Question 71: A 72-year-old man is brought in by his daughter who is concerned about his recent memory impairment. The patient’s daughter says she has noticed impairment in memory and functioning for the past month. She says that he has forgotten to pay bills and go shopping, and, as a result, the electricity was cut off due to non-payment. She also says that last week, he turned the stove on and forgot about it, resulting in a kitchen fire. The patient has lived by himself since his wife died last year. He fondly recalls living with his wife and how much he misses her. He admits that he feels ‘down’ most days of the week living on his own and doesn’t have much energy. When asked about the kitchen fire and problems with the electricity, he gets defensive and angry. At the patient’s last routine check-up 3 months ago, he was healthy with no medical problems. His vital signs are within normal limits. On physical examination, the patient appears to have a flat affect. Which of the following is the most likely diagnosis in this patient?
- A. Pseudodementia (Correct Answer)
- B. Pick’s disease
- C. Delirium
- D. Dementia
- E. Both dementia and delirium
Explanation: ***Pseudodementia***
- The rapid onset of symptoms (within the last month), coupled with the patient's **depressed mood** (feeling 'down', low energy, flat affect, recent loss of spouse), strongly suggests **pseudodementia**, which is cognitive impairment mimicking dementia but caused by depression.
- Patients with pseudodementia often highlight their **memory problems**, get defensive about cognitive failures, and show a more global cognitive decline rather than specific deficits, all of which are present in this case.
*Pick’s disease*
- This is a form of **frontotemporal dementia** characterized by prominent behavioral changes and language difficulties, which are not the primary features here.
- Cognitive decline in Pick's disease is typically **insidious and progressive**, not acute and linked to a depressive episode.
*Delirium*
- Delirium is characterized by an **acute onset of fluctuating attention** and **altered consciousness**, often with disorientation and disorganized thinking.
- There is no mention of fluctuating mental status or altered consciousness, and the patient's presentation points more towards a mood disorder impacting cognition over a few weeks, rather than hours to days.
*Dementia*
- Dementia typically has an **insidious onset** and a **gradual, progressive decline** in cognitive function over months to years.
- While the symptoms include memory impairment and functional decline, the rapid onset, association with a depressive episode, and patient's awareness/defensiveness about cognitive issues are more characteristic of pseudodementia.
*Both dementia and delirium*
- While both conditions cause cognitive impairment, the patient's symptoms do not align with the fluctuating course and acute altered consciousness of delirium, nor the typical insidious progression of true dementia.
- The presentation is more consistent with a **depressive pseudo-dementia**, and there's no evidence to suggest co-occurrence of both dementia and delirium.
Question 72: A 27-year-old man comes to the physician for a follow-up examination. Paroxetine therapy was initiated 6 weeks ago for a major depressive episode. He now feels much better and says he is delighted with his newfound energy. He gets around 8 hours of sleep nightly. His appetite has increased. Last year, he had two episodes of depressed mood, insomnia, and low energy during which he had interrupted his job training and stopped going to the gym. Now, he has been able to resume his job at a local bank. He also goes to the gym three times a week to work out and enjoys reading books again. His temperature is 36.5°C (97.7°F), pulse is 70/min, and blood pressure is 128/66 mm Hg. Physical and neurologic examinations show no abnormalities. On mental status examination, he describes his mood as "good." Which of the following is the most appropriate next step in management?
- A. Discontinue paroxetine
- B. Switch from paroxetine to venlafaxine therapy
- C. Continue paroxetine therapy for 6 months
- D. Continue paroxetine therapy for 2 years (Correct Answer)
- E. Switch from paroxetine to lithium therapy
Explanation: **Continue paroxetine therapy for 2 years**
- This patient has experienced **recurrent major depressive episodes**, with two episodes in the past year. Guidelines recommend continuing antidepressant therapy for **1-3 years or indefinitely** after a second or third episode to prevent relapse.
- Given his significant improvement and history of recurrent depression, long-term maintenance with paroxetine is the most appropriate strategy.
*Discontinue paroxetine*
- Discontinuing the antidepressant now would significantly increase the risk of a rapid **relapse** of major depressive disorder, especially given his history of multiple episodes.
- Antidepressants should not be abruptly stopped once symptoms resolve, particularly in patients with recurrent depression.
*Switch from paroxetine to venlafaxine therapy*
- There is no indication to switch to venlafaxine, as the patient has responded well to paroxetine and is currently in **remission**.
- Switching medications carries the risk of new side effects or a recurrence of depressive symptoms.
*Continue paroxetine therapy for 6 months*
- While 6 months of continuation therapy is standard after a **first episode** of major depressive disorder, it is insufficient for patients with **recurrent episodes**.
- Continuing for only 6 months heightens the risk of relapse for this patient given his history.
*Switch from paroxetine to lithium therapy*
- Lithium is typically used as a mood stabilizer for **bipolar disorder** or as an augmentation strategy for refractory depression.
- There is no evidence in the vignette to suggest bipolar disorder, and the patient has responded well to monotherapy with paroxetine.
