Cognitive impairment reversed by cinacalcet administration in primary hyperparathyroidism

J. G. Timmons,R. Manners,C. McDougall,M. Bailey

doi:10.1007/s42000-021-00292-4

Abstract

Primary hyperparathyroidism (pHPT) is a common endocrine disorder. Often serum calcium is minimally elevated with few symptoms. In elderly patients with multiple co-morbidities, the decision to “watch and wait” is often most clinically appropriate as operative intervention is associated with high peri-operative risk. We present an elderly patient with mild hypercalcemia secondary to primary hyperparathyroidism. The clinical decision was initially to watch and wait. The patient subsequently developed cognitive impairment and was diagnosed with mixed Alzheimer’s disease/vascular dementia. She became dependent for all care and housebound. A therapeutic trial of cinacalcet was commenced following a further acute rise in serum calcium. Significant reversal of her functional and cognitive deficit occurred. She was no longer fully dependent. Mini mental state examination (MMSE) improved from 8/30 to 21/30. In vulnerable neural systems, even mild elevation in serum calcium may have a profound effect on cognition and function. We propose a therapeutic trial of cinacalcet in such patients.

Highlights

Hypercalcemia is a common biochemical abnormality encountered in clinical practice [1, 2]
We present a case of a patient with mixed dementia, marked cognitive and functional decline, and co-morbid primary hyperparathyroidism
Definitive management in the form of parathyroidectomy is often curative in the context of a single benign parathyroid adenoma with excess parathyroid hormone (PTH) secretion [1]

Summary

Background

Hypercalcemia is a common biochemical abnormality encountered in clinical practice [1, 2] While important causes such as malignancy and myeloma should be excluded, in the context of an inappropriately normal or elevated parathyroid hormone (PTH) level, a diagnosis of primary hyperparathyroidism is made [1]. In the interim, Mrs M. had a period of cognitive decline and worsening mobility with falls She was referred to old age psychiatry. Alzheimer’s and vascular mixed dementia was diagnosed Her cognitive condition worsened, and Mrs M. required a full package of care with carers attending 4 times daily. Mrs M received acute medical admission to our hospital following a fall at home Her calcium was found to be 3.23 mmol/L. Repeat MMSE was performed with an improvement in her score to 21/30 from 9/30

Findings

Discussion

Conclusion