Differential Diagnosis of Dementia
Mina Lezcano
Professor Madjaroff
AGNG 200
November 17th, 2017
Abstract
This paper goes into the diagnosis for Mr. Richard Glassman, a 54-year-old white collar male. Mr. Glassman is a patient that was in denial about his illness until his family convinced him that it would be best to come in and have a medical team to make that assessment. His symptoms led the medical team to believe he did in fact have a form of dementia. The research led the team to determine between three specific forms of dementia: Alzheimer’s Disease, Parkinson’s Disease, and Dementia with Lewy Bodies. Research included several sources, such as foundation pages and medical journals listing how each disease can affect the individual as it continues to spread. Through an analysis of the three types of dementia and cross-examining Mr. Glassman’s symptoms, the prognosis is that he is afflicted by Parkinson’s Disease. The conclusion includes steps for rehabilitation to help Mr. Glassman manage his diagnosis in day to day life.
Differentiating Parkinson’s Disease
Introduction
Only two aspects of human life are inevitable: 1) the IRS will always take their portion of taxes owed, 2) death is a guaranteed outcome to life. An unfortunate reality is that death is not a swift means to an end for all. In the United States, “one in three seniors dies with Alzheimer’s or another form of dementia” and is overall the “sixth leading cause of death in the United States” (Alzheimer’s Association, 2017). Richard Glassman is a patient that has been diagnosed with Parkinson’s disease; ultimately the journey to discovery involved analyzing his symptoms, what his family had to say about the changes in him, the changes he saw in himself, and medical testing to accurately diagnose his condition. For Richard, this is a reality that he may face and without a cure for dementia, his best option is for his medical team to determine what type of dementia he is living with to provide the assistance he needs.
Alzheimer’s Disease
The most prevalent form of dementia is Alzheimer’s disease, affecting over 5 million Americans alone (2017). It is a slow, yet progressive brain disease that manifests before symptoms reveal themselves (2017). Early stage symptoms include memory loss related to “recent conversations, names or events,” difficulty communicating, and disorientation (2017). Other typical symptoms are difficulty with problem-solving and with cognitive skills, such as getting themselves dressed amongst other daily routines (Alzheimer’s Disease Facts and Figures, 2017).
Whilst these symptoms may lead many individuals to believe that their older loved ones have developed Alzheimer’s disease, there are other reasons for why an individual may show the symptoms yet not have dementia at all. Depression, thyroid problems, vitamin deficiency and alcoholism are all root causes for why an individual could have Alzheimer’s symptoms (2017). The most efficient way to determine that an individual is afflicted with Alzheimer’s is through medical testing and brain scans. Specifically, in individuals with Alzheimer’s disease, there is a prevalence of “protein fragment beta-amyloid (plaques) and twisted strands of the protein tau (tangles)” in the brain that leads to brain and nerve cell damage (Alzheimer’s Association, 2017).
Current science has yet to discover a cure for Alzheimer’s disease, and although it is the most prevalent form of dementia, it is not the only form that affects many people today.
Parkinson’s Disease
Similar to how Alzheimer’s disease slowly affects an individual, Parkinson’s disease is another form of dementia that individuals can develop earlier in life. The trouble with diagnosing Parkinson’s disease is that each case is unique, and the symptoms may present themselves as a different condition.
On a basic level, Parkinson’s disease occurs when signals are unable to be transmitted from the brain to receptors throughout the body. The inability for the cells to properly transmit cause the individual to lose body function control or balance (Hultquist, 2013). For some individuals, they may begin to show symptoms around age 50 including “trouble with memory, organization, concentration, … and sleep” (2013). One of the symptoms that is closely associated with Parkinson’s that may show up in early stages or in later stages are tremors. With medication, the shaking of the body (usually in hands) can be reduced, otherwise the resulting consequences can include a slower walking pace, improper gait, and muscle stiffness (Mosley, 2009). When an individual has Parkinson’s, the symptoms will continue to get worse and become more pronounced.
Through medical testing, the brain changes that occur in an afflicted individual can better conclude if the person has Parkinson’s. Contrary to Alzheimer’s nerve cell damage, the key signs of Parkinson’s in the brain are “alpha-synuclein clumps” that bundle themselves in a part of the brain called the substantia nigra” (Alzheimer’s Association, 2017). One of the symptoms that results from the clumps is a break-down of the nerve cells that create dopamine, hence why depression is also common in these individuals. There is currently no treatment to cure Parkinson’s, but through either brain surgery to help alleviate tremors, medications, and other therapy can help to reduce the side effects that come with this disease.
Dementia with Lewy Bodies
Dementia with Lewy Bodies also resembles Alzheimer’s, in the sense that the afflicted individual will show memory or other cognitive impairments. These symptoms are prevalent in the beginning of this dementia. Other symptoms that can result include “REM sleep behavior disorder,” in which people have vivid dreams and act them out physically, and changes in walking or gait (Lewy Body Dementia Association, 2017). Dementia with Lewy Bodies typically occurs in individuals between 50 and 85 years old, with a higher risk as age increases, occurring in more men than women.
Other later symptoms mirror the Parkinson’s disease symptoms; tremors as well as difficulty with walking are prevalent amongst affected individuals. Realistic hallucinations can also result from Dementia with Lewy Bodies, sometimes because of a sensitivity to a particular medication that is used for treatments. The brain imaging that is conducted displays the protein alpha-synucleins in the same part of the brain as Parkinson’s disease, but the pattern in which it is displayed is of a different design (Baba, 1998).
Mr. Glassman’s Symptoms
Upon first meeting with Mr. Glassman and his family, some of the initial concerns expressed were related to his ‘forgetfulness’. His career in mechanical engineering was backed by several years of schooling and awards from his company that he had worked with for decades. A physical examination provided the following statistics: Mr. Glassman was 54 years old at our initial visit, had a moderate build, was exercising about once a week, and had no history of smoking. For these reasons, his recent struggles to recall conversations and displaying signs of disorientation brought him and his family in to do further testing.
Initially we had a meeting with Mr. Glassman’s adult children. Their first thoughts to why he might have dementia started when they got calls from their mother about how he would get ready for work on a Saturday. When they came over to visit, he would call his daughter by his wife’s name. When they went to correct him, they saw how he would look confused, then try to laugh it off. He would then go into his office and sit in his chair, staring out the window. Clearly his children were concerned, but it would be necessary to have a discussion with Mr. Glassman himself.
His children were asked to step outside so that he could have a private conversation without feelings of judgement. Mr. Glassman admitted that he felt off and not like his typical self, but didn’t find it necessary to come into the office. It was only at extreme bidding of his children that he decided to come in. Going through a questionnaire, we established that he was still active at work as a team leader and during his free time would occasionally go to the gym to lift weights. When asked how work had been and if he had any difficulties, he mentioned that he deadlines were mixed up in his head and difficulty remembering what notes were with each of his projects. As a result, he had fallen behind on a few of his projects. He stopped going to the gym as frequently because of the late hours he was putting in, and figured that his body was sore because of the inconsistency with his workouts.
After opening up about some of his issues, we discussed in more detail about the soreness that he had been experiencing as of late. He opened up and explained that focusing on driving became a tiring task, yet he couldn’t sleep properly through the night. Throughout the entire interview, we noticed that his left hand would slightly tremble, at which Mr. Glassman would reach over with his right hand subconsciously. We determined that it was between Alzheimer’s, Parkinson’s, or Dementia with Lewy Bodies.
Diagnosis
In a study conducted by doctors in the Netherlands regarding dementia (Ott, 1995), the prevalence of dementia in the sample population between ages 55 to 59 was a mere 0.4%, jumping drastically up to 43.2% for those aged 95 and up. At 54 years old, Mr. Glassman falls into a small group of individuals that unfortunately developed Parkinson’s disease. During a background interview with Mr. Glassman, he found out that his mother’s brother was diagnosed with Alzheimer’s during the late 90s/early 2000s. As a result, it seemed that it could also be Mr. Glassman’s diagnosis as well. Based on his previously listed symptoms that we discovered through interviews with his children and in a personal questionnaire, we had reason to believe that it could be a different dementia. Other possibilities for his potential diagnosis included Parkinson’s disease or even Dementia with Lewy Body. Many of the symptoms began to overlap themselves: difficulty sleeping through the night, lack of concentration on tasks at work, and loss of balance. Many of these symptoms appeared to be the Parkinsonian symptoms.
The next step was to do some brain imaging because it became clear that he was in early stages of dementia, but we couldn’t exactly determine which type he would need treatment to help. Through the brain scans we saw that clumps had bundled themselves in the substantia nigra region of the brain, and the pattern was that of Parkinson’s disease. After explaining to Mr. Glassman and his family of what was discovered, we shared options for treatments through medication and exercise to help improve the quality of life.
Rehabilitation
The primary source of treatment is oral medication. For Mr. Glassman, Levodopa was the best drug to begin with because he had symptoms that fell into both motor and non-motor categories (Medications for Motor Symptoms, 2017). Its main purpose would be to help replace the dopamine levels that had decreased within the brain neurons, thus permitting a better connection between what he is thinking in his brain what he wants the rest of his body to do. Whilst the treatment is but a treatment and not a cure, it would be a good place to start and monitor the rest of his symptoms. Typically, in individuals with Parkinson’s disease, it is common for them to come to a sudden halt when they are walking because they cannot send the signals to their feet to move. The neurological process that is happening is an interruption in the basal ganglia that would otherwise communicate with dopamine to the rest of the body to do a particular action (Palfreman, 2015).
The next step recommended from our team of medical professionals included a regimen of yoga or Tai Chi daily to help work on “balance, strength, coordination, and movement” (Hultquist, 2013). Cycling would also be a good exercise to incorporate as well because of the continual, steady movements. So long as there is an even rhythm in motion or in music, it will help Mr. Glassman for when his Parkinson’s further develops and his physical symptoms worsen. A good experiment to help with his driving would be to play music with a steady bass; the consistent beat will keep him focused and able to concentration on driving.
The outlook for Mr. Glassman is not full of gloom because many individuals with Parkinson’s disease live full lives. The goal is to continue to work with Mr. Glassman’s treatments to determine how he reacts with the medication and exercise. Other options such as neural surgery or service animal are not recommended at this time because he is still in the early stages and the tremors for him are not at a level where it has severely impacted his quality of life. If over the next several months the exercise regimen on his own is not enough, visits with a Physical Therapist to oversee his progress are recommended. Ultimately, with good timing, a loving family, and rehabilitations mentioned, Mr. Glassman is on a path to maximize his quality of life.
Work Cited
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Baba, M., Nakajo, S., Tu, P., Tomita, T., Nakaya, K., Lee, V. M., … Isatsubo, T. (1998). Aggregation of alpha-Synuclein in Lewy Bodies of Sporadic Parkinson’s Disease and Dementia with Lewy Bodies. American Journal of Pathology, 152(4), 879-884. Retrieved October 30, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1858234/pdf/amjpathol00016-0033.pdf.
Hultquist, A. M., & Corrow, L. T. (2013). Can I Tell You about Parkinson’s Disease? : A Guide for Family, Friends and Carers. Jessica Kingsley.
Lewy Body Dementia Association. (n.d.). Retrieved November 01, 2017, from https://www.lbda.org/category/3437/what-is-lbd.htm
Medications for Motor Symptoms. (2017). Retrieved from Michael J Fox: https://www.michaeljfox.org/understanding-parkinsons/living-with-pd/topic.php?medication-motor-symptoms
Mosley, M.D., M.S., A.D., M.D., M, Romaine, D.S., & Samii, M.D., A. (2009). The Encyclopedia of Parkinson’s Disease (2nd ed.). Infobase Publishing.
Ott, A. (1995, April 15). Prevalence of Alzheimer’s Disease and Vascular Dementia: Association with Education. The Rotterdam Study. Retrieved October 30, 2017, from http://www.bmj.com/co1ntent/310/6985/970.short
Palfreman, J. (2015, February 21). The Bright Side of Parkinson’s. the New York Times. Retrieved October 30, 2017, from www.nytimes.com