A 51-Year-Old Who Lost Her Job Due to Cognitive Decline

Lisa C. Silbert, MD; Deniz Erten-Lyons, MD


April 19, 2021

Physical Examination and Workup

Upon physical examination, the patient is alert and afebrile. Her blood pressure is 121/70 mm Hg, and her pulse is regular, with a rate of 70 beats/min. Her body mass index is 20.6 kg/m2. She is pleasant, with fluent and coherent speech, although she does not contribute to the history unless asked specific questions.

General and neurologic examination findings are normal. On cognitive testing, she scores a 24/30 on the Folstein Mini-Mental State Examination, missing 4 points on orientation, 1 point on recall, and 1 point on intersecting pentagon drawing.[1] Further detailed testing using the Neurobehavioral Cognitive Status Examination revealed moderate deficits in orientation, memory, and visual-spatial skills.[2] She also had difficulty with clock drawing. Her Geriatric Depression Scale score was 2.[3]

Brain MRI with and without gadolinium reveals generalized atrophy greater than expected for the patient's age, with notable bilateral hippocampal atrophy and minimal white-matter hyperintensities that do not enhance (Figure 1).

Figure 1.

Laboratory findings, including complete blood cell count, metabolic panel, serum paraneoplastic panel, HIV testing, thyroglobulin antibody titer, and thyroid peroxidase antibody titer, are normal. A cerebrospinal fluid (CSF) study showed a white blood cell count of 1, a red blood cell count of 1, glucose level of 55 mg/dL, and a total protein level of 25 g/dL. No oligoclonal bands were noted, and CSF immunoglobulin G and immunoglobulin G synthesis rates were normal.

The total CSF amyloid beta (1-42) level was 360.1 pg/mL, and the total CSF tau level was 898.1 pg/mL. The CSF phospho tau level was 117 pg/mL, and the amyloid beta (1-42) tau index was 0.28.


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