Alzheimer’s Dementia

Case Study: Dr. Evelyn “Eve” Marshall (DSM-5-TR: Major Neurocognitive Disorder Due to Alzheimer’s Disease, Moderate Severity)

Demographics

• Name: Dr. Evelyn “Eve” Marshall

• Age: 68

• Gender: Female

• Occupation: Retired university linguistics professor

• Living Situation: Lives with her husband of 45 years in their home; two adult children visit weekly

• Background: Excellent academic history, lifelong reader and polyglot, no prior major psychiatric diagnoses

Clinical Presentation

Course of Symptom Development

Over the past 18 months, Eve’s husband and her adult children began noticing subtle changes. Initially she would misplace keys or forget a word mid-lecture when asked to give guest talks. These episodes were occasional and were attributed to “normal aging.”
About 10 months ago, her difficulties escalated: she repeated the same question minutes later, forgot the names of colleagues she had known for decades, and had trouble following the plot of her favorite novels. Her sense of direction in familiar areas (e.g., walking to the campus library) became unreliable. Her fluency in several languages—once a professional hallmark—began to falter: she used simpler vocabulary, paused more, and conflated words across languages.
The past three months have seen more pronounced impairment: she struggles to manage her daily finances, frequently cannot recall appointments or lectures she scheduled, and has increasing difficulty planning and organizing tasks she once managed easily. Her husband reports that she sometimes shows irritability and apathy, wandering through the house at odd hours, confused by changes in routine, and occasionally accusing her husband of “hiding” things.

DSM-5-TR Diagnostic Features

Criterion A: Evidence of significant cognitive decline from a prior level of performance in one or more cognitive domains (complex attention, executive function, learning & memory, language, perceptual-motor, or social cognition).

• Eve shows clear decline in learning & memory: e.g., repeated questions, forgetting names, difficulty retaining new information.

• Also significant decline in language: word-finding problems, reduced multilingual fluency, conflation of languages.

• Decline in executive function/planning: inability to manage finances, schedule, and organize formerly well-managed tasks.

• Family reports and her own concern corroborate the change from a high baseline.

Criterion B: The cognitive deficits interfere with independence in everyday activities.

• She requires increased support from her husband for managing bills, planning appointments, and organizing household tasks.

• She can still perform many tasks but with increased effort and errors; some independence is lost.

• This interference is clinically significant.

Criterion C: The cognitive deficits do not occur exclusively in the context of a delirium.

• There is no evidence of acute onset confusional state; onset was insidious and gradual.

• No indications of medications/substances or acute medical illness producing a delirium pattern.

Criterion D: The cognitive deficits are not better explained by another mental disorder (e.g., major depressive disorder, schizophrenia).

• While Eve has some mood changes (irritability, apathy), these appear secondary to cognitive decline rather than a primary mood disorder.

• There is no history of psychotic or delusional disorder that would better explain the cognitive profile.

Additional Criteria for Major Neurocognitive Disorder Due to Alzheimer’s Disease (DSM-5-TR specifier)

• Insidious onset and gradual decline in cognition are present.

• There is clear evidence of decline in memory and learning and at least one other cognitive domain (language and executive function) consistent with Alzheimer’s disease. MedCentral+3theravive.com+3psychiatryonline.org+3

• There are no other etiologies (vascular, TBI, substance) dominating the clinical picture. While other age-related conditions exist (e.g., mild hypertension well-controlled), the primary decline aligns with Alzheimer’s pattern.

Severity & Specifier

• Based on the DSM-5-TR, Eve’s condition is best described as “Moderate” (major neurocognitive disorder interfering with independence but not fully requiring extensive assistance or full-time care).

• Specifier: With behavioral/psychological disturbance (irritability, apathy).

Psychological and Behavioral Features

• Memory impairment: repeated questions, forgetting recent conversations, difficulty recalling events of the day.

• Language impairment: reduced multilingual fluency, word-finding pauses, substituting simpler vocabulary; sometimes switches between languages inadvertently.

• Executive dysfunction: mismanaging checkbook, forgetting to pay bills, inability to plan weekly schedule or prepare lectures without repeated assistance.

• Apathy/Withdrawal: Decreased interest in previously beloved activities (reading advanced linguistics articles, leading seminars); irritability when interrupted or asked for help.

• Sensory/Perceptual aspects: Occasionally gets lost in her own neighborhood—familiar streets confuse her.

• Insight: She is aware initially and expresses frustration and embarrassment; later becomes more defensive, denying she’s “losing it.”

Differential Diagnosis Considerations

• Vascular neurocognitive disorder: No significant history of strokes or vascular events; MRI does not show multiple infarcts as dominant feature.

• Depressive pseudodementia: Although she has apathy and mood changes, her primary deficits (language, executive, memory) and pattern of decline do not align solely with depression.

• Medication or substance-induced cognitive impairment: No evidence of new medications that could account for the decline; stable medical regimen.

• Other neurodegenerative disorders (e.g., Lewy body dementia, frontotemporal dementia): Her early prominent memory/learning decline and language/executive issues align more with Alzheimer’s; absence of early prominent visuospatial hallucinations (Lewy) or behavioral disinhibition (FTD).

Functional Impairment

• Academically: Previously led seminars and published articles; now unable to prepare lectures without heavy assistance, mistakes slip into her writing, she forgets appointments.

• Socially: Decreased participation in professional conferences, forgets names of colleagues, avoids social engagement due to embarrassment and frustration.

• At home: Husband must help manage finances, set reminders; Eve sometimes wanders or gets up at night confused; family routines adjusted to compensate for her deficits.

• Emotionally: Experiences shame, frustration, occasional tearfulness about losing her cognitive sharpness; spouse reports increased marital strain.

Treatment Considerations (Aligned with Current Best Practice)

• Pharmacologic: Cholinesterase inhibitors (e.g., donepezil) and NMDA-receptor antagonist (e.g., memantine) to help slow progression (though not curative).

• Cognitive rehabilitation/support: Memory aides (planners, smartphone reminders), environmental modifications (clear labeling, consistent routine).

• Behavioral interventions: Structured daily schedules, cognitive stimulation (group activities, simplified academic tasks), addressing apathy by scheduling meaningful but manageable tasks.

• Caregiver support: Psychoeducation for husband and family; stress management to avoid caregiver burnout.

• Safety planning: Monitoring mobility and wandering risk, driving evaluation (likely discontinuation), home safety check (fall risk, easy access to reminders).

• Multidisciplinary coordination: Neurologist, neuropsychologist, geriatric psychiatrist, occupational therapist.

Cultural/Psychosocial Context

• Eve’s identity was tightly connected to her professional role as a scholar; the cognitive decline thus impacts her sense of self, making adjustment difficult.

• Her family initially attributed memory lapses to stress or aging—delayed seeking an evaluation by ~8 months.

• In their cultural context, mental decline carries stigma; Eve resisted the notion of needing “help” or being “less than” her previous self.

• The adult children live out of state; husband is primary caregiver, creating strain on a formerly independent couple.