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Instructor: Mamata Yanamadala, MD
Email: mamata.yanamadala@duke.edu

Read:Chapter 20: Prognosis

Case: Advanced dementia: How much longer does he have, Doc?

69 yo WM was brought to the GET clinic by his wife and a care provider. They are concerned about his deterioration in functional status and wondering if anything else can be done. The patient was diagnosed with Alzheimer’s disease 10 years ago. He had to take early retirement from his position as a patent lawyer. His wife says he just came home one day a decided not to go back. His decline has been gradual. Over the past 3 years he has required assistance with ADLs. He was admitted to several excellent nursing facilities but could not be managed and was briefly admitted a psychiatric hospital but even subsequent to this behavioral issues were such that the family decided to bring him home. For the past year he has been cared for at home by his wife and a grandson who lives nearby. He has been going to adult daycare but he abruptly stopped walking about 3 weeks ago and has not been able to attend. He is now incontinent of urine and stool. He needs assistance with feeding at most meals. A nursing assistant has been hired within the past 3 weeks to work 8 hours per day.

Medications: sertraline 100mg qd, donepizil 5 mg qd, gabapentin 600mg qid, valproic acid 250 mg bid, amantadine 100mg bid, oxcarbazepine 300mg bid, alprazolam 1 mg prn. The family is reluctant to change any of these which were determined in the psychiatric hospital to best control his behavior.
PMH: Ear surgeries for mastoiditis
FHX: father died of AD at age 72, 2 brothers are healthy
SHX: 2pk/dy 20 years, 1-2alcoholic drinks per day most of his adult life
ROS: more sleepy, suspected weight loss, no cough, SOB, fever, chills, change in BMS
PE: Tall, thin man, smiles but speech is not intelligible
106-78 P-72 regular, T 97.3 axillary, R-16 Skin in good condition, mucous membranes moist, lungs clear, abdomen benign, extremities trace edema. Neuro: Anxious, not responding to instructions. Once he became agitated with the exam he did stand and walk a few steps. Resisted movement, some increased rigidity.

Clearly the care needs of this patient are increasing for the family. What can you tell them about his current prognosis? They are very interested in resources that may be available to help care for him at home since institutionalization was unsuccessful in the past.