A 51-Year-Old Who Lost Her Job Due to Cognitive Decline

Lisa C. Silbert, MD; Deniz Erten-Lyons, MD


April 19, 2021

Of the 5.8 million Americans with Alzheimer disease, less than 5% are younger than 65 years. Most patients with early-onset Alzheimer disease have sporadic disease not caused by an inherited genetic mutation. Certain genetic variations are recognized, such as the presence of the epsilon 4 allele of the apolipoprotein E gene, that increase the lifetime risk for Alzheimer disease; however, their presence does not mean that the person conclusively will develop the disease.

Approximately 1% or less of Alzheimer disease cases develop as a result of three autosomal-dominant genetic mutations that are guaranteed to cause the disease in anyone who carries them. These mutations involve the gene for the amyloid precursor protein and the genes for the presenilin 1 and presenilin 2 proteins. Individuals who carry one of these three genetic mutations have a family history of dementia in approximately 50% of individuals from each generation. The absence of dementia in either of this patient's parents excludes the possibility that she carried one of the three known dominantly inherited Alzheimer disease genetic mutations.

Currently, Alzheimer disease has no cure. Treatment for Alzheimer disease dementia include donepezil, galantamine, or rivastigmine, all of which are cholinesterase inhibitors. Treatment also includes consideration of a trial of memantine, which is an N-methyl-D-aspartate antagonist. These medications change certain neurotransmitters in the brain that may prolong the time to further functional impairment.

Patients with Alzheimer disease commonly have mood and behavioral issues during the course of the disease, such as anxiety and agitation, for which treatment should be started. The patient in this case had severe anxiety symptoms and was therefore started on the selective serotonin reuptake inhibitor sertraline.

Advanced dementia can be associated with worsening behaviors that include delusions and hallucinations. Neuroleptics (such as quetiapine) can be helpful in these cases, although a black-box warning describes increased mortality when using neuroleptics in patients with dementia; this needs to be considered and discussed before initiating treatment.

Other issues that need to be reassessed at each visit include safety issues, such as driving and medication management, and caregiver stress. A referral to the Alzheimer's Association for local resources can be helpful for the family.


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