Nicola Lodge Consultation

**Client/family provided verbal consent to use the AI scribe during this visit, understanding its purpose, potential benefits, and limitations, as well as the need for a temporary audio recording for documentation and associated privacy and security risks.** **Consultation Note** **IDENTIFYING INFORMATION:** John Doe, 68‑year‑old widowed male, resides in the memory support unit of Evergreen Retirement Home (resided there for 14 months following wife’s passing). He retired at age 62 from engineering and is financially supported by his pension and savings; his adult daughter lives nearby and visits twice weekly. Referral Source: Dr. Smith, Geriatrician. PHN: 123‑456‑789 **REASON FOR REFERRAL:** Assessment of cognitive decline, recent behavioural changes (agitation, nocturnal wandering), and difficulty managing medications and finances. **History of Presenting Illness:** Information obtained from chart review, nursing staff, and daughter’s report. Over the past six months Mr. Doe has exhibited gradually worsening short‑term memory difficulties, with recent episodes of misplacing his room key and forgetting meals. Three weeks ago he began waking nightly and walking the halls of his unit, appearing agitated and trying to “find his car.” Staff report he has had two falls in the last month—one from standing unsafely at the toilet at 02:00 and one from leaning over the balcony rail at 03:30. He reports feeling “confused during the night” but during daytime states “I’m fine.” He denies visual or auditory hallucinations but acknowledges nights are “more foggy.” He is independent in dressing and bathing until recently when he needed prompting; daughter reports he now often forgets to take his medications and did not pay his taxes this year. There are no known recent infections. He denies chest pain, shortness of breath, focal weakness, or speech changes. **Collateral Information:** Nursing staff in the memory unit report increasing agitation and pacing between 22:00 and 04:00, requiring 1:1 supervision overnight. The daughter reports that her father has not driven since the fall six weeks ago and that he seemed to “lose track of time” during their last visit. She also reports that he did not remember having breakfast two days in a row and left the shower running the previous week. The geriatrician’s recent note indicated MoCA score of 19/30 and noted bilateral hippocampal atrophy on MRI. **Cognitive History:** The patient and daughter both report a progressive decline in short‑term memory over the last year. He no longer reliably remembers recent conversations, appointments, or where he placed items. Long‑term personal memory appears preserved (e.g., childhood details), but he reports occasional “blank spots.” He previously managed his finances and drove independently until the past two months when he was advised to stop. **Cognitive Testing:** MoCA completed two weeks prior: total score 19/30, deficits in delayed recall, attention, and executive tasks; orientation to time/place retained. **Functional History:** ADLs: 1. Dressing: with minimal assistance. 2. Washing/Grooming: with prompting. 3. Bathing: independent but requires supervision. 4. Toileting: independent, but unsafe transfers have led to falls. 5. Transfers: can stand and walk short distances but requires 1:1 overnight supervision. 6. Ambulation: uses walker, ambulates with supervision. IADLs: 1. Meals/Cooking: no longer able to prepare meals independently. 2. Medications: reliant on daughter and nursing staff. 3. Finances: unable to manage taxes or banking. 4. Driving/Transportation: ceased driving two months ago. 5. Housekeeping/Laundry: assistance required. 6. Shopping: no longer able to safely shop independently. **Substance Use History:** Reports minimal alcohol use (1–2 drinks monthly) and denies current or past illicit drug use or tobacco use. **Past Psychiatric History:** No prior psychiatric diagnoses or hospital admissions. No history of major depression or psychosis. **Family History:** Mother diagnosed with Alzheimer’s disease at age 72; father died of myocardial infarction at 67. No known family psychiatric illness. **Past Medical History:** - Type 2 diabetes mellitus, diagnosed 10 years ago - Hypertension, diagnosed 12 years ago - Obstructive sleep apnea, using CPAP nightly - Hypothyroidism, managed with levothyroxine - Mild aortic sclerosis on echocardiogram **Current Medications:** - Metformin 1000 mg BID - Lisinopril 10 mg daily - Levothyroxine 75 µg daily - Atorvastatin 20 mg nightly - CPAP nightly for OSA **Allergies:** Penicillin (rash) **Personal History:** Born and raised in Vancouver; married 35 years, wife deceased six months ago. Two adult children; older daughter lives locally, younger son lives out of province. Enjoyed woodworking and fishing, no longer able to participate safely. **Mental Status Examination:** Appearance and behaviour: Mr. Doe is casually dressed, appears his stated age, groomed though slightly disheveled. He sat quietly but required prompting to engage and displayed limited eye contact. Speech: rate normal, volume audible, coherence intact though responses were delayed. Mood: described as “okay” by patient, though daughter reports increased irritability. Affect: restricted and flat appropriate to content. Thought process: logical and sequential though slowed. Thought content: no delusions or suicidal ideation; denies hallucinations and was not observed to be attending to internal stimuli. Cognition: oriented to person and place but not reliably to time; immediate recall poor (0/5 words at 5 minutes); sustained attention reduced; abstraction intact. Insight: limited – acknowledges memory problems but downplays risk. Judgment: impaired – continues to attempt independent driving despite safety concerns. **Investigations:** - MRI brain: bilateral hippocampal and parietal lobe atrophy. - MoCA: 19/30, deficits in recall, attention, executive function. - HbA1c: 7.8%. - TSH: 2.1 mIU/L. - B12 and folate: within normal limits. **Impression:** 68‑year‑old male with known hypertension, diabetes, OSA, and hypothyroidism presenting with progressive short‑term memory decline, new nocturnal agitation, falls and impaired medication/financial management consistent with major neurocognitive disorder, likely Alzheimer’s type, and associated behavioural disturbances. Risk to self (driving, transfers) is elevated. **Plan:** 1. Certification: Not indicated at this time. 2. Safety: Close overnight supervision, restrictions on driving, remove walker from unsupervised access; plan behaviour huddle after any aggression incidents. 3. Biological: Continue current medications for diabetes, hypertension, and hypothyroidism. Consider starting Donepezil 5 mg nightly after discussing benefits/risks with family. Monitor weight, nutrition, sleep, and all psychotropic screening labs with GP per protocol. 4. Share‑care/Investigations: Contact daughter and GP to communicate findings; request runway labs including CBC, BUN/Creatinine, AST/ALT, TSH, lipid panel; liaise with geriatrician and neurology for further evaluation. 5. Psychosocial: Encourage daughter to engage in structured memory‑supportive activities, maintain regular orientation cues in the unit; referral to occupational therapy for ADL/IADL support. 6. Follow‑up: Arrange return review in 8 weeks with memory clinic; immediate return if increased confusion, aggression, or fall incidents occur. It has been a pleasure being a part of the care for this patient. If there are any questions, please do not hesitate to contact me. Dr. Jane Smith Geriatric Psychiatrist