Part 4: Neuropsychological Evaluation in Clinical Practice: Case Interpretation and Treatment
Lynn W. Shaughnessy, MA, Maureen K. OConnor, PsyD, ABCN, and Janet C. Sherman, PhD
Ms. Shaughnessy is a student, Massachusetts School of Professional Psychology,
Questions 1-3 Refer to the Following Case:
- An 83-year-old right-handed man is referred for an initial neuropsychological evaluation by his primary care physician (PCP) to address concerns about progressive cognitive difficulties. When asked, the patient denies experiencing any cognitive problems. In contrast, his wife, who is present for the clinical interview, describes a 4-5 month history of gradually progressive cognitive difficulties. As examples of these problems, she states that she must repeat things more often and in general feels that her husband does not "remember like he used to." She has managed his medication for the 3 months prior to the evaluation because of concern that he would forget to take them on his own. The patient continues to drive without reported difficulty and has never gotten lost while driving in a familiar area, yet his wife notes that she is no longer comfortable with him driving long distances because he seems to be a less conscientious driver than in the past. The patient reports feeling less interested in doing things he used to enjoy, such as woodworking, although he continues to be interested in reading and visits local libraries daily. The patient describes his mood as "pretty neutral," but he recently had a prolonged grief reaction after a close family member passed away. His wife describes a mild increase in anxiety and irritability. A recent note from his PCP indicates that the patient was passive and withdrawn and that content of speech was somewhat "empty." The patient denies difficulty with sleep and reports no change in appetite. Medical history is significant for hypertension, rheumatoid arthritis, and head injury as a child with a very brief loss of consciousness and no significant post-traumatic amnesia.
The patient’s PCP recommended that he undergo brain magnetic resonance imaging prior to neuropsychological evaluation. Results indicate generalized parenchymal and proportional bilateral mesial temporal lobe volume loss, although there is no regional cortical volume loss to strongly suggest a specific dementia or other neurodegenerative process. In addition, scattered T2/FLAIR hyperintensities in the periventricular and subcortical white matter are noted and felt to be nonspecific, although they are most likely consistent with chronic small ischemic vessel disease.
The patient received a bachelor’s degree in engineering and a master’s degree in business administration and reportedly was always a good student. Family history is significant for cognitive difficulties in his father beginning in his 80s, with no formal diagnosis of dementia. His mother lived to age 98 years and was reportedly very sharp, even in her later years. A maternal aunt lived to 100 years of age, without any significant memory difficulties. The patient has no siblings, and he and his wife have no children.
Given the patient’s history, what is the least likely cause of his cognitive difficulties?