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Rapidly Progressive Cognitive Impairment Without Delirium
Diagnostic Challenges from the Memory Clinic
Dr Andrew Tarbuck (FRCPsych)Dr Yasir Hameed (MRCPsych)Norfolk and Suffolk NHS Foundation TrustNorwich, UK
Objectives
Describe two clinical cases
Rapidly progressive cognitive decline without delirium
Consider differential diagnoses
Lessons to be learned
The problems with current pathways
Case 1: Rapid Descent
Referred urgently by GP in February 2014
63 years old lady lives with husband
Increasing “confusion”
History of a fall 10 days ago.
Evidence of psychosocial stressors.
GP Referral
Reasons for Referral
New onset of panic attacks with anxiety symptoms (hyperventilation) and perceptual distortions (feeling that the room/walls/people closing on her)
Headaches and burning sensation over her body
Unusual experiences: auditory hallucinations, misidentification of family, rooms and furniture
Disoriented in her own home (unable to work out how to get out through a door)
Background HistoryPast Psych Hx: Overdose in 1970s in context of
relationship breakdown. None since.
Past Med Hx: ME since 1987 and IBS. On Amitriptyline 25 mg nocte for years.
Family Hx: Brother died from complications of alcohol dependence. Daughter under Ix by neurologist for ? Peripheral neuropathy.
Personal Hx: Lives with husband. Daughter lives nearby. Son works as a paramedic.
Initial Assessment
Triaged by Single Point of Access to Working Age Adult Services.
Brief period of input from Crisis Resolution and Home Treatment Team (CRHT)
Speech incoherent and vague
Sleeping 18 hours a day
Unsteady on her feet, rapid decline in mobility and self care
Fluctuating presentation
No fever.
No alcohol or drug misuse.
Initial Assessment (cont’d)
Conscious, but disoriented to person, place and time.
Cranial nerves and peripheral nerves intact. GP COG 3/9. She was able to draw a clock and put hands on.
Her appetite fine (she eats everything we put in front of her)
Husband is unable to cope. Her son and daughter visiting regularly.
Over next few weeksCT scan 2.3.14 and bloods: NAD.
CRHT referred to Dementia Intensive Support Team (nurse-led service). Mirtazapine started. Amitriptyline stopped.
Consultant old age psychiatrist review requested
Findings
Thin, very ataxic & unstable, unable to sit upright, choreoathetoid movements, myoclonic jerks, intermittent hyperventilation.
Speech very slow, halting, word-finding problems, perseveration, logoclonia
Labile mood
No psychotic features
Findings (cont’d)
Very poor concentration, unable to give age, DOB, home address, disorientated in time
Exaggerated startle response, pout reflex
What is your differential diagnosis?
Action
Urgent Neurology referral
Neurology Admission 24.3.15
MRI 26.3.14: Extensive bilateral asymmetrical cortical restricted diffusion with mild associated high signal on T2 and FLAIR images. Sparing of subcortical regions.
EEG: diffusely low, nonspecific changes suggestive of neurodegenerative disease.
MRI
EEG
Outcome
Patient passed away on 21.4.14.
Diagnosis:
Sporadic Creutzfeldt–Jakob disease (CJD)
Creutzfeldt and Jakob
Diagnosis of Sporadic CJD
Other types of CJDVariant CJD: First reported in 1996 in UK. Transmission of
BSE infection from Cattle to human. Compared to sCJD: Age onset is younger, longer duration of illness (1 year or more), initial presentation is psychiatric then neurological. Tonsillar biopsy is used to show abnormal protein.
Familial (Genetic) CJD: Caused by an inherited abnormal gene (a mutation in the human prion protein gene, PRNP). Positive family history and genetic testing can confirm the diagnosis.
Case 2: Bewilderment
79 years old man
Referred in April 2014 with 4 weeks history of interrupted sleep, tearful.
Anxious ++ regarding planned prostate surgery
Bewildered with poor memory
Frontal headache
GP referral
GP COG 1/9 (scored 9/9 in November 2013)
GP started citalopram, he didn’t take it.
No obvious neurological or physical sign
Past Med Hx of bladder stones, BPH, AAA surveillance, AF and cardiac stent. On warfarin.
Psychiatric assessment He had severe ear infection and UTI in March. Rapid deterioration from
this point
Reports of visual hallucinations. Right sided inattention (bumping into walls and doorways) with right left disorientation.
Unsteady on his legs
Episodes of urinary incontinence
Reduced motivation and poor self care. Labile mood.
Word finding difficulty and using wrong words (says “water” when he want to go to the toilet). Non fluent dysphasia.
Cognitive assessment: disoriented, severe cognitive impairment.
Nominal dysphasia (unable even to name pen or watch).
Poor comprehension.
Unable to score any points on formal cognitive testing.
Any suggestions for diagnosis?
Differential diagnosis
CVA with subsequent progression (possibly bleeding)
Intracerebral abscess resulting from his recent ear infection
Subdural haematoma (although no history of recent falls or head injuries)
Some other space occupying lesion
MRI 06 May 2014Solitary 4.2 x 3.4 cm centrally heterogeneous mass in the left pareito-occipital region.
Local mass effect with effacement of the left posterior horn of the lateral ventricle.
Outcome
Patient passed away on 26.07.2014
Diagnosis:
Glioblastoma of left parieto-occipital and to a lesser extent, temporal lobe.
Glioblastoma
The most common and most aggressive type of primary brain cancer.
Current treatment include maximal surgical resection followed by concurrent radio and chemotherapy.
The prognosis is poor, with median survival of about14 months.
Challenges in assessments of rapid cognitive impairment Limitations of the Single Point of Access and
“ageless” service model.
Difficulties in the referral pathways between psychiatry and neurology.
Who should do the initial assessment? (Nurses vs Psychiatrists vs Neurologists)
The rapidly changing clinical presentation.
Take home messages
Very rapid change in mental state with focal neurological features is strongly suggestive of an organic/neurological problems.
Have a high index of suspension for the unusual/rare disorders that present with cognitive impairment.
Joint and liaison work with primary care, psychiatry, psychology and neurology is need to optimise assessment and management.