PSEUDODEMENTIA FOLLOWING
FLU DIAGNOSED AS SENILE DEMENTIA OF ALZHEIMER TYPE: RESULTS AFTER
ANTIDEPRESSANT AND ANTISTRESS DRUG THERAPY.
Renato COCCHI, a neurologist and a medical
psychologist.
Summary.
It is reported a case of suddenly
insurgent intellectual deterioration in a woman of 85 years, following a flu
and therapy with antibiotics. A diagnosis of SDAT was done by a geriatrician,
in spite of the normal for her age CAT, the evident depression, and the onset
two weeks ago. The patient had treatment as pseudodementia with antidepressant
and antistress drug therapy, and he improved her cognitive impairment already
after 24 hours from the starting of the therapy. After 42 days since the
beginning of the drug therapy, the patient came back to her preceding mental
conditions before the flu.
Key words: Pseudodementia, SDAT,
depression, stress, elderly woman, antidepressant, antistress, drug therapy,
recovery.
Drug modulation of stress reactions
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In 1997, in my paper "possibilities and
limits of drug therapies of dementias" I wrote:
"If we want to propose even drug
therapy in dementias, we should clarify some basic ideas. In the same time we
have immediately to reduce any excessive trust in a drug able to act alone,
like somebody should assert.
We need starting from a trivial but often
forgotten statement: We cannot revive dead neurons. So, to find a target in our
therapeutic action, we have to reconsider the idea of pseudodementia.
The elaboration of the term
"pseudodementia" as opposed to "dementia" comes out by the
crossing of two conceptual axes. The first axis relates to depression in a
broad sense as the causal factor, and the second derives from reversibility, as
a clinical-therapeutic result (Savoldi, Zerbi, Cocchi 1986; Zerbi and Cocchi,
1986).
Clinical forms of pure pseudodementia, so
defined because fully reversed by suitable drug therapy, first did not show any
specific symptoms driving to a functional origin (Cocchi, 1996).
No doubts that to find frank depressive
aspects can direct both diagnosis and therapy, but these are not always so
evident. Eventually indeed, is the ex juvantibus criterion what until now
remains as the surer way to differentiate these two frames.
Only by that we can distinguish dementia as
organic irreversible disease, from pseudodementia as functional reversible
disease (Fisman, 1985; Bulbena and Berrios, 1986; Savoldi, Zerbi and Cocchi,
1986).
To distinguish dementia from pseudodementia,
the reversibility of the latter opposes non reversibility of the first one
(Reifler and Sherril, 1990). But we can value this reversibility as distinctive
criterion, only after therapy. If cognitive impairment comes back after
suitable therapy, we have faced a form of pseudodementia":
I reported here this quotation because the
following case is a pure pseudodementia, suspected during a more careful and
less conceited visit, and regressed with a more suitable drug therapy.
The case.
Half April 2005. A woman of 85 years, in
more than discreet psychophysical conditions till after flu treated with
antibiotics, in the last March. Since it she has disturbed sleeping, with 3-4
nocturia episodes every night, driven to the bathroom by her daughter. Now she
is using an incontinence pad.
She is confused, abulic and seems intellectually
deteriorated but cries a lot. About surely she has subjective dizziness. Memory
troubles are evident. Now she does foolish speaking and has absurd behaviour.
She doesn't succeed anymore to dress by herself. Since recently, she never
recognizes her relatives, and attributes them identities she had known her
childhood. As for his daughter, she says that her daughter is her mother. The
relatives reported her having visual hallucinations. In the mornings she seems
a little better.
She cannot more to do the little housework
she did till before flu. Sleepy and slowed down in her motility, she has even
some difficulties to orient herself into her house. She is indifferent to the
heat and the cool. A little greedy of sweet things, while she appreciates normally
the meat broth. The appetite is regressing, and often, in the evening, she
refuses to eat.
Consultations and examinations were made,
among which:
08.04.2005: Skull CAT without contrast: Enlargement
of the ventricular system within the limits. The median line is in its axle.
There is light hypodensity of the periventricular white matter. Besides we
signal heavy soft tissue in the nasal left pit.
11.04.05 The abdominal US examination did show
nothing of remarkable, outside "multiple pyelic cysts of the
kidneys".
11.04.2005: Neuropsychological evaluation.
The clinical examination: Poor
collaboration. Normal motility. The body sensory examination is not executable.
The field of the vision is not appraisable. As for extrapiramidal signs, there
is a trochlea to the superior right limb. There is easiness to the reflex
grasping. The right thumb-chin reflex can be elicited and the right palm-chin
reflex too. Time orientation scores 0/5; spatial orientation scores 3/5.
Tests:
MMSE: 9 (pathological);
Rey's test of the prompt memory: 0
(pathological):
Learning curve: 0;0;0;0. (pathological);
Rey's test of delayed memory: 0
(pathological).
Primacy (Primacy/recency on two series: 0
vs. 0 (pathological);
Forced recognition: impracticable;
Direct and reversed oral spans: 0 vs. 0
(pathological);
Evoking of the Rey's image: impracticable;
The simple barrage: impracticable;
The double barrage: impracticable;
The ideomotor praxis: 2 (pathological);
The mouth-face praxis: 0 (pathological);
The Rey's constructional praxis:
impracticable;
Verbal denomination of names: 4/28
(pathological);
Raven's Coloured Matrices: impracticable;
Verbal fluidity: 11.4 as corrected
(pathological).
Echolalia observed.
Conclusion: The neuropsychological
evaluation performed today underlines the presence of a diffused deterioration
of the explored cognitive functions, of a severe degree.
That premised, and having declared of don't
have to account of the CAT because not made with the contrast medium, the
geriatrician of the Local Health Unit did the diagnosis of senile dementia of
Alzheimer type (SDAT), irrecoverable. Nevertheless, she prescribed haloperidol
2.5mg and lorazepam 1.25mg (daily doses, by the oral via).
I warned the relatives that, as for me,
about surely it dealt of a pseudodementia, of somatic depressive origin, caused
from negative effects on the brain, both of the flu and the antibiotics. If so,
the new therapy with drugs would confirm in a short time such a different
diagnosis.
Test therapy (daily doses, by the oral via);
Haloperidol 0.5mg; Lorazepam 1.25mg; Glutamine 125mg; Thiamine 125mg +
pyridoxine. B6 125mg + cyanocobalamine 500mcg; Carbamazepina 100mg;
Amitriptyline 6mg.
About end May 2005, the first checkup. The
daughter had phoned that after a day of the new therapy, the mother came back
to herself. She did not remember absolutely what happened to her during the two
preceding weeks. For the family this was a miracle.
After 42 days of drug therapy, the patient
is much better, has less dizziness. The foolish speaking is all missing,
echolalia disappeared, and she has recovered to recognize rightly the persons.
She restarted to do the little housework like she did previously: To prepare,
to clear the table, to go to the bathroom by herself, to dress by herself. The
visual hallucinations missed. Now, she sleeps well all the night and usually
arrives to the mornings without any need to get up to urinate. If it happens,
it occurs only once.
The motility returned as first. Recently she
fell while she wanted to take an object placed up, and has fractured the right
humerus. This fact did not have any worsening on her psychic condition, denying
the worries of her daughter. Now, she eats with good appetite, even in the
evening. Sometime she cries, but much less than previously. She does not speak
much, but she usually did so even in past.
During this visit, she answers to the point
to the various questions. The short-term memory is more that discreet, as even
for her age. She is not confused and is well orienting both in the time and in
the space. I confirmed, ex-juvantibus, the diagnosis of depressive
pseudodementia.
Current therapy (daily doses, by the oral
via); Haloperidol stopped. Lorazepam 1.25mg; Glutamine 250mg; Thiamine 125mg +
pyridoxine 125 mg + cyanocobalamine 500mcg; Carbamazepine 100mg; Amitriptyline
8mg; A polyvitaminic compound with mineral salts (Supradyn Roche TM) one
effervescent tablet every week.
Discussion.
Discussion.
Unlike the preceding case that was a mixture
between an initial dementia and a pseudodementia (Cocchi, 2003 ), this one was
a pure pseudodementia.
It could be suspect as such, before seeing
the results of a drug therapy with ( The ex-juvantibus criterion)? Surely it
did so. The passage from a normalcy to the serious cognitive deterioration in a
few more than 15 days, without any cranial trauma and a coma, the evident
depression, the normal CAT for the age should have alarmed the physicians.
The neuropsychological examinations can give
the same results both in dementia or pseudodementia (Zerbi and Cocchi, 1986).
Which could be the cause of such cognitive
deterioration? The antibiotics are known as possible factors (Moore and
O'Keeffe, 1999). As for me, I would not exclude that the same flu form can have
an effect pro rate. I suspect it for analogy with the loss of smell after flu
or like-flu episodes, able to stop the functionality of the sense of smell
(see: <www.stress-cocchi.net/Anosmia-it>). However, there is not recent
research in elderly persons, where researchers have separated flu and
antibiotics' therapy, in forms of short-term insurgent cognitive deterioration.
To do however, in a hasty and conceited way,
a diagnosis of SDAT, irreversible and irremediable, it may deal to disarrange
all a family, as happened here. To confound pseudedementia with dementia was
only an exceptional event, or the thing is much more frequent than we presume?
If even the diagnosis were exact, a
pseudodementia share, of some extent, is always coexistent in any dementia and
on it we may always act (Cocchi, 1996; Savoldi, Zerbi and Cocchi 1986).
To have acted on the depression and on the
stress seems to have changed the case history within 24 hours.
Bibliografia.
Bulbena A., Berrios G.E.: Pseudodementia:
Facts and figures. Br. J. Psychiatry 1986, 148: 87-94.
Cocchi R.: Drug therapy of pseudodementia as
modulation of stress reactions: Three cases. It. J. Intellect. Impair. 1996, 9:
173-180.
Cocchi R. A dementia / pseudodementia case,
with intolerance to benzodiazepines, treated with antistress and antidepressant
drugs. Dicember 2003
<www.stress-cocchi.net/Dementia3.htm>
Fisman M.: Pseudodementia. Prog.
Neuro-Psychopharmacol. & Biol. Psychiat. 1985, 9: 482-484.
Moore AR., O'Keeffe ST.: Drug-induced
cognitive impairment in the elderly Drugs Aging. 1999 Jul;15(1):15-28.
Savoldi F., Zerbi F., Cocchi R.:
Sull'entita' clinica di pseudodemenza. In: Atti del 1^ Congresso SIPG, Vol. I.
Idelson, Napoli 1986: 251-256.
Zerbi F., Cocchi R.: La pseudodemenza
depressiva. Minerva Psicogeriatrica 1986, 1/2: 77-79.
Posted on Internet on June
2005. Copyright by Renato Cocchi, 2005.
Author's address: dr Renato COCCHI, via
Rabbeno, 3
42100 Reggio Emilia
renatococchi@libero.it
Drug modulation of stress reactions
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