(P20) Subacute Memory Loss in PALTC: Beyond the Most Common

Introduction: Major Neurocognitive Disorder due to Brain Metastasis in a previously independent Veteran who was admitted to our post-acute care with an unrelated illness and noted with disorganized thinking, apathy, lack of hygiene and memory loss during discharge planning process.

Case Description: 67-year-old male Hispanic Veteran with diabetes mellitus, peripheral vascular disease, benign prostatic hyperplasia, history of alcohol and cocaine abuse in remission, and of Right Upper Lung adenocarcinoma four years prior, who was admitted to our VA Community Living Center (CLC) in San Juan, Puerto Rico for post-acute care with left second toe osteomyelitis. He presented with new short term memory deficits, apathy, disheveled and was unable to teach back insulin instructions as part of discharge planning process. Follow up cognitive testing was done using Montreal Cognitive Assessment (MOCA test) was positive for cognitive impairment 18/30 (normal >26/30) with deficits noted on visual spatial, executive function, word recall, concentration, and orientation. He had been consistently oriented on admission and cognitive screening test on admission 10 weeks prior was negative. Labs including CBC, CMP, TSH, Syphilis, B12, and HIV were normal. Given subacute onset of the cognitive deficits and prior history of lung adenocarcinoma, brain MRI was obtained and showed “Multiple supratentorial lesions, lesions T1 isointense/T2 hyperintense to gray matter centered in right external capsule, right thalamus, and left basal ganglia most consistent with metastatic disease”. Resident met hospice criteria; however after goals of care discussion decision was to pursue medical treatment. He completed radiotherapy and remained with us in our long-term care for chemotherapy.

Discussion: The differential diagnosis for the cognitive changes was broad and included reversible as well as irreversible etiologies and common neurodegenerative processes. He had atherosclerotic vascular risk factors and initially oriented, which could have made Vascular Dementia the suspected diagnosis because the changes were subtle on initial presentation. His memory loss, apathy, cognitive and functional deficits were consistent with the areas of the brain affected on MRI. Our diagnosis is Major Neurocognitive Disorder due to brain metastasis. Our case reminds us of the importance to differentiate acute versus chronic changes in cognition, observation, and thorough clinical history. The post-acute setting in which the interdisciplinary team members can perform comprehensive geriatric evaluations, get to know the residents well aside from primary diagnosis and follow them through time allows and promotes great quality of care for our geriatric population. By identifying even subtle acute and subacute changes promptly, we can make a timely diagnosis that can allow us for early interventions, setting expectations, goals of care, and advance care planning.