Pseudobulbar Affect, Cognitive Dysfunction And Depression In Poorly Controlled Diabetes | 76783
Journal of Neurological Disorders
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A case of unrecognized neurocognitive disorder and pseudo-bulbar affect in a patient with multiple vascular risks, poorly controlled diabetes with subcortical lacunes masquerades as depression. 64 year old ex-smoker male with PMH of hypertension, long standing poorly controlled type 2 diabetes presented with insomnia and depressive mood, where a trial of SNRI was partially effective in his mood control but did not help with his crying bursts. He is still driving with multiple episodes of loss of consciousness due to hypoglycemia. His physical exam was unremarkable except for emotional bursts of laughter and crying that were not affect congruent. On CGA, he was found to have 3 impaired IADL domains (ability to drive with many car accidents, handling finances and administering medication. His cognition test showed MMSE : 26/30, adjusted to education level, he had impaired clock drawing test and impaired trail B test, impaired speed, attention and executive skills, GDS was 4/15, FRAIL scale was 4/5. His labs revealed HbA1c above 10, He has normal B12, folate. His MRI revealed white matter disease, pontine infarct, Left thalamic lacunar infarct and left lenticular lacune as well in addition to cortical atrophy. Patient was recognized as an early vascular Dementia case with associated Pseudo bulbar Affect masked by depressive symptoms, the case triggered a change of his holistic care that revamped his HbA1C goals and advanced care planning. In summary, General psychiatrists and Primary care clinicians may fail to recognize pseudo bulbar affect and cognitive dysfunction during clinic visits using routine history and physical Pseudobulbar Affect (PBA), presents as abrupt episodes of uncontrollable laughter or crying that are incongruent or independent of mood, occurs in many neurological brain diseases or following brain injury. It is important to identify PBA as a different entity from depression, treat and identify underlying vascular cognitive impairment.
Hanan Sheikh Ibrahim is a Clinical Assistant Professor at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Ohio, a Consultant Physician and a Quality Officer at the Cleveland Clinic Abu Dhabi. She was trained at Cleveland Clinic in Ohio, USA under the tutelage of Dr. Robert Palmer, Concept Originator of the Acute Care of Elderly (ACE) unit which was modeled internationally. Then she pioneered in the geriatric care in the UAE by establishing the first MACE unit and the first Geriatric Core Curriculum for resident physicians in training. She received her MD from Damascus University, Syria where she specialized in Pulmonary Medicine then she moved to US where she completed her residency in Internal Medicine at the University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania, US. She completed her Fellowship in Geriatric Medicine at Cleveland Clinic, Ohio. She is board certified in Internal & Geriatrics Medicine.
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