(PO-003) Dupes, delusions, and dementia: Leveraging technology, community resources, and bedside neurocognitive assessment to disentangle a case of probable Binswanger's disease
Background/Significance: Depressive, psychotic and behavioral syndromes can herald the onset of Major Neurocognitive Disorder (MND). Psychiatrists are increasingly called upon to evaluate patients with complex neuropsychiatric presentations via telemedicine and many smaller community hospitals lack immediate access to specialty neurological services. We present a patient with poorly differentiated mood, psychotic and behavioral symptoms where the consulted psychiatrists leveraged pragmatic use of technology, local community civil commitment processes, and bedside neurocognitive examination skills to secure a unifying diagnosis of probable Binswanger’s disease.
Case: The patient was a 60-year-old single unemployed male with poorly controlled hypertension, previously high occupational functioning, and benign psychiatric history. Psychiatry was consulted by a community hospital to provide telehealth evaluation of psychotic symptoms initially thought to be due to hypertensive encephalopathy. Three months prior to presentation, he’d experienced progressively bizarre paranoid and erotomanic beliefs, disinhibited social interactions leading to financial exploitation, frequent falls, and visual hallucinations of bed-bug infestation. Initial evaluation revealed no frank cognitive deficits; however, we were able to obtain an abnormal clock-draw and attentional test via telemedicine. Neuroimaging was notable for multiple chronic white-matter and subcortical vascular infarcts in the pons, left thalamus, and left corpus callosum. Given concerns for further deterioration we obtained a brief civil commitment to our inpatient psychiatric hospital, where we conducted a neurologic exam and thorough neurocognitive bedside evaluation. Assessments confirmed significant executive dysfunction, deficits in complex attention and working memory, as well as unilateral fine motor bradykinesia and gait impairment. The patient was ultimately referred to geriatric psychiatry, connected with Adult Protective Services, and started on low-dose memantine to delay progression of his MND.
Discussion: Our bedside examination combined with neuroimaging clarified the diagnosis of subcortical vascular dementia, likely Binswanger’s disease: a mixed neuropsychiatric syndrome with step-wise progression of cognitive and behavioral change, dysexecutive syndrome, past cerebrovascular insults, and focal neurologic deficits (Vacaras, 2020). While the absence of immediate access to subspeciality evaluation in the community setting could have been restrictive, we were able to leverage our systems resources to accurately diagnose and refer our patient to an evidence-based treatment (Ranz, 2012).
Psychiatrists should keep vascular MND on the differential when considering an atypical course of psychiatric symptoms later in life. Physicians working at the interface of medicine and psychiatry are encouraged to maintain proficiency of bedside neurocognitive evaluation skills and consider a systems-based perspective for patients with assessment needs beyond the reach of their environment of care.
Ranz et al. A Four-Factor Model of Systems Based Practices in Psychiatry. Academic Psychiatry, Dec. 2012 36:6: 473-478.
Văcăraș V, Cordoș AM, Rahovan I, Frunze S, Mureșanu DF. Binswanger's disease: Case presentation and differential diagnosis. Clin Case Rep. 2020 Oct 27;8(12):3450-3457. doi: 10.1002/ccr3.3459
List bedside physical examination techniques to help broaden your differential diagnosis in new onset psychotic disorders
Describe the typical presentation of vascular dementia
Describe how the four-factor perspective of systems-based practice can be applied to caring for patients facing barriers to diagnosis and/or treatment