Case Studies in Cognitive Dysfunction

Praveen Dayalu MD

Clinical Associate Professor

Department of Neurology

University of Michigan

Cognitive “Domains”

• Memory

• Language

• Visuospatial function

• Attention and Executive function

Case 1

• 79 y/o woman brought by family. For 3 years, repeats stories and questions over and over. (“Where are we going to lunch?”) Harder time with grandkids names. Misses appointments, bills. Socially gracious as always (retired wedding planner). She feels her memory is fine.

• She is a lifelong Tigers fan. You ask about this season and she says “They didn’t do too well” but can’t specify recent trades

• Med list: ASA 81mg, HCTZ, OTC med for itching/ sleep

• What are you thinking before MoCA?

Case 1 teaching points

• Alzheimer’s presents with difficulty making new memories. Hippocampus not working right!

• Poor delayed recall (e.g. word list) or loss of orientation, are early clues

• Patients lose detail in describing recent events (e.g. news, sports), but may do fine with remote events.

• Function loss! Ask about finances, appointments, medications• Other domains become involved with time

• Consider reversible contributors!! Medications include anticholinergics (diphenhydramine, bladder meds, TCA’s).

• Check B12, TSH, CBC, comp. MRI or CT brain for structural contributor.• Depression screen

Case 2

• 52 y/o woman concerned about failing memory for the past 5 years, progressing. She is an administrative assistant in a R&D lab. She slips up more in conversations. Give examples of forgetting things (left concert tickets in dresser once), missed an exit recently. She doesn’t feel as smart– at parties, can’t recall names of actors and authors as easily. Father had Alzheimer’s, died at 82.

• What are you thinking before you examine her?

Case 2: MoCA

• MoCA: 28/30 (-1 for sevens, -1 for recall), becomes tearful part way through recall test.

Case 2 teaching points

• Fear of Alzheimer’s is common, especially with a family history, and can lead to vigilance.

• Dementia under age 65 is uncommon. Early onset familial Alzheimer disease (

Case 3• A 70 y/o man began to withdraw from social activity and hobbies. Wife

thought he was depressed and slow. He denied sadness or anhedonia, but admitted he was no longer the life of the party. He had new trouble multitasking, so he stopped doing the accounts and stuck to procurement & sales at the family bakery.

• At age 74 he began to have trouble seeing things in front of him (but eye exam normal). He started to see childrens’ faces in the AM on awakening, or sometimes colored animals out the window. He punches his wife in sleep sometimes. New troubles planning– wouldn’t order supplies for the bakery on time.

• Med list: Warfarin for a-fib; metoprolol; vitamin D and Ca

• Thoughts before MoCA and Physical Exam?

Case 3 teaching points

• Dementia with Lewy Body (DLB) is clinically very similar to Parkinson disease dementia

• Relatively early problems with attention and executive function; visuospatial dysfunction

• Early formed hallucinations are a clue! Look for parkinsonism!

• Complex dream enactment may be present years in advance– this is a red flag for PD/ DLB

• Patients with apathy or flat facial expression may appear “depressed” when they are not

• Management thoughts?

Case 4

• 67 y/o linguistics professor is struggling through courses. She loses track of student names. Walks into room not sure why she went there. Reading papers is harder- mind isn’t taking it in. Was working on a new language board game but stopped. Used to read widely but “doesn’t care”. No longer keeps intellectual conversations going. Still ADL intact, remembers events. Husband says “She’s not the same.”

• Med list: Metformin, Ramipril, simvastatin

• What are you thinking before you examine her?

Case 4 teaching points

• Depression is a major contributor to cognitive problems. It can affect concentration and focus.

• Seniors with new depression are at higher risk for brain degenerations like Parkinson’s and Alzheimer’s

• It may be difficult to determine if a problem is due to depression, something degenerative, or both

• What is the limitation of the MoCA in this particular patient?

• Neuropsych testing is particularly useful when there is diagnostic ambiguity, and in individuals with unusual baselines

Case 5

• 60 y/o retired principal is brought by his family for 1 year of new “manic behavior”. He gets into political arguments with strangers. He is publicly flatulent, and finds it hilarious. His driving is aggressive. His attitude seems newly breezy and careless-- spent $920 on a sweepstakes contest.

• He can’t operate washer and coffeemaker any more; family doesn’t trust him with finances.

• Med list: Norco for low back pain, advil, omeprazole

• What are you thinking before you examine him?

Case 5 teaching points

• Prominent new psychiatric symptoms later in life are less likely to be a primary psychiatric disorder.

• The frontal lobes are a prime driver of personality, self-control, and executive function– brain MRI is a good test here!

• Frontotemporal dementia can present relatively young (middle age)-major personality change, executive dysfunction

• Neuropsych testing may be useful here too– FTD is relatively less common, and this patient is 60

• This is a case where family history might be positive, and an FDG PET scan can support the diagnosis

Case 6

• A 44 year old financial analyst transferring care to you wants treatment for his “Adult-onset ADD”. His ability to focus on anything of substance is “terrible”. He nods off at group meetings and caffeine doesn’t help any more.

• He is doing lots iPad games to keep himself sharp. His Luminosity score is improving a little but not as fast as he’d like.

• His teenage daughter has ADHD and is treating it with medical marijuana. It makes her more creative. He wonders if this might be appropriate for him, too.

• Meds: An OTC herbal product for weight loss

• Thoughts before exam?

Case 6: MoCA

• 27/30 (-1 for letter fluency, -2 for recall)

Case 6 teaching points

• A LOT of memory formation– selective strengthening and weakening of synapses– happens in sleep.

• Poor sleep is an underappreciated cause of attention and memory symptoms

• OSA, shift-work, insomnia, and…

• Bright screens at night!

• Brain training games are of no proven benefit. Better for your patients to get off their rear ends and exercise

• Marijuana? There is no good evidence for a clear cognitive benefit in any condition, and serious concern about its effects on memory and learning, especially in youth.

Case 6 teaching points cont’d

• Adult-onset ADHD? Think again! This diagnosis is often a cop-out and allows you and your patient to miss underlying issues.

The End

• Questions?