![]() It is closely related to pregabalin, which is more potent and has greater bioavailability however, it is 2 orders of magnitude more expensive than gabapentin. I explained that gabapentin most likely functions as a partial blocker of voltage-gated calcium channels. More importantly, I needed a better and safer way to treat her anxiety that despite the large doses of benzodiazepines was still her main complaint. ![]() I suspected this was a case of alprazolam toxicity, which would require slow tapering to avoid withdrawal symptoms in this already fragile patient. 3,7ĭespite the MOCA findings, I was not convinced this woman had dementia. 6 My review of the literature showed that SPECT scans have a sensitivity of 96% and a specificity of 90% in detecting dementia for normal aging.3 PET scans are slightly better (90% sensitivity 98% specificity) but are more expensive. The MOCA has better sensitivity-roughly 100%. The American Academy of Neurology reports it has a sensitivity of 83% and a specificity of 72% for diagnosing moderate to severe dementia, but is quite poor for the diagnosis of mild cognitive impairment.4 Some studies put its sensitivity at 40% 5 however, when it is positive, it means there is a brain problem. The Draw-A-Clock test is generally fairly insensitive. Her attempt at a clock was a circle with a few stray marks within. Her attempt at a Trails-A test was unsuccessful. She could not name animals or recall the date. She could not recall any of 5 items after 5 minutes. Her initial performance is shown in the top half of the Figure. She required a protracted period of time to complete it with me. The MOCA combines features of the Trails test, Mini-Mental Status examination, Draw-A-Clock test, and other key tests for dementia. Her mental state prompted me to perform a Montreal Cognitive Assessment (MOCA). Could this be the source of her difficulty?ĭuring the mental status examination, she was disoriented to day and date, although she did correctly state the year. In addition to duloxetine, omeprazole, and a statin, she was taking 2 mg of clonazepam and a staggering 8 mg of alprazolam per day. Her husband spoke up and reviewed her medications and dosages. 3 So perhaps for this woman, she may be having more anxiety as her cortex functions less and less well.Īs the examination proceeded, I asked her about her medications. 1,2 The other type of anxiety occurs in those who have diffuse cortical hypofunction, either from dementia, intoxication, toxic injury, infectious disease, or many other causes of cortical dysfunction. Patients with anxiety or PTSD will show increased activity (evident as increased perfusion on a single-photon emission computed tomography scan and increased glucose uptake on a positron emission tomography scan) in the caudate, putamen, inferior orbital cortex, and operculum. I thought to myself, “Well, anxiety can be an increasing issue with dementia.” In fact, I typically see 2 different patterns associated with anxiety in patients from whom I have functional brain scan data. I asked her if she knew why she was coming to see me. I looked at her birth date-she was only 66 years old. She appeared ashen, confused, weak, and very old. When she reached the office, I took her arm and guided her to a seat. She had to stabilize herself on the wall several times. I stopped them and asked her to walk down the remainder of the hallway on her own. ![]() She slowly teetered down the hallway toward my office, her husband holding one arm and her other hand holding the wall. ![]() “OK, these things happen,” I thought to myself. She looked to be in her late 70s and he in his mid-50s. She introduced herself and we shook hands. As I approached, I determined that I needed a release of information form signed, so he could join us as a collateral historian. At her side sat a younger-looking man, who appeared to be her son. The elderly woman sat in my waiting room, referred for a dementia workup by her primary care physician.
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