Question

Pat is 68-years old, single, and of German decent. Pat arrived on time to our meeting, but appeared disheveled. An apology was made for missing last week’s initial appointment and it was admitted that a chauffeur had escorted Pat today. The flow of conversation was often interrupted and thoughts often wandered from the conversation during this intake interview. Pat reported primarily episodes of forgetting mundane things and being overly distracted. Other complaints included loss of appetite and disrupted sleep patterns. Affect varies across a broad range, but was generally appropriate to the topics discussed. Pat smelled of a strong urine as well as tobacco; it was noted through self-report that smoking seemed to help Pat feel and function better.

Psychosocial History

Pat had just returned to complete a university degree after a long hiatus playing in a band. Pat was described by family members as a wild child, who was often getting into mischief. In the past, they noted that Pat always seemed to have taken pride in dress and appearance. In contrast to previously being extremely popular, Pat had gradually alienated many friends, including long-time bandmates, over the past few months.

Initiating and maintaining conversations are a particular difficulty reported by Pat’s partner and friends. They suggest that Pat seems unable to understand a lot of what is said and wonder about hearing impairment. One of the few ways they’ve found to make a connection is to sing songs from the band. At these times Pat often becomes more engaged and seems to perk up.

Environmental History

Pat has been spending most of the time in a private room at the acute care center. There is minimal participation in any of the planned activities on the floor and on a number of occasions Pat has become irritated and agitated when among larger groups of people in the common areas. Mobility has declined significantly. While Pat used to walk with a cane, Pat is now in a wheelchair because of a series falls.

Psychiatric History

Pat had been treated by a family physician with anti-psychotics, anti-depressants, and hypnotics, all of which were reported to provide little, if any, improvement. In fact, Pat reported that some of these, especially the anti-psychotics, actually worsened the memory problems, as well as causing a horribly dry mouth (xerostomia). Pat was hospitalized because of some delusional thinking, especially increasing paranoia, and concerns from neighbours about Pat wandering seemingly aimlessly around.

A magnetic resonance imaging (MRI) scan of Pat’s brain and neuropsychological testing were scheduled by our office prior our initially scheduled meeting. Results from these assessments revealed hemorrhagic infarcts in the basal forebrain area and confirmed difficulties with memory and attention/concentration.

QUESTIONS:

1.Consider the cholinergic system as a potential source of Pat’s problems. What examples/ pieces of information from the case report would support this conclusion? Why? (list and explain)

2. What are the main types of cholinergic receptors? How might they relate to some of the symptoms described in the case report? (select and explain at least 2 examples)

3. What type of medication might be helpful for Pat? Why? How does it act pharmacologically to increase or decrease cholinergic function?

Answer 1

the pieces of information suggesting cholinergic system problems in Pat are-

• inability to understand communication.
• agitation and irritability
• loss of ability to memorize or recall

• MRI result suggesting hemorrhagic infarct in fore brain.
• forgetting things.
• smelling strong urine as well as tobacco

cholinergic problems in body occurs when receptors are dysfunctional so here in this case Pat has MRI result suggesting infarct in fore brain where receptors are present, and its obvious therfore receptors will not work properly for this reason.For this reason the reduced cholinergic effect of less acetylcholine affecting Pat's regulation of memory and learnings. Hence Pat is forgetting things and memory is getting weaker.

The types of receptors are-

1. nicotinic receptors.

​2.mucarinic receptors

these receptors work for releasing acetylcholine neurotransmitter and transmits signal. So when receptors are not working properly due to hemorrhagic infarct in brain, its obvious that cholinergic functions will reduce or hamper. While acetylcholine does not secrete due to muscarinic receptors inability and nicotinic receptors characterised through their interaction with nicotine of tobacco.

Cholinergic drugs are to be useful for Pat.

Cholinergic drugs mechanism of action- these drugs enhance, mimic function of neurotransmitter acetylcholine and increases the availability of acetylcholine and thus transmits signal in parasympathetic nervous system.