A 75-year-old man with cognitive impairment and gait changes

Abstract

Two to three years prior to presentation to Mayo Clinic, this elderly man, a former practicing psychiatrist, noted reduction in the ease and fluency of dictating progress notes. The problem progressed, and he developed difficulty operating the dictation system itself. He had difficulty writing prescriptions, and, for example, would leave the patient’s name off the prescription. One year prior to presentation, one of the facilities for which he worked expressed concern that he might be a danger to his patients, and he promptly retired. The patient and his wife noted other problems as well. He would pay some bills twice and had difficulty doing arithmetic in his head. His wife said he would veer toward the center line while driving, and she would need to remind him to get back in the lane. Once he made a wrong turn and went 100 miles out of the way before realizing the problem. He had trouble thinking of words he wanted to say. On one instance his language was “garbled” for a few seconds. He was slower getting dressed. His gait had changed, and he was described as “hunched over” and having difficulty stopping walking if he was walking very fast. He had one fall. He had a tremor of both hands at rest, more pronounced on the right than the left, and difficulty getting up out of a chair. Eight or nine years earlier, during sleep, he would vocalize, yell, vigorously shake a limb, or act as if he is running in bed. When awakened, he often described being chased by something. At present these activities were occurring one night per week. His wife learned to awaken quickly and would either wake him or move out of the way to avoid injury. These behaviors tended to occur earlier in the night …