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Advanced Neurology Dementia with Lewy bodies and substance misuse

discarded over 20 bottles of prescription medications. distorted and poorly organized. On the clock drawing, he
Discharge medications included levothyroxine, made spacing errors of the numbers, some of which were
venlafaxine, divalproex, trazodone, and risperidone. placed on the clock border, and errors in hand placement.

Following discharge from the hospital, the patient There was allegedly no evidence of interval decline
attended an intensive 16-week outpatient program with compared to 2014 (Table 3). There was reported
subsequent weekly visits for a year. Urine samples for drug “frontal-executive dysfunction, mild frontal-subcortical
and alcohol screening were negative. He started seeing dysfunction (mild cognitive impairment) likely
a new psychiatrist. He continued to suffer from loss of multifactorial secondary to severe anxiety, mild depression
executive function, apathy, lack of self-care, and short- and history of alcohol abuse.” The possibility of incipient
term memory loss. His postural symptoms worsened frontotemporal dementia (FTD) was raised; therefore,
dramatically following discharge from the hospital, continued monitoring was recommended.
and he suffered from severe dizziness/light-headedness The patient went for a consultation with a neurosurgeon
and worsening fluctuating difficulty walking, as well as (FH) to rule out any treatable proximate causes for his
complained of leg weakness and numbness. symptoms. Additional symptoms included frequent
In April 2017, neuropsychological testing was repeated. tripping, tremors, shaking episodes, skin “crawling,”
At the time, the patient was on trazodone 100 mg QHS dysphagia, difficulty sleeping, tinnitus, anosmia, and
and diazepam 2 mg BID. The neuropsychologist noted paresthesia of the feet. History was positive for remote
that his attention fluctuated during testing, but formal test sports-related concussions and mild hyperthyroidism that
measurements for attention reported average attention and later resolved after a brief course of thyroxine. 19-21 A past
above-average auditory attention. His speech was fluent. ANA comprehensive panel showed immunoglobulin (Ig)G
He demonstrated mildly impaired initiation and severe positive (IgM negative) for past coxsackievirus, Chlamydia
preservation errors. He scored 130 on dementia screening pneumoniae, herpes simplex virus 1, Epstein–Barr virus,
(≤123 for dementia). The MMSE of 24/30 reportedly Mycoplasma pneumoniae, influenza A, and parvovirus
reflected mild impairment but no dementia. The copy B19. Vitamin B12 folate, calcium, thiamin, and niacin
22
of a complex design on the visuoconstructional task was were normal. 23-28 He had two recent hospitalizations for

Table 3. Comparison in neuropsychological screening from 2014 to 2017
Screening domain Improved No change Worsened
Cognitive screening
MMSE X (27/30–24/30)
Memory functions
Prose recall X (mildly impaired)
Verbal list recall X (low average)
Verbal list recall (recognition format) X (average)
Visual memory X (mildly impaired)
Visual memory (recognition format) X (low average)
Language functions
Confrontation naming X (low average)
Visuospatial perception and constructional skills
Visuospatial attention/Clock drawing X (impaired)
Visuoconstructional skills (pentagon) X (severely impaired)
Executive functions
Mental flexibility X (severely impaired)
Letter fluency X (low average)
Semantic fluency X (mildly impaired)
Visual attention and processing speed X (severely impaired)
Note: A year following benzodiazepine withdrawal, language functions, and visual memory were improved; visuoconstructional skills, visual attention,
processing speed, and mental flexibility remained severely impaired; and MMSE worsened. Abbreviation: MMSE: Mini–mental state examination.

Volume 3 Issue 1 (2024) 4 https://doi.org/10.36922/an.2232