Virginia Research Day 2021

Utility of Neuroimaging in Patients with Chronic Cognitive Impairment: A Case Report

Charlotte Patel, DO Elliot Freed, DO Brady DeHart, PhD

Introduction

Imaging

Discussion

Primary care physicians commonly see patients with complaints of cognitive impairment and functional decline. Neuroimaging is unequivocally indicated in patients with acute onset of such symptoms; however, the use of imaging in the evaluation of patients with more progressive symptom onset is controversial. This case highlights the importance of neuroimaging as a tool for finding treatable causes of cognitive decline in patients with known dementia who exhibit any change in their cognitive/functional status, whether abrupt or gradual. An 82-year-old male with past medical history significant for dementia, depression, and hypothyroidism presented for his annual Medicare wellness visit in October 2020. He was accompanied by his wife and daughter, who expressed concerns about an abrupt decline in his functional status 2-3 weeks earlier. The patient was initially diagnosed with mild dementia in March 2018 after he was referred to neurology for evaluation of confusion, irritability, and somnolence. CT imaging at that time revealed generalized atrophy and scattered white matter disease. He was started on donepezil, which he did not tolerate. The patient was then prescribed memantine, which helped significantly. The patient’s cognitive and physical impairments remained well-controlled for over 2 years with memantine, sertraline, and levothyroxine. At the time of his annual wellness visit in October 2020, recent lab results were reviewed, his levothyroxine dose was increased accordingly, and the patient was referred to physical therapy. Because of the abrupt nature of the reported symptoms, a head CT was also ordered. Ultimately, the patient was found to have a brain lesion consistent with a glioblastoma. He was promptly referred to oncology, where treatment options were discussed with the patient and his family. They chose to forego additional work up or treatment, and they enrolled him in hospice/palliative care. The patient passed away less than 3 weeks later. Case Details

Primary care physicians commonly see patients with complaints of cognitive impairment and functional decline. First and foremost, thorough history should be obtained from these patients and their family. Medications should be reviewed, and urine drug screens should be performed. Patients should be screened for depression, hypothyroidism, and vitamin deficiencies (ie B12, folate). Neuroimaging with non-contrast CT or MRI should also be considered in order to assess for other treatable causes of cognitive impairment and functional decline. Of course, work-up should be guided by the desires of the patients and their families using a shared decision making model.

Routine screening for cognitive impairment or dementia is not recommended, but thorough work-up should be offered to patients presenting with signs of cognitive difficulty or functional decline.

Imaging should not only be included in the initial evaluation of patients with cognitive decline but also in any patients with known dementia who experience an abrupt change in their symptoms.

A thorough history, complete physical examination (including MMSE or MoCA), blood work, and depression screening should be performed. Family members should be involved, if possible.

Conclusion

This case highlights the utility of neuroimaging in all patients who present with acute cognitive impairment or functional decline – even those with known dementia. It is critical that medical professionals, especially primary care providers, remain diligent in their assessment for treatable causes of such symptoms and not simply attribute them to known dementia, existing depression, or other chronic conditions.

References

1. Larson MD PhD, E., 2019. Evaluation of cognitive impairment and dementia . [online]. Available at: UpToDate.com. [Accessed 1 December 2020]. 2. Batchelor MD PhD, T., 2020. Initial treatment and prognosis of newly diagnosed glioblastoma in adults . [online]. Available at: UpToDate.com. [Accessed 1 December 2020]. 3. Gaillard, F. and Rasuli, B., 2020. Glioblastoma - Radiology Reference Article . [online]. Available at: Radiopaedia.org. [Accessed 31 January 2021].

March 2018

October 2020

November 2020

Initial diagnosis of mild dementia

Abrupt decline in his functional status

He enrolled in hospice care

CT head revealed generalized atrophy

CT head revealed a concerning lesion

Patient passed away at home

The above CT image is not from this patient’s case. The findings in the above image are similar to those found in this patient’s CT scan but on the opposite side of the brain. The above image is provided courtesy of Associate Professor Frank Gaillard via Radiopaedia.org (rID: 4756).

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

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