F.Y, a 72-year-old retired seamstress, was brought to the clinic by her daughter due to a 2-year history of worsening memory loss, confusion, and changes in behaviour. Initially, F.Y began forgetting recent events, such as where she placed household items and the names of distant relatives. Over time, these memory lapses became more frequent and severe. In the past six months, her confusion has worsened, leading to incidents where she became lost while walking to familiar places in the village.

F.Y has also exhibited changes in personality; she has become more irritable and suspicious of her family members, accusing them of stealing from her. Recently, she has had difficulty performing daily activities, such as cooking and dressing herself, and has started to neglect personal hygiene. The family has noticed she sometimes struggles to find the right words during conversations and occasionally does not recognize close family members.

Her daughter reports that F.Y has had no significant medical issues in the past but now requires constant supervision due to her worsening condition.

- Hypertension: Diagnosed 10 years ago, managed with a traditional herbal remedy.

- No history of head injury, stroke, or major psychiatric illness.

- Dementia: No known family history of dementia or other neurodegenerative disorders.

- Chronic Illness: Both parents died in their 60s from unknown causes; her siblings are alive and well.

- Living Conditions: Lives with her daughter and grandchildren in a small house in a rural village. The family supports themselves through farming and small-scale trading.

- Education: Completed primary school education, with limited literacy.

- Diet: Primarily consists of maize, millet, vegetables, and occasional fish or meat.

- Substance Use: Non-smoker, no alcohol consumption.

- Social Support: Strong family ties, with regular interaction with neighbours and community members.

- General Appearance: Fatimah appears frail but is cooperative, though confused about the time and place.

- Vital Signs: Temperature: 36.5°C, Heart Rate: 82 bpm, Respiratory Rate: 16 breaths/min, Blood Pressure: 140/85 mmHg.

- Neurological Examination:

- Cognitive Function: Oriented to person but disoriented to time and place; unable to recall recent events or the names of her grandchildren.

- Mini-Mental State Examination (MMSE): Scored 15/30, indicating moderate cognitive impairment.

- Speech: Occasional word-finding difficulties and fragmented sentences.

- Cranial Nerves: No focal deficits.

- Motor Function: Normal strength and tone, with a slightly unsteady gait.

- Sensory Function: Intact to light touch and pinprick.

- Reflexes: Normal and symmetrical.

- Complete Blood Count (CBC): Normal

- Thyroid Function Tests: Normal

- Vitamin B12 and Folate Levels: Normal

- Blood Glucose: Normal

- Head CT scan: Mild cerebral atrophy, with no evidence of stroke, haemorrhage, or mass lesions.

- Alzheimer’s Disease: Likely given the progressive nature of memory loss and cognitive decline, along with personality changes.

- Vascular Dementia: Possible due to her history of hypertension and the presence of cerebral atrophy, though no clear history of stroke.

- Mixed Dementia: A combination of Alzheimer’s and vascular dementia could explain her symptoms.

- Depression: Considered but less likely, given the primary cognitive deficits and lack of a significant depressive history.

Plan:

1. Pharmacological Management: Consider starting cholinesterase inhibitors (e.g., donepezil) to slow cognitive decline, along with antihypertensive therapy to better manage her blood pressure.
2. Non-Pharmacological Management: Recommend cognitive stimulation activities and involve the family in creating a safe, structured environment to reduce confusion and agitation.
3. Social Support: Engage community health workers to provide regular check-ins and support for the family in caregiving tasks.
4. Education: Educate the family about dementia, its progression, and strategies to manage behavioural symptoms, such as maintaining routines and using memory aids.
5. Follow-Up: Regular follow-up visits to monitor cognitive function, behavioural changes, and the effectiveness of treatment.

F.Y was diagnosed with probable Alzheimer’s disease, with a possible contribution from vascular dementia. She was started on donepezil and a more structured antihypertensive regimen. Her family was provided with guidance on managing her condition and coping with the challenges of caregiving. Over the following months, F. Y’s condition remained stable, with some improvement in her agitation and sleep patterns. The family continues to receive support from community health workers and has adapted to her care needs, allowing her to remain at home in familiar surroundings.