NEJM 65 Female

 https://www.nejm.org/doi/story/10.1056/feature.2022.02.21.100090

A 65-Year-Old Woman with Depression, Recurrent Falls, and Inability to Care for Herself

Case

The case description for a Case Records of the Massachusetts General Hospital appears below. What is the diagnosis? What diagnostic test is most likely to be helpful? Cast your vote on the diagnosis and submit a comment about what diagnostic test is indicated. The correct diagnosis, along with the full description of the case and the procedures performed, has been published in the March 10, 2022, issue of the Journal.

A 65-year-old woman with depression presented with worsening neuropsychiatric symptoms, weight loss, unsteady gait, recurrent falls, and progression of weakness on the left side for several months.

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Presentation of Case

 

Diana L. Stern (Psychiatry): A 65-year-old woman was admitted to this hospital because of depression, recurrent falls, and difficulty caring for herself.

Four years before the current admission, the patient received a diagnosis of depression that was precipitated by psychosocial stressors. She was treated with bupropion, citalopram, and cognitive behavioral therapy. The depression was well controlled until 1 year before the current admission, when she began to have anhedonia, decreased energy, sadness, and poor concentration. She resumed cognitive behavioral therapy, but her symptoms worsened during the next 4 months, and she had suicidal ideation. The dose of bupropion was increased, and treatment with trazodone was started.

Fourteen weeks before the current admission, the patient was in a motor vehicle accident that was attributed to her falling asleep while driving. After the accident, she reported increased sadness, low energy, and inability to perform her usual activities. One week later, she fell and struck her head, and she was evaluated in the emergency department of this hospital. She reported that, before her fall, she had been feeling unsteady because of weakness in the left leg. A physical examination was normal. Computed tomography (CT) of the head, performed without the administration of intravenous contrast material, revealed hypodensities involving the subcortical and periventricular white matter, findings consistent with chronic small-vessel disease. The patient was referred to the neurology clinic of this hospital and was discharged home.

During the next week, the patient had balance difficulties and began using a walker. When she was evaluated in the neurology clinic, she reported imbalance and occasional nausea. On examination, she had a depressed affect. Strength was assessed as 5−/5 in the proximal and distal muscles of the arms and legs. Reflexes were 1+ and symmetric at the biceps, triceps, and patellar tendons and were absent at the ankles, with downgoing toes. The gait was wide-based and unsteady, with mild dragging of the left leg. A diagnosis of postconcussive syndrome was considered, and treatment with ondansetron was started for nausea. Additional tests were performed.

Magnetic resonance imaging (MRI) of the head, performed after the administration of intravenous contrast material, revealed increased signal intensity in the pons and in a periventricular distribution on T2-weighted imaging, without associated contrast enhancement. There was a region of decreased signal intensity in the right corona radiata on a map of the apparent diffusion coefficient. Results of electroencephalography were normal, as were results of electromyography and nerve-conduction studies of the left leg. Physical therapy was recommended, and repeat MRI was planned for 6 weeks later.

Over the next 6-week period, during sessions of cognitive behavioral therapy, the patient was noted to be less talkative, with slow processing, impaired recall, and mild inattention. Repeat MRI with angiography performed 6 weeks after the first study revealed patchy hyperintensity involving the centrum semiovale, corona radiata, internal capsule, and corticospinal tract bilaterally on T2-weighted fluid-attenuated inversion recovery (FLAIR) imaging, without contrast enhancement; the cerebral vasculature was normal.

The patient had recurrent falls without loss of consciousness and began using a wheelchair. She reported worsening sadness, anxiety, and anhedonia, and treatment with buspirone was started. On evaluation in the neurology clinic 6 weeks before the current admission, testing of leg strength yielded inconsistent results, but strength in both legs was assessed as 5−/5 with maximum effort. Dragging of the left leg was also noted to be inconsistent. There were concerns that her depression might be contributing to her neurologic changes, and further follow-up with the psychiatric service was recommended.

Five weeks before the current admission, the patient’s husband brought her to the emergency department of this hospital for an evaluation of worsening memory impairment, poor self-care, and frequent falls. The patient had stopped participating in physical therapy and was spending most of the day in bed. She reported that she had lost 14 kg during the previous 4 months. Other medical history included hypertension, diabetes, and osteoarthritis of the knees. There was a history of postpartum depression 27 years earlier that had lasted for several months. Medications included amlodipine, buspirone, bupropion, cholecalciferol, citalopram, metformin, and trazodone. There were no known drug allergies. The patient lived with her husband in a suburb of Boston and worked as a teacher. She was a lifelong nonsmoker, drank alcohol only occasionally, and did not use illicit drugs. Her mother had a history of anxiety and depression in her seventh decade of life. Her sister had a history of stroke.

On examination, the patient appeared tired and disheveled, with psychomotor retardation. Strength in both legs was assessed as 5/5. She had a monoplegic gait, with buckling of the left leg, when walking down a hallway, but she had a normal gait when walking on a treadmill. Her score on the Montreal Cognitive Assessment was 25, indicating mild cognitive impairment; scores range from 0 to 30, with higher scores indicating better cognitive function. The complete blood count, results of liver-function and kidney-function tests, and blood levels of cobalamin, thyrotropin, and electrolytes were normal. Screening for syphilis, Lyme disease, and the human immunodeficiency virus was negative, as was urine toxicologic screening. After an evaluation by a neurology consultant, the patient was voluntarily admitted to the inpatient psychiatric unit.

While the patient was in the hospital, the dose of citalopram was tapered, and treatment with desvenlafaxine and amphetamine–dextroamphetamine was started; her levels of attention and wakefulness increased. She participated in group psychotherapy, cognitive behavioral therapy, and occupational and physical therapy. She continued to have variable weakness in the left leg and had three witnessed falls, during which she reportedly had fatigue and lowered herself to the ground.

On hospital day 11, the patient reported being unable to use her left arm because of weakness. Although her left arm rested across her chest for most of the day, she was observed holding her husband’s hand with her left hand when saying goodbye. On evaluation by a neurology consultant, strength in the left arm was assessed as 5/5. The working diagnosis was functional neurologic disorder. On hospital day 12, the patient was discharged to a rehabilitation center.

At the rehabilitation center, the patient received physical, occupational, and speech therapy, as well as medications to treat depression. During the first week, she made progress toward independence in bathing, toileting, and grooming but had limited attention, memory, and problem solving. During the second week, she became more withdrawn. There was a paucity of speech with hypophonia, decreased attention, and less eye contact with visitors who sat on her left side than with visitors who sat on her right side. During the third week, the patient stopped answering questions and following commands. She was evaluated again in the emergency department of this hospital.

On examination, the temperature was 36.7°C, the blood pressure 141/90 mm Hg, the pulse 98 beats per minute, the respiratory rate 16 breaths per minute, and the oxygen saturation 99% while the patient was breathing ambient air. She was withdrawn and minimally interactive. She was able to state her name but not the date or location. She did not blink in response to threat on the left side and did not track the examiner’s finger past the midline to the left. There was flattening of the left nasolabial fold. The left arm was hypertonic and held in flexion; there was no spontaneous movement of the left arm or leg, and she declined to participate in a strength examination. She did not withdraw the left arm in response to nail-bed pressure; she withdrew the left foot with antigravity movement in response to tactile stimulation.

The white-cell count was 12,940 per microliter (reference range, 4500 to 11,000), with a normal differential count. The remainder of the complete blood count was normal, as were the results of liver-function and kidney-function tests and blood levels of electrolytes.