to
manage his finances) orientation (evident from the ACE-III), apraxia
(problems buttoning his shirt) and visuospatial functions (Evident
form the ACE-III). He also has some other typical features of
vascular dementia such as the unprovoked falls. He also has
vascular risk factors present such as being an ex-smoker, having
angina and hypertension.
William also agreed to attend for a MRI scan of his brain to possibly
help with determining a diagnosis and to rule out any other causes
for the cognitive impairment such as subdural hematoma, brain
tumour, normal pressure hydrocephalus, metabolic
encephalopathies. According to NICE (2007) MRI scans are the
preferred type of structural imaging if a diagnosis of vascular
dementia is suspected.
The results of the MRI scan were returned within a few weeks, which
reported that Williams brain showed evidence of small vessel
ischaemic change with a patchy low attenuation in the deep white

matter of both cerebral hemispheres. This scan confirmed that

William did have Vascular dementia.

Case study 2
This case study concerns a lady who was first referred to the
Community Mental Health Team five years ago by the GP. Emily (not
her real name) had been to see her GP as she had been
experiencing hallucinations at night, and during the consultation,
she admitted to be getting a little forgetful at times. However, it
was thought that her symptoms might be related to bereavement as
it was around the time of the anniversary of her husbands death.
She was seen in clinic where she completed a Mini Mental State
Examination and scored 27/30, losing one point for orientation, one
point for recall and one point for visuospatial difficulties. Emily was
initially diagnosed with Mild Cognitive Impairment and psychotic
depression. Emily was treated with anti-depressants and attended
an anxiety management course. Within six months her
hallucinations had completely stopped and she has not experienced
any since then. However, she has continued to experience
symptoms of depression and anxiety.
For the next 4 years various Community Psychiatric Nurses and
Healthcare Assistants had seen Emily in the community and
introduced her to social groups and anxiety management
programmes. I had been visiting Emily for about a year and noticed
that she was struggling more and more to manage her anxiety,
despite all the support she had received. She was repetitive in
conversation and could not recall what had been discussed at
previous visits. She was experiencing anhedonia, poor sleep and
appetite and her attention to her Activities of Daily Living had
declined. She was also becoming isolative and was avoiding going
out. Emily attributed these changes to the vertigo, tinnitus and
irritable bowel symptoms, all ongoing conditions, she was now
experiencing on a regular basis. Emily could not manage her
symptoms or take on board advice given to her from other
professionals regarding relaxation techniques, medication or dietary
advice. Emily had recently been treated for a urinary tract infection
and there was no other evidence that her cognitive deterioration
was due to delirium. Delirium can be distinguished by its quick
onset, fluctuating cognition, inattention, hallucinations and changes
in behaviour, none of which were in evidence at the time. Her
deterioration had an insidious onset with a progressive impairment
of her episodic memory.
I had begun to suspect that Emily was experiencing more than Mild
Cognitive Impairment, so I decided to perform a cognitive test with
Emily. I used the Addenbrookes Cognitive Examination (ACE III) as it
one commonly used in my Trust. I documented that Emily is right
handed, left school at age 15, and worked in factories before having
to stay at home to look after her mother. Emily appeared alert and
responsive and was able to maintain good eye contact and a rapport

was established. No abnormal perceptions were observed. She was

oriented to place and time, except for the month. Emily scored
61/100: 13/18 for Attention, 15/26 for Memory, 5/14 for Fluency,
17/26 for Language and 11/16 for Visuospatial. The cut off point for
dementia is 82-88/100 (Crawford, Whitnall, Robertson and Evans
2011). NICE (2007) recommend that structural imaging, such as a
CT or MRI scan be employed in the assessment of a person with
suspected dementia. However, the day before the ACE, Emily had
attended for an MRI scan as part of an investigation of her tinnitus.
The results of the scan, and subsequent re-reporting, showed mildmoderate atrophic changes with no temporal involvement. There
were mild ischemic changes, but no visible infarcts. So, the MRI scan
did not confirm a diagnosis of any particular dementia, but the ACEIII did suggest marked cognitive impairment. I wanted to be sure
that whether the ACE score was due to a decline in cognitive
functioning or if anxiety had impacted on the test results. I then
referred Emily, with her agreement, to the teams clinical
psychologist for further testing. The clinical completed several
tests: The Repeatable Battery for the Assessment of
Neuropsychological Status, The Test of Premorbid Functioning UK,
The Trail Making Test and the Haylings Test. The tests demonstrated
that Emily, did indeed, have a deterioration in almost all areas of her
cognitive functioning and the profile suggested the impairment was
of an organic nature, possibly of the Alzheimers type. This would
explain why she was unable to process information, which is
something I had noticed at the beginning.
Emily was invited to an outpatients appointment with the
consultant psychiatrist five months later to discuss her test results.
Emily was accompanied by her daughter-in-law and granddaughter.
It is important to note that Emily has five children and appears to
have a difficult relationship with all of them and their respective
spouses. Various family members have told her, and professionals,
that she exaggerates her problems, is too demanding of their time
and has become a burden to them. Therefore it was imperative that
the triad of communication between healthcare professional, patient
and carer did not disempower Emily or create a disabling dementia
communication (Adams and Gardiner 2005). As I had a good
relationship with Emily, it was decided that I should deliver the
diagnosis to her.
I spoke with Emily about the concerns I had regarding her anxiety
and difficulties she had been having with her activities of daily
living, which she acknowledged. I explained the process I had
started to determine what might be the cause of the problems and
reminded her of the various cognitive tests she had completed. I
informed her that the results of the tests and MRI scan showed that
she had a likely diagnosis of Alzheimers disease. Emily stated that
she was hoping that this was not going to be the outcome, but

suspected she had some type of dementia. I reassured Emily that

this formal diagnosis enabled her to take medication, which could
slow down the progression of the disease. She could also be referred
to our day hospital for a programme of cognitive stimulation.
This management plan was initiated in such a way as to promote a
positive outlook for the future for Emily and her family and help to
quash any negative responses that maybe held.

Case study 3
This case study involves the delivery of a diagnosis of Alzheimers
disease to Olivia (not her real name) and her family. Olivia, age 85,
had been referred to the Memory Assessment Service (MAS) by her
GP. Initially, Olivia had seen her GP on the insistence of her
daughter, Cheryl (not her real name) who had noticed her mums
memory had deteriorated and she was struggling to manage her
own medication. Cheryl was also concerned that her mum continued
to drive, even though she only travelled as far as the local shops.
Cheryl informed the GP that Olivia did not appear to have any
insight into the extent of memory difficulties, which resulted in a few
arguments between mother and daughter. Aneshensel, Pearlin,
Mullan, Zarit and Whitlatch (1995) have found conflict can occur
when care givers see things differently to the person experiencing
cognitive change, for example, Olivia accused Cheryl of making her
appear senile when some of the difficulties were discussed. Her
GPCOG score was 0/9, which indicated a cognitive impairment
(Brodaty, Kemp and Low 2002). The GP had advised Olivia to cease
driving until she had been seen in the MAS Clinic.
Olivia was seen in the MAS clinic a month later and a clinical history
was taken and she completed a Mini Mental State Examination
(MMSE). Olivia stated she was keen to start driving again and
agreed to be referred to a local Drivabilty Centre for her driving
skills to be formally assessed. She also agreed to attend for a CT
scan, as recommended by NICE (2007), to ascertain the true nature
of her underlying dementia.
Before the visit to Olivia and her family, the Consultant Psychiatrist
and I discussed whether it would be appropriate to tell her the
diagnosis. According to Pinner and Bouman (2003), practitioners had
previously wanted to protect patients from the diagnosis for fear
that they would not be able to cope with the harsh reality of the
prognosis. Initially, the person may display psychological
mechanisms to protect themselves such as denial, externalisation,
displacement or somatisation, but Carpenter and Dave (2004) state
there is a lack of evidence supporting the idea that disclosure will
result in long-term psychological damage for the individual. We
agreed that telling Olivia her diagnosis would be the correct course
of action as she did have some insight into her cognitive decline.
Hopefully we could allay any fears she had that she was going
mad and would encourage her to accept pharmacological and
social interventions.
We arrived at Olivias house and her daughter Cheryl and her
partner Mike (not his real name) were also present. I asked Olivia if
she wanted her daughter and partner present as the Mental
Capacity Act (GB 2005) states that a person with dementia has the

right to decide who else is told their diagnosis. Olivia consented for
Cheryl and Mike to stay in the room. Using the SPIKES framework
(Baile,Buckman, Lenzi, Glober, Beale and Kudelka 2000), I
questioned Olivia on her Perception and Invitation. She stated that
she knew she had some problems with her memory and could
remember seeing the Consultant Psychiatrist for an assessment and
completing a cognitive test. She also remembered attending for a
CT brain scan. I confirmed that we had the results of the CT scan
and asked if she wanted to know the details, which she replied that
she did.
I explained to Olivia that the CT scan did not show any significant
changes to her brain. I stated that there was a degree of age related
shrinkage, which was to be expected for her age group. I clarified
that although the CT scan did not confirm diagnosis of a particular
dementia it did help us to rule out any other possible causes for her
memory impairment, such as vascular dementia, dementia with
Lewy Body, fronto-temporal dementia, intercranial haemorrhages,
lesions and so on. I then went on to explain the results of the MMSE,
where she scored 21/30 which, according to Folstein, Folstein and
McHugh (1975), the cut off point for dementia is 24/30. I stated that
with the clinical history she had previously given; her memory
decline had an insidious onset over two years with evidence of short
term memory loss, impaired judgement, decision-making and
orientation were signs and symptoms compatible with a probable
diagnosis of Alzheimers disease.
Olivia and her family appeared to take this news quite well,
especially when she was informed that there was a medication
available that could slow down the progression of the disease. Olivia
was keen to try this medication and asked questions about potential
side effects, which were explained to her. At the present time, Olivia
did not require a referral to Social Services, as she was quite
independent in her Activities of Daily Living except for the
management of her medication. Olivia stated she remembers to
take her tablets, but in fact Cheryl has to organise them into a
dosette box and prompt her mum to take them on a daily basis.
The family were informed of a local Alzheimers caf, run by the
Alzheimers Society, which was an opportunity for people to meet
others in a similar circumstance. They were also encouraged to
attend a dementia question and answer session held at the local
day hospital. Olivia and her family had previously discussed issues
such as Power of Attorney and were in the process of instigating
this. The final issue was approached, regarding the driving
assessment. Olivia was aware that she had failed the assessment
and was advised she was not safe to drive. She had already
returned her driving license to the DVLA, but she could not
understand why she had failed. Due to this the family agreed to

ensure that the car keys were kept in a safe place to prevent Olivia
from getting in the car on occasions where she may forget that she
can no longer drive.
Olivia and her family thanked me for delivering the diagnosis in an
accessible manner, so that they all understood what had been
happening to Olivia and what support they could give her and how
to access support for themselves if needed in the future.