Test and Answers – 106 References – 108
4.2 Case Studies
4.2.1 Case 1 Case 1 History
Mr. X. is a 55-year-old married police officer with three teen- aged children. He suffered a myocardial infarction at age 49, after which he experienced a subjective memory decline. He and his wife reported a number of changes, including diffi- culties with word finding and following conversations, mis- placing commonly used items, and forgetting personal events. Mr. X. underwent screening with the MoCA and per- formed entirely within normal limits. Given his young age, he was referred for a neuropsychological assessment to fur- ther evaluate his subjective concerns.
Interview Mr. X. stated that his memory difficulties started suddenly following myocardial infarction. Initially they were not prominent but have gradually worsened. He denied expe- riencing difficulties with way finding, though on occasion he may forget where he was going. On a daily basis, he will enter a room and forget why he went there. He stated that he is usually good at remembering to take his prescribed medications. He has always enjoyed cooking and will still prepare meals for his family, but when alone he may just have a sandwich. Bill pay- ments are a big problem, as he will discover a bill is overdue when he thinks he just paid it. He relies on his wife to keep track of his appointments. He writes things down but often then loses the notes.
Collateral Interview Mrs. X. corroborated the changes to her husband’s cognitive abilities and stated that he will tell her the same message numerous times without being aware of his repetition. She noted that he is not as mentally sharp as he used to be. He was previously very high functioning and able to multitask effortlessly; now he will become irritable and dis- tracted if someone is talking to him while he is attempting to perform a task. He used to be active in a bowling league and coaching his son’s hockey team but has withdrawn from activ- ities given his concerns about difficulty keeping up in conver- sations.
Medical History In addition to coronary artery disease, medical conditions include moderate obesity, hypertension, type 2 diabetes mellitus, and sleep apnea. A recent magnetic resonance imaging of his brain showed cerebral small vessel disease. The sleep apnea is treated with continuous positive airway pressure (CPAP), but Mr. X. has gained weight and the mask does not fit properly anymore. Mr. X. reported a history of mild depressive disorder, and he has become increasingly irritable and “short fused” over the last 2–3 years.
Neuropsychology in Late Life
100
4
Case 1 Questions and Answers Case 1 Questions
?Question 1. What is the unique aspect of Mr. X.’s neuro- psychology profile that is most important to take into consideration when interpreting the results?
?Question 2. What differential diagnoses would be rel- evant in Mr. X.’s case?
?Question 3. What is the etiology of Mr. X.’s subjective concerns and objective impairments?
?Question 4. What are the main neuropsychology- informed treatment recommendations in this case?
Case 1 Answers
Case 1 Answer 1 (Question 1—What is the unique aspect of Mr. X.’s neuropsychology profile that is most important to take into consideration when interpreting the results?)
The neuropsychological assessment results are summa- rized in .Table 4.2. Testing revealed Mr. X.’s current general intellectual abilities to fall in the superior range. There is no evidence of a generalized decline in intellectual ability com- pared to his premorbid ability. Most other aspects of neuro- cognitive functioning fall within normal limits compared to age- matched normative data; however, his performance var- ied from the mildly impaired to superior range across tests, with lowest performance obtained in the areas of informa- tion processing speed, working memory, and mental set shifting. Mental health screening using the Depression
.Table 4.2 Profile of neuropsychological test results for Mr. X.
Domain Functional area Test Performance
level Intellectual
functioning
Global intellectual functioning Wechsler Adult Intelligence Scale (WAIS-IV) full-scale IQ Superior
Estimated premorbid IQ Test of premorbid functioning High average
Attention Simple attention Digit span forward Average
Working memory WAIS-IV working memory index Low average
Digit span backward Low average
Digit span sequencing Low average
Visuomotor attention Trails A High average
Processing speed WAIS-IV processing speed index Low average
Stroop word reading Mildly impaired
Executive function- ing
Alternation Trails B Low average
Concept formation Wisconsin Card Sorting # categories, % conceptualization, total errors, failure to maintain set
High average
Perseveration WCST perseverative errors High average
Response inhibition Stroop color-word naming High average
Memory Verbal acquisition
Verbal learning Verbal delayed recall Verbal delayed recognition
Wechsler Memory Scale logical memory (stories) immedi- ate recall
Average
Logical memory stories delayed recall High average
Logical memory % retention Superior
California Verbal Learning Test (CVLT-II) total words learned Superior
CVLT-II list delayed recall High average
CVLT-II recognition discrimination High average
Visual acquisition Visual learning Visual delayed recall Visual delayed recognition discrimination
Brief Visual Memory Test-Revised (BVMT-R) total Superior
BVMT-R delayed recall Average
BVMT-R delayed recognition discrimination High average H.E. McNeely and J.P. King
4
Anxiety and Stress Scale (DASS) [32] revealed mildly ele- vated symptoms of depression, anxiety, and stress. Therefore, the unique aspect of Mr. X.’s neuropsychology profile that is most important to take into consideration when interpreting these results is his superior IQ.
Case 1 Answer 2 (Question 2—What differential diagnoses would be relevant in Mr. X.’s case?)
Mr. X. and his wife both report concerns regarding declines in his cognition which began following a myocardial infarction at age 49 years but worsened more noticeably in a gradual fashion within the last 2–3 years. His mood has also declined over the same time frame. Given his history of depressive disorder, recent increase in irritability, and endorsement of mild symptoms on self-report, one consider- ation would be that Mr. X.’s subjective cognitive concerns could be attributable to a depressive disorder. Depressive dis- order tends to be associated with attentional impairment, slowed processing speed, and retrieval memory problems.
In examining his profile, relative difficulties are noted in the areas of information processing speed, working memory, and mental set shifting. These areas of cognition are vulner- able to the effects of normal aging and are still within normal limits compared to his age-matched peers; thus, his profile could be interpreted as depressive disorder related. However,
when one considers his global IQ, probable declines of as much 2 standard deviations are evident within these cogni- tive domains, which is in excess of normal age-related changes or changes that would be expected given mildly ele- vated symptoms of depression and anxiety.
Case 1 Answer 3 (Question 3—What is the etiology of Mr.
X.’s subjective concerns and objective impairments?)
Mr. X. has multiple cardiovascular risk factors such as obesity, coronary artery disease, hypertension, type 2 diabe- tes mellitus, and sleep apnea. He has a history of depression, which also appears to be an independent risk factor for car- diovascular disease [33]. Ultimately, he had a cerebrovascu- lar disease burden that could predispose him to cognitive decline. In fact, a number of studies suggest that cardiovascu- lar risk factors are independently associated with the devel- opment of major NCD [34]. For example, coronary artery disease may lead to major NCD through its association with cerebral small vessel disease (as in Mr. X.’s case), which dis- rupts the cerebral blood flow regulation, perfusion, and blood-brain barrier, with resulting increased susceptibility to neurological insults [34]. Given that there has not been a glo- balized decline in IQ and Mr. X. is maintaining functional independence with minimal supports from his wife at this time, a diagnosis of mild vascular NCD is warranted.
.Table 4.2 (continued)
Domain Functional area Test Performance
level
Language Overall verbal functioning WAIS-IV verbal comprehension index High average
Vocabulary WAIS IV vocabulary High average
Phonemic fluency Verbal fluency (FAS) Low average
Semantic fluency Animal fluency Low average
Confrontation naming Boston Naming Test High average
Verbal reasoning WAIS-IV similarities High average
Visual perception construction
Overall visual perceptual organizational skills
WAIS-IV perceptual reasoning index Very superior
Visual abstraction Matrix reasoning Very superior
Visual puzzles Very superior
Visual planning/organizing Rey Complex Figure copy Intact, well
organized
Visual construction Block design High average
Motor functioning Right-hand speed/dexterity Finger tapping/grooved pegboard Low average
Left-hand speed/dexterity Low average
Performance level descriptions based on normative data correction for age, gender, and education level (when possible corrected based on all three variables): very superior (≥ 98th percentile); superior (91st to 97th percentile range); high average (68th to 90th percentile range); average (30th to 67th percentile range); low average (16th to 29th percentile range); mildly impaired (6th to 15th percentile range);
mildly-to- moderately impaired (2nd to 5th percentile range); moderately impaired (0.6th to 1.9th percentile range); moderately-to- severely impaired (0.1st to 0.5th percentile range); and severely impaired (< 0.1st percentile)
Neuropsychology in Late Life
102
4
Case 1 Answer 4 (Question 4—What are the main neuropsy- chology-informed treatment recommendations in this case?)
Mr. X. will benefit from the following neuropsychology- informed treatment recommendations:
A4.1. Given the presence of numerous cardiovascular risk factors, ongoing optimal management and medical monitoring, including monitoring of cognition, is recommended. Neuropsychology reassessment in approximately 12 months would be advised to monitor for progression to major NCD.
A4.2. Although Mr. X. performed well on memory testing, attention and information processing speed deficits were noted. Given that attention is the gateway to memory, poor attention in daily life is likely to be associated with memory difficulties even when none are noted during the structured assess- ment session. To compensate for difficulties with attention and information processing speed, it will be helpful for Mr. X. to give himself more time to complete tasks than he is used to requiring in the past. Eliminating distractions when performing complicated tasks or when listening to important information is also recommended. Providing psychoeducation to family members to help minimize distractions and communicate at a slower pace will also be important.
A4.3. The “see-it-and-say-it” strategy is also useful to focus the attention on the task at hand and improve subjective memory. This strategy is useful for circumventing commonly “forgotten” events. For example, when locking the door, one is to look at their hand with the key in the lock and say aloud, “I am locking the door.” By using multiple modes of registration of the event, one focuses the attention on the act and increases memory quality of the event.
A4.4. Mr. X. may benefit from using a memory aid such as a large calendar to record all important information in a central location. He should develop a habit of checking the calendar every day to help stay oriented to time. Programming alarms into his phone for medications, checking blood glucose level, time to eat, etc. will help him remember and better manage these tasks.
A4.5. Creating a daily routine that includes physical activity, preparing healthy meals, and taking care of paperwork and bill payments according to a schedule will help Mr. X. stay organized.
A4.6. Re-engaging socially is encouraged as this has also been shown to benefit cognition and mood.
A4.7. Although he adheres to CPAP treatment for his sleep apnea, the machine has not been optimized since he gained weight. Ensuring his CPAP machine is optimized is strongly recommended as insufficient oxygen saturation during sleep may cause cognitive difficulties as well as irritability.
Case 1 Analysis Mr. X. presented with a number of cardio- vascular risk factors for the development of cerebrovascular disease and subsequent vascular cognitive impairment. (See 7Chap. 21.) Relative difficulties were noted in his neuropsy- chological profile in the areas of information processing speed, working memory, and mental set shifting. However, these areas of cognition are known to be vulnerable to the effects of normal aging, which were still within normal limits when compared to his age-matched peers. Consequently, his profile could have been associated with a depressive disorder. However, the evident decline of as much as 2 standard deviations within these cognitive domains in the context of his global IQ was considered to be in excess of normal age-related changes or changes that would be expected given his mildly elevated symptoms of depression and anxiety. Important neuropsychol- ogy-informed treatment recommendations pertinent to Mr.
X.’s situation include medically supervised lifestyle changes, optimal management of cardiovascular risk factors and the use of cognitive strategies, and regular monitoring of his cognitive function.
4.2.2