Cognition related topic vascular dementia in a old age male

Case presentation on cognition

1. Cognitive dysfunction Speaker- Dr Madhurima Raj Chairperson – dr Gautam das

2. Patient particulars Name- X Age- 65 years Sex- male Religion – Hinduism Address – Bhowanipur , kolkata Occupation – driver Date of admission – 5/7/24 Date of discharge – 21/7/24

3. Chief complaints 1) Difficulty in walking for last 3 years 2) Multi-domain cognitive impairment for last 2 months

4. HOPI Patient was apparently well 3 years back, then he developed sudden onset loss of consciousness for few minutes while attending a festival, that was not associated with any neck and eye deviation, jerky limb movement, involuntary passage of urine and stool at that time, there was no history of palpitation, sweating, dryness of mouth before the event. Following the event patient was hospitalized and since then patients family member noticed difficulty during walking Patient felt unsteady and he couldnot stand or walk without support, there was tendency to fall forward , even with support he used to walk with short step with broad base gait.

5. There were few instances when patient had history of difficulty to initiate walking on his own, but with support Patient has no history of difficulty in negotiating chappal , frequent slippage of chappal , recurrent knee buckling, difficulty in mixing food , breaking chapatis , recurrent knee buckling, buttoning unbuttoning, raising arm above head, tremulousness, stiffness of limb at that time There was no history of vertigenous sensation, tinnitus, vomiting, tingling paraesthesia of limbs or any increment of unsteadiness in eye elosing

6. At this time patient family member noticed mild slurring of speech , associated with jumbling of words, infrequently at, the end of sentences, there was no history of difficulty in initiation of speech, repeated self correction, difficulty in particular words , undue stress on few syllable, or any explosiveness. Although he used to communicate less than previous, patient could understand everything told to him, there was no history of mispronunciation , jargon, or difficulty in reading For last 1 year patient’s son noticed slowness while walking, which was slowly progressive, while walking used to drag his right leg, although patient walking was slow

7. But he could not long time in other daily living activities eg - bathing, eating, combing There was no history of involuntary prolong opening of mouth or drooling of saliva There was history of tremulousness while holding heavy object, no history of tremulousness while reaching object or at rest For last 6 months, patient became less verbal, upon asking any questions multiple times he used give correct answer with one or two words, took less interest in daily family activities

8. He used to loss in conversation, he did not seem to have interest in well being of any family member, which was very unlikely of him Most of the time he used to sleep There was no history of low mood, suicidal ideation, thought of worthlessness, overeating etc For last 6 months he had history of difficulty in wearing clothes, there were multiple times where he tried to put head in sleeves, but there was no history of difficulty in using tools of daily living

9. For last 6 months, he also had some vision problem, according to his son, he had difficulty in finding object, even if it was placed infront of him, sometimes he had difficulty in finding right light switch or doorknobs, but there was no history of bumping into objects or corner of the door, or eating from one side of plate. At that time there was no history of anger outburst, agitation abusive behaviour , irritability, sweet craving, new addiction

10. Sometimes he used to forget what he ate at morning or at dinner, but he could remember it with hint, he could remember his past events Ar that time he has few episode of visual hallucinations, he used to see his dead elder brother or friends, upon asking whether they talked to him or why they came, he could not answer There was no history of auditory hallucinations, delusion There was no jerky movement or any dream enactment

11. For last 2 months all the above mentioned symptoms increased gradually including visual hallucinations, gait problem, and patient became dependent for all his daily living activities Although for last 1 year, he had history of increased urinary frequency and urgency , but all these episode was associated with shame, but for last 2 months there was shameless urination Forlast 2 months there was instances of fluctuations of his cognitive symptoms, at times he could not identify his sonand there was increased frequency of forgetfulness, drowsiness, blank staring

12. There was no history of headache, seizure, dimness of vision, diplopia, difficulty in chewing, abnormal facial sensation, facial deviation, dysphagia, nasal regurgitattion , nasal intonation

13. PAST HISTORY – Diabetic and hypertensive for last 2 years Addiction – tobacco chewing Family history – not contributory

14. Summary 65 years old diabetic, hypertensive male presented with 3 years history of difficulty during walking, progressive bradykinesia, Multi-domain fluctuating sensorium and cognitive impairment ( including attention, apathy, higher order visuospatial dysfunction, dressing apraxia, nonfluent aphasia and visual hallucinations with bladder dysfunction and 1 episode loss of consciousness without seizure or any cranial nerve involvement At present patient both IADL AND ADL is impaired due to his predominant cognitive and motor disability

15. Possibilities 1) Vascular dementia 2) DLB

16. Nervous system examination HMF- ACE3 ILLETERATE 1

17. Meningeal sign- absent Cranium and spine- normal Cranial nerve 1 st – normal 2 nd - pupil normal in size , shape, bilateral reacting to light, no RAPD 3 rd , 4 th , 6 th - saccades slow, pursuits – normal 5 th , 7 th - normal 9 th 10 th 11, 12- wnl

18. Motor 1) bulk- no wasting 2) Tone-right upper and lower limb spasticity and cog wheel rigidity 3)power

19. DTR- RIGHT SIDE 3+, LEFT SIDE- 2+ PLANTAR RESPONSE,, RIGHT- EXTENSOR, LEFT- NO RESPONSE Sensory – within normal limit Cerebellar- within normal limit Romberg- negative Gait- right side spastic with mild ataxic gait, no dystonia Credence- irregular, base,- normal, step lenth – increased , height- normal

20. Extra pyramidal 1) postural tremor both upper limb 2) bradykinesia 3) no rest tremor 4) no other involuntary movement

21. Possibilities 1)Vascular dementia 2) DLB

22. Investigation 1)CBC- HB- 12 gm/dl Wbc - 6000/mm3 Plt - 2 lakhs 2) LFT BILI- 0.35 AST- 34, ALT- 32, ALP-202 3)RFT SODIUM- 140 POTASSIUM – 4.2 4) VITB12- 1789 5) FT4- 1.14, TSH-2.25 , ANTI TPO-33

23. IMAGING Mri brain