Annals of African Medicine
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Table of Contents
CASE REPORT
Year : 2013  |  Volume : 12  |  Issue : 1  |  Page : 46-48  

Neuropsychiatric and Parkinsonian manifestations of dementia: A case report in a Nigerian woman


1 Department of Medicine, Neurology Division, Federal Medical Centre, Idi-Aba, Abeokuta; Department of Medicine, Neurology Unit, Ladoke Akintola University of Technology/Ladoke Akintola University of Technology Teaching Hospital, Ogbomoso, Nigeria
2 Department of Medicine, Neurology Division, Federal Medical Centre, Idi-Aba, Abeokuta, Nigeria

Date of Web Publication7-Mar-2013

Correspondence Address:
Philip B Adebayo
Neurology Unit, Department of Medicine, Ladoke Akintola University of Technology, Ogbomoso, Oyo-State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1596-3519.108252

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   Abstract 

Neuropsychiatric manifestations sometimes referred to as behavioral and psychological symptoms (BPSD) are not uncommon in dementias, especially in moderate-to-severe cases. When these symptoms occur in the setting of Parkinsonism, fluctuating cognition, visual hallucinations and neuroleptic sensitivity, then the most likely diagnosis is dementia with Lewy bodies (DLB). Although this type of dementia is not infrequently encountered in primary care, it may be missed because of its tricky modes of presentation. We report a clinically diagnosed DLB in a 67-year-old Nigerian female to raise awareness among primary care and mental health practitioners in order to enhance better detection and treatment, especially in the setting of a developing economy.

   Abstract in French 

Manifestations neuropsychiatriques parfois appelés symptômes comportements et psychologiques (SCPD) ne sont pas rares dans les démences, en particulier dans les cas modérés à graves. Lorsque ces symptômes se produisent dans le cadre du parkinsonisme, fluctuante de la cognition, des hallucinations visuelles et sensibilité neuroleptique, alors le diagnostic le plus probable est la démence à corps de Lewy (DLB).Bien que ce type de démence n'est pas rarement rencontré en soins de première ligne, il peut manquer à cause de sa délicates modes de présentation. Nous rapportons un DLB cliniquement diagnostiqué chez une femme nigériane de 67 ans à sensibiliser davantage les soins de santé primaires et les professionnels de la santé mentale afin d'améliorer la meilleure détection et le traitement, en particulier dans le cadre d'une économie en développement.
Mots clés: Corps de Lewy, la démence, l'Afrique, neuropsychiatrie, Nigeria, parkinsonisme

Keywords: Africa, dementia, Lewy bodies, neuropsychiatry, Nigeria, parkinsonism


How to cite this article:
Adebayo PB, Ajani AA, Adeniji OA, Akinyemi RO. Neuropsychiatric and Parkinsonian manifestations of dementia: A case report in a Nigerian woman. Ann Afr Med 2013;12:46-8

How to cite this URL:
Adebayo PB, Ajani AA, Adeniji OA, Akinyemi RO. Neuropsychiatric and Parkinsonian manifestations of dementia: A case report in a Nigerian woman. Ann Afr Med [serial online] 2013 [cited 2020 Aug 11];12:46-8. Available from: http://www.annalsafrmed.org/text.asp?2013/12/1/46/108252


   Introduction Top


Neuropsychiatric manifestations are sometimes referred to as behavioral and psychological symptoms (BPSD) are not uncommon in dementias, especially in moderate-to-severe cases. They constitute a significant burden to caregivers and are often the trigger for presentation to primary care or dementia care providers in memory clinics, psychiatric or neurology outpatients. [1],[2] These symptoms include visual and auditory hallucinations, apathy, delusions/paranoia, night-time behavioral disorder including sleep alterations, incontinence, depression, dysphoria, anxiety, agitation/aggression, euphoria, disinhibition, irritability, aberrant motor behavior such as wandering, phobias, poor eating habits and schizophreniform/paranoid psychosis. The spectrum of BPSD symptoms is particularly common in the degenerative dementias notably Alzheimer's disease (AD), frontotemporal dementia (FTD), dementia with Lewy bodies (DLB) and Parkinson's disease dementia (PDD) and less common in vascular dementia (VaD). [3],[4]

Parkinsonian manifestations in dementia are most commonly seen in cases of PDD, DLB, and occasionally in cases of FTD and AD. A combination of neuropsychiatric and Parkinsonian features may however be seen in PDD and DLB. When this combination occurs in the setting of a fluctuating cognition, visual hallucinations and neuroleptic sensitivity, then the most likely diagnosis is DLB. [5],[6]

DLB is of both epidemiological and clinical importance because it usually has a clinical presentation and course, which differs from AD and other non-AD dementias. Furthermore, the management of psychosis and behavioral disturbances, which are frequent in DLB, is complicated by sensitivity to neuroleptic medications. [5],[6] Although this type of dementia may not be infrequently encountered by physicians caring for individuals with dementia in developing countries, it may however be missed because of the tricky modes of presentation. The study by Stubendorff, et al. suggests that DLB patients have a more malignant clinical course than AD patients; [7] however, the paucity of survival studies in sub-Saharan Africa precludes an objective assessment of the course of DLB in this environment. In the light of the foregoing, we report a clinically diagnosed DLB in a 67-year-old Nigerian female.


   Case Report Top


A 67-year-old Nigerian woman with a background Hb SC presented with a 6-month history of progressive visual hallucinations and behavioral symptoms characterized by social withdrawal, apathy, talking to self, irrational and incoherent speech as well as aimless wandering around the house. She became unable to look after herself, and neither could she supervise younger members of the family in their domestic duties. Over time, she became incontinent of bladder function and had episodes of reduced awareness to her environment. In addition, she had a history of progressive gait impairment, rest and action tremors prominent in the hands. She also had reduced spontaneous movements and memory impairment. She was not a known hypertensive or diabetic patient. She had no prior history of falls or head injury. There was a family history of progressive cognitive impairment in her elder sister.

She was presented at a neuropsychiatry clinic a month earlier where she was commenced on haloperidol and benzhexol. However, she developed a generalized dystonic reaction after about 2 weeks on the medications for which she was referred to our facility. Her neuropsychometric assessment on admission showed a conscious and alert elderly woman, with a mini-mental state examination (MMSE) score of 13/30. Her performance on selected items of the Cambridge Cognitive Assessment Battery (CAMCOG) [8] and the Ibadan Neuropsychological Battery (I-NB) [9] revealed a score of 2/5 in the category (Animal) fluency test and 0/5 in the phonemic (Letter) fluency test. Additionally, her verbal reasoning (similarity test) score was 0 while the ideational fluency score was also 0. She scored 2/9 in the visual reasoning test. Her score on the Boston naming test was 13/15. She scored 5/30 in word list learning and 1/10 in delayed recall of word list. She had a grand total score of 7/24 in the modified token test. Although she scored 11/12 in the stick design test, her delayed recall of stick design score was 0/12. This assessment revealed executive dysfunction, as well as memory, language, visuo-spatial and visuo-constructive impairment.

Her neurologic examination revealed a mask-like facial expression with a decreased blinking rate and a positive Myerson's sign. Her gait was festinant with poor arm swing and turning en-bloc. She also had a mild rest tremor of both hands. She had generalized hypertonia with cog-wheel rigidity in the extremities as well as full power in all the limbs. Her muscle stretch reflexes were globally brisk with flat plantar responses bilaterally. She had a positive palmomental reflex but there were no cerebellar, sensory or dorsal column signs.

Her cardiovascular, respiratory and abdominal examinations were normal. Her blood chemistry, complete blood count and urinalysis were within normal limits. Her cerebrospinal fluid analysis was essentially normal. HIV screening as well as VDRL test were negative. Her brain MRI showed generalized cerebral atrophy and no evidence of small vessel disease.

A diagnosis of probable DLB was made and she was commenced on oral l-dopa/carbidopa of 125/12.5 mg twice daily, donepezil 5 mg daily, risperidone 0.5 mg daily, aspirin 75 mg and vitamin E 200 mg daily. Haloperidol and benzhexol were stopped as soon as she was reviewed by the first physician (AAA) with a consequent improvement of the dystonia. She was commenced on physical as well as psychological therapy and was later discharged home having made significant motor improvements. During subsequent visits, her caregivers admitted to a sustained motor improvement and reduced distress though she still had fluctuating cognitive functions.


   Discussion Top


DLB is the second most common neuropathologically diagnosed cause of degenerating dementia after AD although most cases are not diagnosed during a lifetime; apparently because of its tricky presentation. [10] Besides the first documented sub-Saharan African case of a pathologically proven DLB in a Nigerian by Ogunniyi, et al. about a decade ago, [11] and in some recent case series; [4],[12] there is a paucity of information on DLB in sub-Saharan Africa probably due to poor awareness and under-diagnosis among primary care doctors and mental health practitioners.

Although its clinical presentation may be similar to that of AD, 2 of the following core features are essential for the diagnosis of probable DLB; one is essential for possible DLB: (a) fluctuating cognition with pronounced variations in attention and alertness, (b) recurrent visual hallucinations that are typically well formed and detailed, and (c) motor features of  Parkinsonism More Details. Repeated falls, syncope, transient loss of consciousness, neuroleptic sensitivity, systematized delusions and hallucinations in other modalities are features suggestive of the diagnosis. [5] This case illustrates the diverse presentation of DLB with early BPSD symptoms and Parkinsonism in the presence of cognitive fluctuation and neuroleptic sensitivity. Increased awareness, early recognition and diagnosis will improve early commencement of care and treatment and possibly slow the process of cognitive decline and improve quality of life of the patients and their caregivers.


   Conclusion Top


We have highlighted the neuropsychiatric and Parkinsonian manifestations of dementia in a 67-year-old Nigerian woman to raise awareness among primary care and mental health practitioners and enhance better and early detection and treatment, especially in the setting of a developing economy.

 
   References Top

1.Finkel SI, Costa e Silva J, Cohen G, Miller S, Sartorius N. Behavioural and psychological signs and symptoms of dementia: A consensus statement on current knowledge and implications for research and treatment. Int Psychogeriatr 1996;8:497-500.  Back to cited text no. 1
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2.O'Donnell BF, Drachman DA, Barnes HJ, Peterson KE, Swearer JM, Lew RA. Incontinence and troublesome behaviors predict institutionalization in dementia. J Geriatr Psychiatry Neurol 1992;5:45-52.  Back to cited text no. 2
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3.Tripathi M, Vibha D. An approach to and the rationale for the pharmacological management of behavioral and psychological symptoms of dementia. Ann Indian Acad Neurol 2010;13:S94-8.  Back to cited text no. 3
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4.Amoo G, Akinyemi RO, Onofa LU, Akinyemi JO, Baiyewu O, Ogunlesi AO, et al. Profile of clinically-diagnosed dementias in a neuropsychiatric practice in Abeokuta, South-Western Nigeria. Afr J Psychiatry (Johannesbg) 2011;14:377-82.  Back to cited text no. 4
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5.McKeith IG, Galasko D, Kosaka K, Perry EK, Dickson DW, Hansen LA, et al. Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): Report of the consortium on DLB international workshop. Neurology 1996;47:1113-2.  Back to cited text no. 5
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6.Zupancic M, Mahajan A, Handa K. Dementia with Lewy bodies: Diagnosis and management for primary care providers. Prim Care Companion CNS Disord 2011;13.  Back to cited text no. 6
    
7.Stubendorff K, Hansson O, Minthon L, Londos E. Differences in survival between patients with dementia with Lewy bodies and patients with Alzheimer's disease-measured from a fixed cognitive level. Dement Geriatr Cogn Disord 2011;32:408-16.  Back to cited text no. 7
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8.Huppert FA, Brayne C, Gill C, Paykel ES, Beardsall L. CAMCOG: A concise neuropsychological test to assist dementia diagnosis: Socio-demographic determinants in an elderly population sample. Br J Clin Psychol 1995;34:529-41.  Back to cited text no. 8
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9.Akinyemi RO, Okubadejo NN, Akinyemi JO, Owolabi MO, Owolabi LF, Ogunniyi A. Cognitive dysfunction in Nigerians with Parkinson's disease. Mov Disord 2008;23:1378-83.  Back to cited text no. 9
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10.Rahkonen T, Eloniemi-Sulkava U, Rissanen S, Vatanen A, Viramo P, Sulkava R. Dementia with Lewy bodies according to the consensus criteria in a general population aged 75 years or older. J Neurol Neurosurg Psychiatry 2003;74:720-4.  Back to cited text no. 10
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11.Ogunnyi A, Akang EE, Gureje O, Takao M, Piccardo P, Baiyewu O, et al. Dementia with Lewy bodies in a Nigerian: A case report. Int Psychogeriatr 2002;14:211-8.  Back to cited text no. 11
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12.Okubadejo NU, Ojo OO, Oshinaike OO. Clinical profile of parkinsonism and Parkinson's disease in Lagos, Southwestern Nigeria. BMC Neurol 2010;10:1.  Back to cited text no. 12
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