Developmental Disorder or Dementia: A case study of assessment for Aspergers Syndrome in a 59yearold

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Developmental Disorder or DementiaA case study
of assessment for Aspergers Syndrome in a
59-year-old man

• Dr Christina ILSE
• Clinical Psychologist

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Aim

• To present a case which illustrates the diversity
  and complexity of cases admitted to Older Adult
  Inpatient units
• To show how thinking outside the square is
  helpful, important and necessary
• Referral / admission
• Past history
• Progress while on the ward
• Assessment process
• Diagnosis / Formulation

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Referral Norman

• 59-yr-old European man
• Admitted to an Older Adult Inpatient Unit from an
  adult CMHT.
• Precipitating events
• Inability to care for himself at home
• Poor food and fluid intake
• Poor personal hygiene
• Faecal incontinence
• Depressed and anxious mood
• Referral question Is dementia the cause for his
  presentation?

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MSE on admission

• Behaviour rigid, wooden body posture, poor eye
  contact. Dishevelled, soiled, malodorous
• Oriented appropriately to time, place person
• Speech quiet, mumbling, reduced prosody /
  intonation
• Thought form paucity of content, somatic
  ruminations
• Affect poorly reactive
• Mood depressed
• CT Head NAD

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Functioning

• On the ward
• Stayed in his room, coming out only for meals
• Not initiating any social interaction
• Able to remember staffs names / roles
• Incontinent of faeces, unable to explain why
• Past diagnoses include
• Dysthymia,
• Depression,
• Anxiety,
• ?personality disorder (narcissistic, schizoid)

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Initial differential diagnosis

• Axis I
• ?Depression
• ?Anxiety
• ?Dementia
• Axis II
• ?personality disorder
• ?schizoid

• Possibility of a Pervasive Developmental Disorder
  raised- especially in light of
• Poor eye contact
• Lack of shared attention
• Nil spontaneous social interaction
• Ongoing faecal incontinence

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Treatment on the ward

• Nursing aim to treat incontinence
• Extensive physical investigations revealed that
  Norman was faecally loaded and experiencing
  overflow incontinence
• No cause / reason found for his apparent
  inability to use the toilet for bowel motions
  (i.e. intact sphincter control etc)
• Behavioural plan instigated with successive
  approximations (sitting, pushing, wiping, washing
  hands, food reward) nil effective
• Norman refusing to sit on the toilet, unable to
  state why
• Continuing faecal incontinence
• Toilet program also trialled with commode- nil
  effective
• Medical aim treat depression
• Started on Paroxetine, also on Diazepam

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A diagnostic dilemma

• Why did the toilet plan fail?
• Because the underlying diagnosis made this
  intervention inappropriate??
• Is this a dementia?
• Unlikely b/c Norman able to learn ward routine,
  names and roles of staff, able to navigate on the
  ward, oriented to time and place
• Why is it important to diagnose?
• Access to appropriate funding / services
• Appropriate treatment depends upon accurate
  diagnosis

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Assessment process

• Plan to intensively investigate possibility of
  PDD or Autistic Spectrum Disorder (ASD)
• Consultation from Dual Disability Psychologist
  specialising in this area
• File review,
• Multiple interviews w Norman by various staff,
• Collateral Hx from uncle (only living contactable
  family member)
• WAIS-III,
• ToM test,
• AQ Test,

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Social History from Uncle

• Only child, lived w parents all his life
• Mother overprotected him kept him away
• He stayed in his room when people came over
• Aggressive towards other children, no friends
• Odd, a loner
• Left school after Form 5
• Worked in clerical role, excessive hand-washing
  noted after packing each box
• Left there (after 10yrs) b/c boss asked him to do
  something which he didnt consider his job
• Parents were put into care when they became
  incontinent (late 1990s around the same time
  he first presented to CMHT)
• Parents died in 2002 and 2005

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File Review Summary of Past Psych Hx

• 1st presentation to CMHT 1998,
• Depression, anxiety
• s/b psychiatrist, numerous meds trialled, nil
  effective
• Angry w parents / feeling cheated that his
  inheritance was used up by their care
• Thoughts of killing parents
• Episodes of anger- verbal abuse of strangers,
  yelling racist comments, scratched a car w a
  knife, impulsively walking in front of traffic
• Opinion anger towards parents a narcissistic
  insult
• D/C in 2001 after not engaging w psychologist,
  CSW, KW

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October 2001-March 2005

• Multiple (18) presentations to ED w
• Limb pain
• Leg pain
• Dizziness
• Abdo pain
• Constipation
• Hyperventilation
• Nil clear cause found

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March 2005 - ongoing

• Re-presented to CMHT, depressed, anxious
• Ongoing resentment of parents care
• Admitted to adult IP unit after decline in
  self-care
• d/c after 6 days mental state consistent with
  personality (schizoid, narcissistic) disorder
  rather than Axis I
• Panic attack on the way home ? ED ? IP unit ?
  opposite action (facing anxiety) indicated ?
  back home
• Blg manager voiced grave concerns for Normans
  functional ability
• Under CMHT who noted ongoing functional decline
  diagnostic uncertainty ? ?dementia ? OA IP unit

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WAIS-III

• Full Scale IQ Low Average
• Verbal IQ Average
• Performance IQ Borderline
• Significant difference b/w Verbal and Performance
  IQ (seen in only 8.9 of standardisation sample)

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Theory of Mind Test

• Series of social situations
• Test taker rates whether behaviour of people in
  the stories is strange or normal
• Significant difficulties with conceptualizing
  situations from another persons viewpoint

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Autistic-Spectrum Quotient Test

• Self-administered rating scale
• Measures to what degree an adult w normal
  intellectual functioning has traits associated w
  ASD
• A score of 36 or higher indicates presence of ASD
  traits
• Norman scored 20/50 (below cut-off)
• Had poor insight however
• Rated self as enjoying social chit-chat and
  finding social situations easy when observations
  clearly indicated otherwise
• Concrete responses stated he noticed patterns in
  things, and explained that his mother was a
  dressmaker, hence saw patterns frequently.

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Evidence supporting a diagnosis of Aspergers
Syndrome

• Reviewed the information gathered in relation to
  characteristics commonly seen in people with
  Aspergers Syndrome (based on Gillberg, 1991) in
  these areas
• Social / Emotional Abilities
• Communication Skills
• Cognitive Skills
• Specific Interests
• Movement Skills
• Other Characteristics

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Evidence not clearly consistent with a diagnosis
of Aspergers Syndrome

• Scoring below cut-off on ASQ
• May be due to poor insight
• No clear evidence given from Uncle regarding
  developmental markers (e.g. no stereotyped
  behaviour, no language delay, no clear special
  interests)
• May be due to Uncles conceptualisation of
  Norman- he believed that Normans mothers
  behaviour had caused Norman to be odd, rather
  than perhaps her behaviour being a response to
  Normans behaviour

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Diagnosis and Formulation

• Weight of the evidence consistent with Aspergers
  Syndrome
• Late-life diagnosis possibly partly due to
• Parents protecting / isolating Norman from
  uncomfortable situations (social interactions)
• AS only actively assessed in NZ in last 5-10yrs
• International criteria for AS established in 1994
  

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Formulation

• Supported by parents all his life. First
  presentation to MH happened around the same time
  that his mother went into care.
• Functional decline coincides with parents
  declining health and dying
• Likely that failure to engage w treatment at CMHT
  due to difficulties w social interaction (central
  to AS)
• Likely that anxiety and/or depression are also
  present

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Formulation re Incontinence

• Remains unclear why Norman is faecally
  incontinent
• Hanging on so he can stay in care rather than
  going back home where he is unable to cope
• Hanging on due to hypersensitivity / pain when
  moving bowels, hence resultant overflow
• Hanging on to avoid having incontinence to in
  turn avoid going into care like his parents did
  when they became incontinent (ie direct opposite
  of (1)

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Where to from here?

• Recommendation for supported accommodation
• Application for funding from Taikura Trust
• Needs property manager appointed
• Needs psycho-education about Aspergers Syndrome
• Would benefit from further intervention from a
  psychologist / clinician experienced in
  developmental disorders / AS to address mood
  symptoms and incontinence

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Final Reflections

• Little change in presentation whilst on ward
• Sometimes attends Quiz group / some other
  activities
• No change in incontinence
• Need to think outside the square highlighted
• Service gaps highlighted (funding / supported
  accommodation / specialized services)
• Diagnosis was important
• to inform treatment (of mood / incontinence) from
  now on,
• to promote understanding of symptoms amongst
  carers, Uncle, clinician