I saw a lady last year, referred to me for assessment and management of her dementia. She was confused, her Addenbrookes Cognitive Examination (ACE-R) was poor, her functional level had declined (with constricted activities of daily living).
Poor memory, confusion, reduced functional level and poor ADLs, with a poor ACE-R, it all stacked up as significant congitive decline. She'd had low mood, too, which her GP had sensibly treated with an antidepressant (citalopram) for an appropriate length of time.
Her history, presentation and depression rating scales didn't suggest depression, so either her citalopram was working or she wasn't depressed. After a conversation with her GP, who had started citalopram because her family felt she wasn't coping and thought she was depressed, we stopped her citalopram.
A month or so later and her confusion had resolved, her mental state was stable, with no significant cognitive impairment and no mood disorder. I saw her recently. Her ACE-R is normal. Her CT brain scan, again, was normal. Critically, her functional level was normal.
History, evidenced functional level, mental state, cognitive testing and serial brain imaging finds her to be well, with no features to attract a diagnosis of dementia or major mood disorder.
It's not often we get to cure someone of their cognitive deficits so completely, it's heartening that withdrawl of citalopram really did enable a pick up your bed and walk moment!
So why did she originally get worse? Was she originally depressed which citalopram helped, then the citalopram itself caused problems?
A fair quuestion and one I've explored with the GP. It may have been a silent MI (an ECG clearly shows a past MI but there's no history of this). It may have been exacerbation of COPD, with or without a LRTI, causing delirium. Or constipation. Or pain. Or dehydration (with biochemical indices persistently evidencing this).
We speculated, but I honestly don't know what the cause was.
That's life in clinical medicine though, I guess; considering the known factors/salient details whilst accepting we're endlessly managing uncertainty!
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