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CASE STUDY 1
Patient Presentation
Tony is a 74-year-old retiree who lives with his wife Sara
in the home they have shared for over 30 years. He was
diagnosed with AD following a diagnostic workup, at
which time he scored a 27 on the MMSE. He started on
ChEI therapy 2 months ago.
Social and Occupational History
Tony was a professional golf instructor and general
manager of a country club. Since his retirement, he has
remained active in golfing and spends an afternoon each
week volunteering in the pro shop at the country club.
Cognitive problems were suspected based on
observations from his wife and other golf partners
because he had trouble choosing appropriate clubs and
making change at the pro shop.
Current Medication Regimen
Rivastigmine 6 mg/day
Assessment
1. The patient has come to an office visit with
symptoms of confusion, dysurea, and incontinence.
During this visit, what other information or procedures
would you advise?
A. An MMSE to evaluate his mental status
B. A urine sample to check for a urinary tract infection
C. Question him about his response to ChEI
treatment and side effects
D. A and B
E. B and C
Two weeks later, the patient returns. Although the prior
visit’s symptoms have resolved, he is not tolerating the
new dose of rivastigmine (9 mg/day).
2. What are your options at this point?
A. Decrease the dose of rivastigmine to 6 mg/day and
try escalating the dose after a longer time period
B. Stop the oral medication and use the rivastigmine
transdermal system (patch)
C. Switch to another ChEI after an appropriate
washout interval
D. B or C
E. All of the above
Six-Month Follow-Up
Six months after starting ChEI treatment, Tony comes in
for a follow-up assessment for AD. At this time, he
scores a 27 on the MMSE and says the side effects have
resolved. He has no other complaints.
Three-Year Follow-Up
After 3 years of ChEI treatment, Tony scores a 24 on the
MMSE. He remains active, but gets disoriented more
frequently in familiar surroundings. Sara notes that Tony
is frequently irritated and forgetful of his duties at the pro
shop, where he continues to volunteer. She is having
difficulty convincing him not to drive, but he finally
concedes to giving up driving the car, but not the golf
cart.
With treatment, Tony has averaged a 1-point decline in
MMSE score for the last 3 years.
3. If Tony were to discontinue treatment, would you
expect his rate of cognitive decline to:
A. Increase over time
B. Decrease over time
C. Remain steady until death
D. Impossible to hypothesize
4. Given the information you have been provided at this
3-year follow-up visit, what would you not consider as a
next step?
A. Provide the caregiver with support and assess her
level of stress
B. Schedule another visit in 6 months
C. Prescribe chronic, low-dose haloperidol
D. None of the above
Six-Year Follow-Up
Over the last few years, Tony has stopped working at the
pro shop and retired from golfing. You perform a routine
exam and administer the MMSE. He scores 20. Sara
notes that he is often agitated and gets lost when he is
out. You spend time with Sara assessing the safety of
their house, yard, and neighborhood. You also discuss
potential triggers for Tony’s agitation to determine if
pharmacologic therapy is appropriate. Counseling takes
20 minutes of this 35-minute visit.
5. How do you code this visit?
A. ICD-9-CM 780.93 with CPT 99213
B. ICD-9-CM 290.0 with CPT 99214
C. ICD-9-CM 294.11 with CPT 99214
D. ICD-9-CM 331.0 with CPT 99213
Eight-Year Follow-Up
At routine follow-up, Tony’s scores 18 on the MMSE.
Findings are unremarkable.
One week later, Sara comes in for a 30-minute office
visit. She admits to being overwhelmed with Tony’s care
needs and delusions, and is considering a nursing
home for him. Sara is concerned that the medication is
no longer working. She asks if there is something else
you can give him. You discuss Tony’s rate of decline in
terms of MMSE score. You also discuss the nature of the
delusions to assess whether or not they are distressing
to Tony. Sara reports that he often talks with and pets an
“imaginary dog”. Upon further questioning, you determine
that the delusion upsets Sara, but does not cause Tony
distress.
6. How do you code this visit?
A. ICD-9-CM 780.93 with CPT 99213
B. ICD-9-CM 331.0 with CPT 99213
C. ICD-9-CM 290.0 with CPT 99214
D. ICD-9-CM 294.11 with CPT 99214
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CASE STUDY 2
Patient Presentation
Lois is a 70-year-old woman who lives in an
independent living community. She was diagnosed
with AD 3 years ago and began treatment on a ChEI at
the time of her diagnosis. Her MMSE score was 24.
Her daughter has brought her in because her mother
had become uncharacteristically argumentative and
accused others of stealing her cat, which the daughter
found alarming.
Social and Occupational History
Lois worked as a clerk in a grocery store for 20 years
before she retired. She has enjoyed bird watching
from her kitchen window. She regularly attends
organized neighborhood social gatherings and visits
with her grandchildren on alternating Sundays. Her
family has recently started to insist that Lois move into
the assisted living area of the community because
they feel she requires more assistance than she
admits.
Current Medications
Donepezil, 10 mg/day
Assessment
7. What information is the least important for you to
know at this point?
A. Her score on the HAM-D
B. Whether she has a cat
C. Whether the family has noticed changes in
Lois’ functioning or cognitive abilities
D. Events that precipitate her bouts of disruptive
behavior
After evaluating Lois, you feel that her symptoms are a
sign of progressing AD. At her follow-up visit 6 months
ago, she scored 22. The score has now fallen to 20.
8. At this point, what do you do?
A. Add memantine to her treatment regimen
B. Prescribe an anxiolytic to address her agitation
C. Remove her from treatment
D. B and C
E. A and B
Seven-Year Follow-Up
It is 7 years since Lois was diagnosed with AD. Her
MMSE score is 17. Her family is considering
transferring her from assisted living to a nursing
home. Two of Lois’s daughters come in for an office
visit to ask you about long-term care options and the
need for continuing treatment. You spend 45 minutes
with the daughters and agree to coordinate care with
the medical director at the chosen nursing facility.
9. What is your recommendation?
A. Suggest that they remove therapy because
many patients with dementia in nursing facilities do
not receive these medications
B. Evaluate the goals of treatment and if they are
achievable
C. Suggest that she remain on therapy until she
no longer has meaningful social interaction
D. B and C
Nine-Year Follow-Up
Lois has lived in a nursing home for the last 2 years.
For the last 8 months, she has been unresponsive to
family members and caregivers, and cannot perform
basic ADLs. Although she still receives medication,
her family has questioned its need.
10. What do you suggest?
A. Schedule a meeting between the nursing home
medical director and the family
B. Withdraw all antidementia medications
C. Schedule a comprehensive workup to rule out
other causes for social withdrawal
D. Prescribe a low dose of a selective serotonin
reuptake inhibitor
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