Case 1:
The first individual was a 73-year-old male from Iran who had received 16 years of formal schooling and was employed as an English instructor at a language institution. He was fluent in five languages: Persian, English, and Turkish, and had an intermediate degree of proficiency in Dutch and French. He came to our specialized dementia clinic because of slight forgetfulness during the previous two years. He has had episodic visual hallucinations for the last year. He said, ”I observe the objects on the ceiling descending towards the floor.” Postural instability has been apparent over the previous eight months. He had a mild symmetric resting tremor in his hands since 1.5 months ago. His partner saw violent activity in the second half of his sleep. She said he ”appears to be struggling with his dreams.” His medical background includes a history of hypertension, and he was prescribed Aspirin, Valsartan, Fluoxetine, Buspirone, Haloperidol, and Trihexyphenidyl. He refused any familial background of mental disorders.
The neurological examination determined that the Montreal Cognitive Assessment (MoCA) scores were 15 out of 30 during the first appointment. The MoCA sub-scores were as follows: visuospatial/executive function 1 out of 5, Naming 3 out of 3, Attention 2 out of 6, Language 1 out of 3, Abstraction 2 out of 2, Recall 0 out of 5 with Memory Index Scale (MIS) 6 out of 15, and Orientation 6 out of 6. The Clock Drawing exam has an estimated tilt of 30 degrees (Figure 1, A). Additional observations during the examination were pronounced hypokinesia, tactile-sensitive myoclonic-like motions in the upper limbs, stiffness on the left side, and retraction of both eyelids.
The electroencephalogram (EEG) revealed intermittent delta waves in the posterior alpha background. The Brain MRI showed slight enlargement of both ventricles, bilateral grade 2 medial temporal lobe atrophy (MTA), and areas of increased signal intensity in T2/FLAIR images in the cerebral white matter (Fazekas grade 2) (Figure 1, C). The cerebrospinal fluid (CSF) and blood examination revealed no notable findings.
The diagnosis of probable Dementia with Lewy body (DLB) was established based on the presence of recurring visual hallucinations, parkinsonism REM-sleep behavioral disorder, and fluctuating cognition.