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.