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Depression or Dementia? Case Study

Lukenotes, Winter 2016

Though retired from teaching, Sr. Moira continued to stop in at the parish school almost daily. At first this was fine, but then she began to become disruptive.

Always a bit strong-willed, Sr. Moira was getting into more conflicts with school staff and within her community. She also seemed to be having trouble remembering things. She would blame others for conflicts, and become angry quickly. It came to a head after she refused to leave her room or answer
knocks at the door for three days. She was told she would need to move to the motherhouse, a decision she resisted.

There, her unusual behavior continued, and she began giving one-word answers. When asked to elaborate, her answers often became tangential and confused. Her superior thought she might have become depressed about retiring, but wasn’t sure and called Saint Luke Institute.

Sr. Moira came to Saint Luke for an evaluation that included psychological, spiritual and psycho-social assessments, neuropsychological testing and consultations with Saint Luke’s physician and nursing staff.

While meeting with the psychologist, she expressed feelings of depression, saying, “I was never like this. I enjoyed everything. I’m scared. I feel like I am going out of my mind trying to remember stuff. I find I don’t have much to say anymore. I can’t figure out and what’s wrong with me.”

The psychologist not only talked with Sr. Moira, but administered a number of tests. Personality tests assessed Sr. Moira’s personality traits and the strengths and weaknesses that accompany those traits, as well as the level of psychological distress she currently is experiencing. Projective testing assessed her habitual ways of handling thinking, emotional processes and the presence of specific psychological conflict areas.

Her responses were compared to objective norms to help validate interview impressions. Sr. Moira was engaged during this testing and showed moderately to significantly impaired cognition, moderately impaired attention and concentration, and fair to limited insight/judgment. The Rorschach
test suggested she was experiencing situational stress that was overwhelming her capacity to cope.

This stress appeared to consist of both abstract and emotional demands. Tests also indicated she tended to display more dependency than most people, yet struggled to form close attachments to others and escaped into fantasy when confronted with difficult situations.

Sr. Moira next met with Dr. Thompson, Saint Luke’s neuropsychologist. He administered more in-depth
tests that assessed whether Sr. Moira’s depressive symptoms might actually be indicators of dementia.

The neuropsychological evaluation revealed significant impairment in multiple neurocognitive abilities. Sr. Moira was able to give the correct year, but not the correct month, date or day of the week. Her memory of verbal and nonverbal material (i.e., stories, word lists and two-dimensional drawings) was moderately impaired when assessed immediately after exposure and was severely deficient after a delay of 30 minutes.

On problem-solving tests, her responses were concrete. She was not able to use feedback about answers to improve her performance. She had difficulty drawing a clock face with a specific time. The shape, symmetry and location of numbers were distorted. Yet, her expressive vocabulary, auditory
attention span, simple motor skills and perceptual abilities were intact.

At the feedback session with Sr. Moira and her superior, the evaluation team indicated the findings were consistent with a major neurocognitive disorder, most likely due to Alzheimer’s disease, with depressive features, late onset.

The team recommended Sr. Moira meet with a psychiatrist to prescribe medications that would help address her Alzheimer’s symptoms. Assessment interviews, especially the psycho-social portion of her assessment, indicated she long had suffered childhood and adult abuse.

Team members recommended that Sr. Moira begin outpatient treatment that is trauma-focused to deal with resulting PTSD and to consider adjunct therapies such as Eye Movement Desensitization and Reprocessing (EMDR) to deal with reactivity and emotional stimulation that is a part of PTSD.

The team also provided practical suggestions on how to engage with Sr. Moira more effectively in the future. This included asking concrete and concise questions that were not open-ended, breaking tasks down into basic steps, and ensuring the community is aware of issues related to cognition so she has appropriate structure and support. Her superior also was advised if she expresses sadness or confusion, it would be better not to engage in a discussion, as this would negatively reinforce Sr. Moira’s presenting issues.

Six months later, the superior called to say things were going much better for Sr. Moira and the community after following the recommendations.

Confidentiality is important to us. This case study is not based on a particular client. Details of treatment and other information have been altered.

Author:

Kathleen Glufling, Psy.D., served on the Continuing Care clinical staff.