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DESCRIPTION: MRI brain and PET scan. Dementia of Alzheimer’s Type with primary parieto-occipital involvement.

CHIEF COMPLAINT: Memory difficulty.

HISTORY: This 64-year-old right handed male had had difficulty remembering names, phone numbers, and events for the past 12 months prior to presentation on 2/28/95. This had been called to his attention by the clerical staff in his parish. He was a Catholic priest. He had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the neurology clinic on his own referral.

MEDICATIONS: None.

PREVIOUS MEDICAL HISTORY: Appendectomy, tonsillectomy, childhood pneumonia, and allergy to sulfa drugs.

FAMILY HISTORY: Both parents experienced memory problems in their 9th decade but not earlier. Five siblings have had no memory troubles. There is no neurological illness in his family.

SOCIAL HISTORY: Catholic priest. Denied tobacco or illicit drug use.

EXAMINATION: Blood pressure 131/74 mmHg, heart rate 78, respiratory rate 12, temperature 36.9°C, weight 77 kg, height 178 cm.

MENTAL STATUS: A&O to person, place and time; 29/30 on MMSE, 2/3 of recall at 5 minutes, 2/10 word recall at 10 minutes. Unable to remember the name of the president. Twenty-three words 60 seconds on Category fluency testing, which is normal. Mild visual constructive deficit.

The rest of the neurological examination was unremarkable the there were no extrapyramidal signs of primitive reflexes noted.
COURSE: TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved in electrical functioning and orientation, 2)significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual constitution, and clock drawing, 4) limited insight into the scope and magnitude of cognitive dysfunction. The findings indicate multiple areas of cerebral dysfunction. With the exemption of the patient’s report of minimal occupational dysfunction, which may reflect poor insight. The clinical picture is consistent with regressive dementia syndrome such as Alzheimer disease. MRI brain, 3/6/95, showed mild generalization of atrophy. More severe on occipital-perineal regions.

In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed in recognition were within normal limits, whereas delayed in recall was moderately severely impaired. Immediate and delayed visual memory was slightly below expectations. Temporal organizations and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular but not exclusive involvement of temporal lobes.

On 9/30/96, he was evaluated for 5 minute spell of visual loss, OU. The episode occurred on Friday 9/27/96 in the morning while sitting in his desk doing paperwork. He suddenly felt that his gaze was pulled towards the pile of letters; then a “curtain” came down over both visual fields “like everything was in a shade” he said. During the episode he got fully alert and aware of his surroundings. He concurrently heard a grating sound in his head. After the episode, he made several phone calls, during which he reportedly sounded confused and perseverated about opening a bank account. He then drove to visit his sister in Iowa, without accident. He was reportedly “normal” when he reached her house. He was able to perform mass over the weekend without any difficulty. Neurologic examination 9/30/96, was notable for: 1)category fluency score is 18 items in 60 seconds, 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178(elevated), ESR liquid profile, GS, CBC with differential. Carotid duplex scan, EKG and EEG were all normal. MRI brain on 9/30/96 was unchanged from previous on 3/6/95.

On 1/3/97 he had a 30 second spell of lightheadedness without vertigo but with balance difficulty after picking up a box of books. Episode was felt due to orthostatic changes.

On 1/8/97 neurological evaluation was stable and his MMSE score was 25/30, with deficits in visual construction, orientation and 2/3 recall at 1 minute. Category fluency score 23 items/60 seconds. Neurologic examination was notable for graphesthesia in the left hand.

In 2/97, he had episodes of anxiety, marked fluctuations in the job performance and resigned his pastoral position. His neurologic examination was unchanged. An FDG-PET scan on 2/14/97 revealed decrease uptake in the right posterior temporal-parietal and lateral occipital regions.