Thursday 19 March 2009


Happy days.

I was referred a gentleman with memory problems, over a couple of years, who had a daughter who, "wanted something doing about it." Unlike Dr Crippen's locale, I read each and every referral letter, even if they're addressed to a CPN or psychologist or social worker. We work as a team, not as individuals in the same building, so I've no qualms in contributing to each and every referral made. Likewise, letters addressed to me are shared with the team every day. People have good ideas. Thoughts are stirred.

I thought this elderly gentlemen had symptoms suggesting Alzheimer's disease and may merit treatment, but he'd had a few falls and was on more drugs that I could count, so a CPN saw him at home first to look at his mood, his function, realistic goals we could achieve, his drug regimen and daughter's input and expectations.

The CPN then met with me that afternoon and talked it through. He was woeful with medication. My CPNs are canny, on this occasion she'd asked about his medication and he'd told her, then she'd checked his account out with the daughter who'd corroborated this. She then looked at the dates on the boxes of pills and realised they should have been replaced. She saw each was for 28 days. Over 365 days, that means a little over 13 requests for repeat prescriptions. The GP surgery confirmed he'd had 8 repeat prescriptions issued in the last 12 months. Ah ha! Suboptimal complicance with medication, another relevant factor. I'm so blessed by savvy CPNs.

So she'd sorted out home care, drugs in a Nomad box for home care to prompt, done a lot of information gathering and assessment but felt, "It wasn't quite right." I saw him at home, with the CPN. It all seemed quite right to me. Elderly man, losing his memory for 3 years, steady decline, increasing periods of confusion. On lots of meds for COPD and OA and prostatism and management of hypertension. One fall of late, no head injury sustained, attributed to joint pain (with NSAIDs bd and co-codamol being used qds to manage this). I spent an hour with him. No worrying symptoms. No new problems, other than his prostatism being more of a nuisance so some more nocturia. No recent infections to destabilise things (with normal WCC and CRP). But my CPN is clever. If she doesn't think it stacks up, there's a high index of suspicion that something's afoot.

I organised a CT brain scan. It showed no vascular damage at all, which for a bloke in his 70's with hypertension necessitating 4 tablets, surprised me. It showed modest atrophy, in keeping with a brain that was 70-odd years old. There were no infracts. There were no space occupying lesions. Phew. There was enlargement of ventricles. Normal pressure hydrocephalus (NPH) was suggested.

NPH classically presents with cognitive changes suggesting dementia, urinary incontinence and gait disturbance. I thought his dementia was likely to be through Alzheimer's disease since he had a global, progressive deterioration in all domains consistent with this. I'd put his urinary disturbance down to his prostatism. His gait I'd assumed was antalgic, through his arthritis (and somewhat affected through 240mg codeine a day on top of everything else). I'd not thought of NPH since I'd ascribed other significance to his symptoms.

I referred him on to a neurosurgeon. This happens fairly often. On this occasion the neurosurgeon agreed he had NPH and operated last year. Unusually, things didn't get a fair bit better, they got completely better. His procedural and declarative memory, sequencing, decision making, concentration, praxis, registration and new learning, all ticking along nicely. Fantastic.

I reviewed him. He thanked me enormously for, "being cured."
Okay, I had a small role to play. But really, it was a CPN seeing a pattern that didn't quite fit with Alzheimer's disease progressing over time, then a radiologist seeing atrophic changes but ventricular abnormalities on the CT scan suggesting increased pressure, then a neurosurgeon who fixed it.

But the outcome's excellent. A person's referred with dementia, an incurable condition that'll get worse. They leave, cured. A heartening result, in otherwise chequered times.


XE said...

What a great story, Shrink! Thanks for sharing.

UCL Med Student said...

A non-depressing story in psychiatry.
Very nice to hear.

Cat said...

Indeed, a great outcome!

Kelly said...

Wow! That's awesome. What a marvellous CPN you have and kudos for listening to her concerns even when there were already perfectly acceptable explanations for his symptoms.

medic999 said...

Good catch. It just goes to show what a good team can achieve when all members are valued participants.