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1　History

Jon is a 69-year-old man,who has been to your practice several times over the past six months or so with various concerns.Initially he presented seeking assistance for his sleep problems,a few weeks later attended because he was experiencing vague pains in the chest and subsequently he came seeking something to ′help my digestion′.On this occasion,he presents complaining that his memory is poor.

2　Further history

Jon has no significant past medical history.He is an ex-smoker,previously 30/day.He retired from his job as an accountant 6 months ago.He had intended to work till 70 years old but decided to retire after his wife was diagnosed with breast cancer.Fortunately she responded well to treatment and is currently clear of disease.The couple have two adult children,one living in London and the other in Australia.Following his wife′s good response to treatment the couple had planned a trip to London,but Jon is concerned that his physical health is not good enough to go that far from home.He′s also quite concerned about his memory,and is worried he might be developing dementia.He has a family history of Alzheimer′s disease,and he watched his father progressively deteriorate until he no longer recognised who Jon was.He also has a family history of depression,and he thinks he might have been depressed himself after his father′s death 15 years ago.

3　Examination

Jon is well dressed and groomed,walks slowly into the consulting room and appears quite tense.He seems somewhat dejected,and his hands are shaking slightly.Physical examination shows normal vital signs,no evidence of Parkinson′s disease per se,and normal cardiovascular,respiratory and abdominal examinations.He is willing to answer questions,but his responses are brief and without much detail.He returns to the topic of dementia and mentions his concerns about his memory several times.He admits he′s thought that if he has got dementia then life would not be worth it,and he′d not want to go on.He denies any perceptual disturbance such as hallucinations.Testing of his concentration and attention (note 1) reveal some impairment.Unfortunately there is no time at this appointment to undertake a detailed memory evaluation but simple memory testing shows (note 2) shows problems in immediate and short-term memory.

4　Questions

4.1What is the probability diagnosis?

4.2What other diagnoses should be considered?

4.3What further history,examination and investigations are required?

4.4How should he be treated?

5　Answers

5.1The most likely diagnosis is depression[1].Jon has presented several times describing vague symptoms,all of which could be due to depression-sleep problems,chest pains,digestive problems and most recently memory problems.Jon has a past history and a family history of depression.He has recently experienced two significant stressors-his wife′s diagnosis of cancer and his own retirement from work.On mental state examination he appears sad and anxious,and has problems with concentration and attention and memory.He has voiced thoughts of not wanting to go on.

5.2Other diagnoses which must be considered include:(1) physical cause for his symptoms such as thyroid disease,malignancy,liver impairment.(2) dementia given his family history and his subjective concerns about his memory.The testing you have undertaken has shown deficits which could be due to his depression,but you note similar results could also indicate an early dementia.

5.3In order to exclude physical causes for his symptoms a thorough physical examination is required as well as a number of laboratory tests including FBE,U&E,LFT,thyroid function tests,vitamin B12 and folate,ESR,a Urine Micro and Culture,and in view of his smoking history a chest X-ray.Further history is required to support/exclude the diagnosis of depression-so check for symptoms including low or irritable mood,appetite and weight change,loss of enjoyment in activities,loss of interest,energy and motivation,symptoms of anxiety,loss of sexual interest,social withdrawal,and thoughts of guilt,self-reproach,hopelessness,self-harm or suicide.It may be useful to have Jon complete a self-report questionnaire to quantify the severity of symptoms you elicit e.g.the Beck Depression Inventory (BDI)[2].

If Jon is depressed,and particularly if the symptoms are of moderate or greater severity,excluding dementia (at this time) may be difficult,as individuals who are depressed usually have poor attention and concentration and so often perform poorly on tests for memory.This is particularly the case with older depressed persons.As dementia is a clinical diagnosis,tests such as a CT brain scan are not likely to be of assistance at this stage.

5.4After excluding a physical cause for his symptoms,if the diagnosis of depression is confirmed treatment should include a combination of psychological and pharmacological treatment.Psychological therapy should focus on how Jon has dealt with his wife′s diagnosis of cancer and how he is coping with his retirement.Interpersonal Therapy (IPT),or the adaptation of this for use in for general practice Interpersonal Counselling (IPC) is an approach which specifically addresses issues of loss and role transitions and may be particularly suitable[3].Given that his symptoms are of moderate severity an antidepressant medication is indicated.The most often used medications are the SSRI antidepressants.As Jon is physically well and not taking any other medications,the antidepressant can be started at the usual dose e.g.Fluoxetine 20 mg/day.

Jon should be reviewed regularly.The antidepressants will take 2-4 weeks to have an effect,and any dosage increase which may be needed should be deferred until at least 6 weeks following which the dose can be increased if his depressive symptoms have not resolved.If Jon′s memory problems are due to his depression they should improve along with his other depressive symptoms.If this is not the case,and he continues to have memory difficulties but his mood,sleep,appetite,interest,motivation and energy have improved he will need to be carefully reassessed and formal testing of his memory will be required.This will then confirm or exclude objective memory disturbance.

Notes:

1AttentionandConcentration

Attention:the ability to focus and direct cognitive processes-test using digit span forwards and backwards-expect 5-7 numbers forwards and 4-6 numbers backwards

Concentration:the ability to focus and sustain attention for a period of time-test using:Subtract serial 7′s from 100;spell WORLD backwards.Can be disrupted by performance anxiety,mood disturbance,alteration of consciousness or poor educational level.

2Simplememorytesting

Immediate:registration or capacity for immediate recall of new learning-lasts a few seconds.Repeat 4 items-e.g.dog,shoe,blue,apple.

Short-term:temporary memory,lasts few seconds-few minutes.Repeat the 4 items after 5 minutes.If cannot,prompt with a semantic cue e.g.animal,piece of clothing,colour,fruit.

Long-term declarative memory:data or facts;test both episodic and semantic memory.Episodic memory-time-tagged,personalised,and experiential knowledge e.g.Date of patient′s wedding.Semantic memory-general information a person could reasonably be expected to have learnt e.g.year WWII started.

1Clarke DM,Blashki G,Hickie IB.Depression// Blashki G,Judd F,Piterman L.General Practice Psychiatry[M].McGraw Hill Medical,2007.

2Beck AT,Ward CH,Mendelson M,et al.An inventory for measuring depression[J].Archives of General Psychiatry,1961,4:561-71.

3Judd F,Weissman M,Davis J,et al.Interpersonal counselling for general practice[J].Australian Family Physician,2004,33:332-337.