Fleisher Cases Latest

8/13/2019 Fleisher Cases Latest

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Case 1

62yo right handed man, Manager for anengineering firm.

Gradual cognitive decline for 3 years

Planning, decision making, word finding,reading, writing, misplacing objects

Finding objects (e.g. car keys) even when in

plain sight. Seen by Ophthalmologist,WNL.

ADLs: Intact, except difficulty with work due toproblems reading and typing reports on the

computer. Mild navigation problems, not getting

lost. Otherwise independent.

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Case 1

PMHx: Obstructive sleep apnea, not using CPAP. no

chronic anhedonia or depression. well-controlled

hypertension, hyperlipidemia, chronic back pain,

gastro-esophageal reflux, and osteoarthritis.

Meds: amlodipine, atorvastatin, dexlansoprazole and

cetirizine. Tramadol for management of chronic back

pain. Flaxseed oil, glucosamine, chondroitin, a

multivitamin, vitamin B complex and garlic

supplementation. FamHx: Mother with Vascular dementia

Soc Hx: No substance abuse, 14 yrs education

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Case 1

Physical Exam:

Visual acuity and color vision were grossly intact

Mild L5 radiculapathy

Positive palmo-mental reflex

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Case 1

Bedside cognitive testing:

MMSE 26/30: Pentagon copy (drew squares),

writing a sentence minor error

Category retrieval: 22 animals in one minute Fund of Knowledge: 5/7 correct

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Case 1

MOCA 21/30:

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Case 1

Physical Exam:

Cortical Vision:

No prosopagnosia, neglect or simultagnosia

Bisecting lines, and identifying symbols on a page symetrical, but slower on right side of page

Difficulty with picture interpretation and object

identification: Self corrected with time and prompting

e.g. This is either

French fries or carrots

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Case 1

Working Diagnosis:

MCI: Lewy Body Disease,

AD-posterior cortical variant, Vascular,

non-neurodegenerative (space occupying lesion, NPH, ,etabolic, etc)

Tests:

Labs: CBC, CMP, B12, TSH

Repeat Sleep study for OSA

MRI brain

Formal Neurocognitive testing

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Case 1

Labs: normal

Repeat Sleep study: OSA resolved

MRI (Brain, non-contrast):

moderate atrophy of the hippocampi

global atrophy with a posterior predominance

There was no significant cerebrovasculardisease.

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9/24

Case 1

Formal Neurocognitive testing:

Impaired concentration, attention and decision

making, symbol digit identification

Poor calculations Impaired visual memory, but recall of encoded

items intact

Visual-motor speeds reduced

Difficulty with complex figure copy Semantic language mildly impaired, mild anomia

Low avg verbal memory, normal logical memory


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Case 1

Clinical diagnosis:

MCI: AD-posterior cortical variant

Lewy Body Disease (no EPS, RBSD)

Other non-neurodegenerative

Next Steps:

Consider FDG PET and/or Amyloid PET


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Case 1

Biomarker-based diagnostic assessment:

Amyloid PET (evidence of A)


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Case 1


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Case 1

Biomarker-based diagnostic assessment:

FDG PET (evidence of Neuronal Dysfunction)


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Case 1

Final NIA-AA Clinical diagnosis:

MCI due to AD with two biomarker evidence:

AD-posterior cortical variant

Outcomes:

Discussed role of current approved meds for

AD in MCI

Referred to support services and educationalresources

Discussed AD research opportunities

Follow clinically for cognitive decline, mood

disorders, behavioral changes


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16/24

Case 2

62yo right handed women, HR dept manager

for the US state department, Russian

translator.

Short term memory decline for 5 years forgetfulness to events and conversations and

occasional repetition

mild delayed word-finding

increased dependence on calendars

ADLs: Intact, remains independent with

increased effort

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Case 2

PMHx: Mild depression/anxiety,

B12 deficiency

Meds: B12 QD, MCI, Levapro, asa 81mg

FamHx: No family history of dementia

Physical Exam: No abnormalities

Bedside cognitive testing:

MMSE 30/30, MOCA 27/30 (2/5 on recall) 9 animals in 1 minute

AVLT: total score 37, 7/15 words on delayed

recall17


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Case 2

Working Diagnosis:

MCIpossibly due to AD

Tests:

Labs: CBC, LFTs, B12, TSH

MRI Brain

Neurocognitive testing

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Case 2

Labs: Normal

Neurocogntive testing: mild decreased

delayed recall and visual perceptual skills,

good attention.

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Case 2

MRI: No significant atrophy. 2 Venous

cavernous angiomas in the medial basal

frontal lobe and anterior rostral caudate.

Surrounding hemosiderin staining.

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GRE Heme FLAIR T1 post gad


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Case 2

Clinical diagnosis:

MCI: possible AD vsMCI due to structural brain lesion

Next step? Amyloid imaging


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Case 2

Biomarker-based diagnostic assessment

Amyloid PET (negative for A)


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Case 2

Final Diagnosis and recommendations:

Mild Cognitive Impairment, non-AD

Recommendations:

Follow clinically for decline

Repeat MRI in 6 and 12 months

Discuss risk of bleeding

Stop taking aspirin

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